Current opinion in critical care
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Small bowel transplantation has become the treatment of choice for patients with chronic gut failure whose illness cannot be maintained on home parenteral nutrition. Outcomes have improved as a result of refinements in patient selection, surgical techniques, and the prevention, diagnosis, and treatment of graft rejection. Early listing is important because of the shortage of organ donors. ⋯ Sepsis rates are also higher for patients who have had small bowel transplantation than for those who have received other organs because of bacterial translocation from the gut secondary to preservation injury and graft rejection. Graft and patient survival rates after small bowel transplantation are comparable to rates after lung transplantation. Successful transplant recipients resume unrestricted oral diets.
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Curr Opin Crit Care · Feb 2001
ReviewClinical relevance of monitoring respiratory mechanics in the ventilator-supported patient: an update (1995-2000).
The introduction of mechanical ventilation in the intensive care unit environment had the merit of putting a potent life-saving tool in the physicians' hands in a number of situations; however, like most sophisticated technologies, it can cause severe side effects and eventually increase mortality if improperly applied. Assessment of respiratory mechanics serves as an aid in understanding the patient-ventilator interactions with the aim to obtain a better performance of the existing ventilator modalities. ⋯ Thanks to it, new ventilatory strategies and modalities have been developed. Finally, on-line monitoring of respiratory mechanics parameters is going to be more than a future perspective.
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The basic mechanism of patient-ventilator asynchrony is the mismatching between neural inspiratory and mechanical inspiratory time. Alterations in respiratory drive, timing, respiratory muscle pressure, and respiratory system mechanics influence the interaction between the patient and the ventilator. None of the currently available partial ventilatory support modes are exempt from problems with patient-ventilator asynchrony. ⋯ The set inspiratory flow rate in the post-trigger phase for assist-control volume cycled ventilation affects patient-ventilator asynchrony. Likewise, the initial pressure rise time, the pressure support level, and the flow-threshold for cycling off inspiration for pressure support ventilation are important factors affecting patient-ventilator asynchrony. Current investigations have advanced our understanding in this area; however, its prevalence and the extent to which patient-ventilator asynchrony affect the duration of mechanical ventilation remain unclear.
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Neutrophils are considered to be central to the pathogenesis of most forms of acute lung injury (ALI). For the sake of clarity, neutrophil involvement in ALI can be conceptualized as consisting of sequential stages, beginning with their sequestration in the pulmonary microvasculature, followed by adhesion and activation, and culminating in the production of a microbicidal or "effector" response, such as the generation of reactive oxygen species or release of proteolytic enzymes. Great strides have been made in elucidating these various stages of neutrophil involvement. ⋯ We believe that the inflammatory response in ALI may initially be adaptive, such as the pivotal role played by neutrophils in a bacterial or fungal infection. Ultimately, it is the persistence or the dysregulation of neutrophil activation that may lead to ALI. An increased understanding of how neutrophils function will facilitate the design of therapeutic strategies that retain the beneficial aspects of the inflammatory response, while avoiding unnecessary tissue damage.
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Subjective and objective measures of sleep quality indicate that the sleep of patients in the intensive care unit (ICU) is extraordinarily disturbed. Several studies spanning the past two decades have demonstrated that critically ill patients exhibit reduced sleep efficiency, reduced restorative sleep, and frequent arousals and awakenings. A number of potential sleep disrupters exist in the ICU environment, with noise being the predominant focus of investigation. ⋯ Medications, light, and frequent care-related activities can also interfere with a patient's ability to obtain good-quality sleep. Sleep disruption can have significant adverse consequences for critically ill patients, such as immune system compromise and respiratory abnormalities. Although several questions remain unanswered, including the impact of sleep disruption on the clinical outcome of patients in the ICU, there is a growing interest in developing new strategies to improve sleep quality.