Current opinion in critical care
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Neuroemergencies are life-threatening situations in which, whatever the cause, common pathologic phenomena result in secondary brain lesions. The goal of critical care management is to stop these self-aggravating processes as soon as possible. Initial resuscitation is devoted to control of the airway and hemodynamic and hydroelectrolytic stabilization. ⋯ Normoventilation, deep sedation, osmotherapy with mannitol or hypertonic saline solutions, and optimization of mean arterial pressure are the basis of management. A purely pressure-driven approach aimed at controlling cerebral perfusion pressure could be potentially harmful, and associated measurement of blood flow velocity with transcranial Doppler and jugular bulb oxygen saturation monitoring allows an approach to cerebral blood flow and metabolism. Outcome can be improved in dangerous situations such as severe brain injuries, cerebral arteriovenous malformation rupture, status epilepticus, and acute hydrocephalus, provided that emergency management could be applied efficiently.
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With increasing interest in enteral feeding and the role of the gut in the development of infection and multiple organ failure in critically ill patients, the use of enteral feedings enriched with immune-enhancing ingredients is attracting considerable interest. This approach to modulating the immune and inflammatory responses has become known as immunonutrition, and many products are now available for clinical use. ⋯ Two systematic reviews have been published, both with positive results. Nevertheless, as new products become available they should be subjected to controlled clinical trials, especially because several of the mechanisms involved are not yet fully understood.
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The brain is sensitive to changes in substrate delivery. In neurologically critically ill patients (e.g., those with head injury, subarachnoid hemorrhage, or stroke), interruption of this supply causes ischemic brain damage and thus impairs the outcome. To prevent, detect, and treat these ischemic events as soon as possible, the cerebral blood flow is continuously monitored, its coupling or not with the consumption of oxygen and so forth, and the detected derangements of normal physiology. ⋯ Transcranial Doppler ultrasonography is a noninvasive technique with the same purpose but with less clinical relevance. The new neuromonitoring technique, microdialysis, is useful for understanding the mechanisms involved in brain ischemia. However, it is clear that the physician who interprets the measurements given by devices and the clinical data (e.g., temperature, glycemia) is still the cornerstone in the management of neurologically critically ill patients.
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Neurologic complications in intensive care occur as the result of critical illness, intensive care therapies and procedures, or medical or surgical conditions; perioperatively; or because of underlying primary neurologic disease. These complications occur at greater frequency and are often unrecognized because critically ill patients are often intubated, sedated, and/or receiving neuromuscular blocking agents. ⋯ Neurologic complications are associated with increased disability, longer hospital stay, and increased mortality. This review focuses on neurologic complications that are the result of critical illnesses and intensive care management.
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Curr Opin Crit Care · Apr 2001
ReviewDiagnosis of intra-abdominal infection in the critically ill patient.
Intra-abdominal infection continues to pose a significant threat to critically ill patients in the year 2000. A review of the current literature reveals that despite remarkable developments in critical care medicine and extensive study of patients with tertiary peritonitis, the associated mortality rate remains nearly 30%. ⋯ Scoring systems developed to identify those patients at risk for progression to tertiary peritonitis, the more chronic, lethal form of intra-abdominal infection associated with multisystem organ failure, reflect the current emphasis in the literature on the importance of early diagnosis and early intervention. This has led to a renewed interest in conservative, data-dependent surgical management employing radiographic and microbiologic evidence to guide therapy.