Current opinion in critical care
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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 term permissive hypercapnia defines a ventilatory strategy for acute respiratory failure in which the lungs are ventilated with a low inspiratory volume and pressure. The aim of permissive hypercapnia is to minimize lung damage during mechanical ventilation; its limitation is the resulting hypoventilation and carbon dioxide (CO2) retention. In this article we discuss the rationale, physiologic implications, and implementation of permissive hypercapnia. We then review recent clinical studies that tested the effect of various approaches to permissive hypercapnia on the outcome of patients with acute respiratory failure.
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Low tidal volume (4-8 mL/kg) during mechanical ventilation in adult respiratory distress syndrome is the standard of care. However, there are questions regarding the approach to setting positive end-expiratory pressure and the use of recruitment maneuvers in patients with adult respiratory distress syndrome. ⋯ Prone positioning has also become established a method of recruiting lung and improving PaO2 in those with adult respiratory distress syndrome. The data suggest that recruitment maneuvers in the prone position are most effective in improving PaO2 and that the positive end-expiratory pressure level required to sustain the improved PaO2 is less in the prone position than in the supine position.
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The technique or approach of damage control surgery in trauma is not new; packing liver injuries has been an accepted treatment strategy for some time. What is new is the realization that an abbreviated laparotomy, or completion of only the essential portions of the operation, is often the best treatment for the patient as a whole. Recent developments include strategies in the operating room and the intensive care unit to manage patients undergoing trauma laparatomy, including prevention of hypothermia, methods to accurately assess resuscitation status with right ventricular catheters and measurements of end-organ perfusion, and recognition of abdominal compartment syndrome, with emphasis on prevention.