Current opinion in critical care
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Although longstanding practice in trauma care has been to provide immediate, aggressive intravenous fluid resuscitation to injured patients with presumed internal hemorrhage, recent experimental and clinical data suggest a more discriminating approach that first considers concurrent head injury, hemodynamic stability, and the presence of potentially uncontrollable hemorrhage (e.g., deep truncal injury) versus a controllable source (e.g., distal extremity wound). ⋯ Future research efforts in trauma should focus on the timing and rate of infusions as well as the concept of infusing alternative intravenous resuscitative fluids such as hemoglobin-based oxygen carriers (HBOCs) and the use of hemostatic agents and special blood products.
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To examine the role of fluid therapy in the pathogenesis of severe sepsis and septic shock. The type, composition, titration, management strategies and complications of fluid administration will be examined in respect to outcomes. ⋯ Although this pathogenesis is evolving, early titrated fluid administration modulates inflammation, improves microvascular perfusion, impacts organ function and outcome. Fluid administration has limited impact on tissue perfusion during the later stages of sepsis and excess fluid is deleterious to outcome. The type of fluid solution does not seem to influence these observations.
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In surgical patients, outcome is strictly dependent on the occurrence of postoperative complications, and a postoperative failing kidney has a significant independent effect on outcome. Acute kidney injury (AKI) occurs in 1% of noncardiac surgical patients and is commonly associated with more serious complications. It is important to prevent AKI wherever possible. ⋯ Adopting adequate nephroprotective strategies is favored by knowing the moment of the actual insult to the kidney. Nevertheless, in the literature too many areas of uncertainty still exist due to the lack of renal risk stratification, of adequately powered studies, of uniform AKI definition, and of appropriate sample composition. The only recommendation for renal protection still consists in maintaining an optimal blood volume and an adequate cardiac output.
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This review aims to describe recent research on perioperative microvascular alterations, with an emphasis on direct visualization of the human microcirculation. ⋯ Recent research has elucidated the incidence of perioperative microvascular alterations, as well as its association with prognosis. Future research should further unravel the fascinating and complex interplay between the microcirculation and perioperative interventions.
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Significant attention has been recently focused on both maintenance fluid and resuscitation fluid use in critical care. Accordingly, a focused review of the properties of crystalloid and colloid fluids, their expected benefits, and potential deleterious side effects is appropriate and timely. ⋯ This focused review further enables the clinician to appropriately investigate, modify, and optimize bedside clinical care related to fluid and acid-base management.