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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Intravenous fluids are widely administered in the ICU with the intention of preventing or ameliorating acute kidney injury (AKI). This review focuses on recent studies examining fluid administration and renal function in critical illness to critically examine conventional justifications for fluid administration. ⋯ Adequate volume resuscitation remains a cornerstone to the emergent treatment of critical illness. However, continued fluid administration and positive fluid balances have not been shown to improve renal outcomes and may worsen overall prognosis in AKI. Concerns about renal dysfunction should not deter clinicians from adopting more restrictive approaches to fluid administration.
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To discuss the perioperative monitoring tools and targets for haemodynamic optimization and to assess the influence of goal-directed therapy (GDT) on organ function, complications and outcome in different categories of surgical patients. ⋯ GDT provides a number of benefits in major surgery. Based on adequate monitoring, the goal-directed algorithms facilitate early detection of pathophysiological changes and influence the perioperative haemodynamic therapy that can improve the clinical outcome. The perioperative GDT should be early, adequate and individualized for every patient.
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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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Currently available crystalloids were designed over a century ago for dehydration and not for the treatment of hemorrhagic shock. Information regarding fluids used for resuscitation has grown and thus resuscitation has changed radically in the last two decades. Artificial fluids such as crystalloids and other solutions typically used for resuscitation are now recognized to be inflammatory when infused at high volumes to replace blood. ⋯ Seemingly innocuous fluids have a dose effect and can be detrimental. Crystalloids can create inflammation when used at high volumes and may be the reason for the sequelae seen after massive resuscitation. This has led to the recognition that whole blood is extremely complex and does much more than carry oxygen. Resuscitation has changed recently with the adoption of damage control resuscitation which is the practice of allowing permissive hypotension, minimizing crystalloids and early aggressive use of blood products. This has led to a decrease in multiple organ dysfunction syndrome and acute respiratory distress syndrome.