Current opinion in critical care
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Delirium is frequently encountered in the ICU and is associated with significant adverse outcomes. The increasingly recognized consequences of ICU delirium should enhance efforts to improve recognition and management of this serious problem. We aim to review the recent literature on ICU delirium, including risk factors, detection, management and long-term impact of disease. ⋯ Delirium remains an underrecognized and underdiagnosed problem. Detection tools are readily available and easy to use. Further understanding of risk factors is needed to identify most susceptible individuals and plan management, which should include prevention and therapy based on available evidence.
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Curr Opin Crit Care · Apr 2012
ReviewManifestations of the hyperadrenergic state after acute brain injury.
Hyperadrenergic activity leading to autonomic dysfunction after acute brain injury is an underrecognized, yet important source of complications following a variety of neurologic injuries. Autonomic dysfunction may prolong ICU stay and increase healthcare costs driven by extensive diagnostic workups and/or ensuing complications. In this review article, we intend to illustrate commonalities between various hyperadrenergic states in acquired brain injury. Specifically, this review will focus on autonomic dysfunction in two common conditions in the neurocritical care unit, traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH). ⋯ The pathophysiology of autonomic dysfunction is incompletely understood and treatment options are few. However, recognizing hyperadrenergic commonality in disparate neurologic disease may facilitate novel inquiries into lesion localization and therapeutics. It is possible that adrenergic blockade may diminish or abrogate end-organ dysfunction in TBI and SAH.
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To describe the management principles that have not been verified or tested but nonetheless successfully guide the logic of everyday practice at the bedside. ⋯ The practitioner of intensive care often has no choice but to make difficult decisions and to select a course of treatment that remains unguided by specific, scenario-specific evidence from observational studies and clinical trials. Experience gathered over many prior encounters combined with solid physiologic understanding helps to develop guiding principles and unproven rules of management that serve well in confronting complex, ever changing problems of acute illness. Although some element of trial and error is unavoidable, careful monitoring, short loop feedback, and mid-course corrections render many logic-driven and experience-driven decisions relatively safe to implement and often effective in an uncertain, high-stakes environment.
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Curr Opin Crit Care · Feb 2012
ReviewExtracorporeal membrane oxygenation for respiratory failure in adults.
This article reviews case series and trials that evaluated extracorporeal membrane oxygenation (ECMO) for respiratory failure and describes patient and circuit management in the modern era of ECMO support. ⋯ The latest generation of ECMO systems is more biocompatible, better performing and longer lasting. Although recent studies suggested that veno-venous ECMO might improve the outcomes of patients with ARDS, indications for ECMO use remain uncertain. Future trials of ECMO for severe ARDS should strictly control for standard-of-care mechanical ventilation strategies in the control group and early transportation on ECMO for patients in the intervention arm.