Current opinion in critical care
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Curr Opin Crit Care · Dec 2004
ReviewLipids in the nutritional support of the critically ill patients.
This review reports recent findings on lipid use in artificial nutrition in patients with acute respiratory failure or severe sepsis or undergoing major surgery. It examines current knowledge of fatty acid safety, biologic effects, and the impact on patients' morbidity and mortality. The newly emerging area of genotypic influence and timing of immunonutrition is also discussed. ⋯ Overall, lipids, in particular n-3 fatty acids, emerge as powerful nutrients with pharmacologic properties potentially improving prognosis in critically ill patients. However, heterogeneity in study design makes the interpretation of available studies difficult. Consequently, larger prospective, randomized, double-blind trials with comparable methodologies are necessary for detailed evaluation of the pharmacologic impact of lipids. In addition, a better knowledge of the influence of genotypic variation and postinjury inflammatory/immune temporal patterns may improve our current therapeutic use of various fatty acids.
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The management of the traumatically injured patient has evolved during the past half century despite continually high morbidity and mortality rates. The management of the trauma victim requires timely intervention and damage control in an attempt to maintain normal hemodynamic parameters and adequate systemic perfusion. There is a fine balance between oxygen delivery and consumption, and when this is perturbed, oxygen debt may ensue. The presence of ongoing oxygen debt is rather deleterious, resulting in an inflammatory cascade that can lead to multisystem organ dysfunction. The rapid identification and restoration of oxygen debt are central to the resuscitation of the critically ill patient, be it the result of sepsis or trauma. ⋯ This review addresses (1) resuscitation end points to optimize cardiac function, (2) resuscitation end points to assess the microcirculation, (3) recent developments in the management of hypotensive hemorrhagic shock, and (4) the translation of early goal-directed therapy from septic shock to use in trauma. Past findings are reflected on and direction for future investigation and clinical practice based on recent clinical advances is provided.
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Curr Opin Crit Care · Dec 2004
ReviewThe relative adrenal insufficiency syndrome revisited: which patients will benefit from low-dose steroids?
Several clinical studies have given rise to optimism about low-dose steroid treatment in patients with sepsis. It reduces time to shock reversal and may even have a positive effect on mortality. The pathophysiology of the relative adrenal insufficiency syndrome has not yet been determined, and the usefulness of basal and stimulated cortisol levels in diagnosing this syndrome is still uncertain. This review will examine recent evidence to elucidate these questions. ⋯ It has been shown that low-dose corticosteroid administration to catecholamine-dependent patients in septic shock results in shock reversal. There seems to be a relative shortage of cortisol, because low-dose hydrocortisone administration resulting in cortisol levels as much as four times the already increased levels results in shock reversal. Strong evidence for a positive effect on mortality is still lacking, perhaps because of the relatively low number of patients investigated. A very important topic in interpreting studies is that total (free plus protein-bound) cortisol has been measured. Future studies should also measure free cortisol concentrations, which could add to our knowledge of the pathophysiology and treatment of the relative adrenal insufficiency syndrome. On the basis of current knowledge, there is no evidence to support a treatment strategy based on a random or stimulated cortisol level. At the moment, rapid hemodynamic improvement of catecholamine-dependent patients after the administration of low-dose corticosteroids still seems the best available clue to diagnosis.
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Recent studies demonstrating that mild therapeutic hypothermia can improve the outcome from several ischemic and traumatic insults have led to increased interest in the potential benefits of hypothermia after injury. Previous clinical studies, however, have suggested that hypothermia is detrimental to trauma patients. This most likely is a result of differences in the physiologic effects between uncontrolled exposure hypothermia and controlled therapeutic hypothermia. The laboratory and clinical data regarding traumatic hemorrhagic shock and hypothermia are presented, as well as a novel approach to the patient with exsanguinating trauma: suspended animation. Therapeutic hypothermia for traumatic brain injury is discussed. ⋯ The dichotomy between laboratory findings that show a benefit of hypothermia and clinical findings that suggest detrimental effects remains difficult to explain. For now, preventing hypothermia remains prudent. Suspended animation seems promising for patients with exsanguinating trauma. Clinical trials of mild hypothermia during hemorrhagic shock and suspended animation for exsanguination are indicated. Clinical trials of hypothermia for traumatic brain injury are in progress.
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Curr Opin Crit Care · Dec 2004
ReviewDefining the standard of care in randomized controlled trials of titrated therapies.
To discuss the appropriate standard of care in randomized controlled trials of titrated therapies in critically ill patients. ⋯ The incorporation of current practice patterns into randomized controlled trials of titrated therapies is essential for producing generalizable results and safeguarding patients.