Current opinion in critical care
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Curr Opin Crit Care · Aug 2022
ReviewPoor physical recovery after critical illness: incidence, features, risk factors, pathophysiology, and evidence-based therapies.
To summarize the incidence, features, pathogenesis, risk factors, and evidence-based therapies of prolonged intensive care unit (ICU) acquired weakness (ICU-AW). We aim to provide an updated overview on aspects of poor physical recovery following critical illness. ⋯ Impaired physical recovery is observed frequently among ICU survivors. The pre-ICU health status, demographic, and ICU treatment factors appear to be important determinants for physical convalescence during the post-ICU phase. The pathophysiological mechanisms involved are poorly understood, thereby resulting in exiguous evidence-based treatment strategies to date.
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This review describes considerations preintensive care unit (ICU), within ICU and in the post-ICU period regarding nutrition management and the current state of the literature base informing clinical care. ⋯ Nutrition for the critically ill patient should not be viewed in isolated time periods; what happens before, during and after ICU is likely important to the overall recovery trajectory. It is critical that the impact of nutrition on clinical and functional outcomes across hospitalisation is investigated in specific groups and using interventions in ways that are biologically plausible to impact. Areas that show promise for the future of critical care nutrition include interventions delivered for a longer duration and inclusion of oral nutrition support, individualised nutrition regimes, and use of emerging bedside body composition techniques to identify patients at nutritional risk.
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The modern cardiac intensive care unit (CICU) has evolved into a high-intensity unit that cares for critically ill patients. Despite this transformation, changes to the staffing model and organizational structure in these specialized units have only recently begun to meet these challenges. We describe the most recent evidence which will inform future CICU staffing models. ⋯ Although the preponderance of data suggests improved outcomes with a closed, intensivist staffed CICU model, future multicenter studies are needed to better define the ideal staffing models for the contemporary CICU.
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Curr Opin Crit Care · Aug 2022
ReviewOutcomes in cardiogenic shock: the role of surrogate endpoints.
Early revascularization, invasive hemodynamic profiling, and initiation of temporary mechanical circulatory support (MCS) have all become routine components of cardiogenic shock (CS) management. Despite this evolution in clinical practice, patient selection and timing of treatment initiation remain a significant barrier to achieving sustained improvement in CS outcomes. Recent efforts to standardize CS management, through the development of treatment algorithms, have relied heavily on surrogate endpoints to drive therapeutic decisions. The present review aims to provide an overview of the basis of evidence for those surrogate endpoints commonly employed in clinical trials and CS management algorithms. ⋯ Although further validation is necessary, multiple clinical, hemodynamic, and biochemical markers have demonstrated utility as surrogate endpoints in CS, and will undoubtedly assist physicians in clinical decision-making.
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Curr Opin Crit Care · Aug 2022
ReviewInotrope and vasopressor use in cardiogenic shock: what, when and why?
Despite increasing interest in the management of cardiogenic shock (CS), mortality rates remain unacceptably high. The mainstay of supportive treatment includes vasopressors and inotropes. These medications are recommended in international guidelines and are widely used despite limited evidence supporting safety and efficacy in CS. ⋯ Review of the current literature fails to show significant mortality benefit with any specific vasopressor or inotropic in CS patients. The upcoming DOREMI 2 and levosimendan versus placebo trials will further tackle the question of inotrope necessity in CS. At this time, inotrope selection should be guided by physician experience, availability, cost, and most importantly, individual patients' response to therapy.