Current opinion in critical care
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This review discusses the macrocirculatory and microcirculatory aspects of renal perfusion, as well as novel methods by which to measure renal blood flow. Finally, therapeutic options are briefly discussed, including renal-specific microcirculatory effects. ⋯ The optimal mean arterial pressure (MAP) needed for preservation of renal function has been debated but is most likely a MAP of 60-80 mmHg. In addition, attention should be paid to renal outflow pressure, typically central venous pressure. Heterogeneity in microcirculation can exist and may be mitigated through appropriate use of vasopressors with unique microcirculatory effects. Excessive catecholamines have been shown to be harmful and should be avoided. Both angiotensin II and vasopressin may improve glomerular flow through a number of mechanisms. Macrocirculatory and microcirculatory blood flow can be measured through a number of bedside ultrasound modalities, sublingual microscopy and urinary oxygen measurement, SUMMARY: Acute kidney injury (AKI) is a common manifestation of organ failure in shock, and avoidance of hemodynamic instability can mitigate this risk. Measurement of renal haemodynamics is not routinely performed but may help to guide therapeutic goals. A thorough understanding of pathophysiology, measurement techniques and therapeutic options may allow for a personalized approach to blood pressure management in patients with septic shock and may ultimately mitigate AKI.
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The aim of this study was to describe important features of clinical examination for the surgical abdomen, relevant investigations, and acute management of common surgical problems in the critically ill. ⋯ Physical examination remains an integral part of the evaluation of the surgical abdomen. Interpreting laboratory investigations in context and appropriate imaging improves diagnostic ability; intravenous contrast should not be withheld for critically ill patients with acute kidney injury. Surgical intervention should not be delayed for the patient in extremis. The intensivist and surgeon should remain in close communication to optimize care.
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Curr Opin Crit Care · Dec 2020
ReviewRefractory cardiac arrest: where extracorporeal cardiopulmonary resuscitation fits.
Extracorporeal cardiopulmonary resuscitation (ECPR) is a powerful technique increasingly used to care for patients with refractory cardiac arrest. This review will detail where ECPR fits in the current care of cardiac arrest patients, including the key aspects of ECPR deployment and patient selection shown to maximize its benefit. ⋯ ECPR is a system of resuscitation care that must be optimized at every level to successfully treat patients with refractory cardiac arrest.
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Acute pain management in the surgical ICU is imperative. Effective acute pain management hastens a patient's return to normal function and avoid the negative sequelae of untreated acute pain. Traditionally, opioids have been the mainstay of acute pain management strategies in the surgical ICU, but alternative medications and management strategies are increasingly being utilized. ⋯ Even after major elective surgery or significant injury, opioid-minimizing MMPRs can effectively treat acute pain.
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Curr Opin Crit Care · Dec 2020
ReviewPoint-of-care cardiac ultrasound during cardiac arrest: a reliable tool for termination of resuscitation?
Point-of-care ultrasound (POCUS) is commonly used during cardiac arrest to screen for potential causes and to inform termination of resuscitation. However, unique biases and limitations in diagnostic and prognostic test accuracy studies lead to potential for misinterpretation. The present review highlights recent evidence regarding POCUS in cardiac arrest, guides the incorporation of POCUS into clinical management, and outlines how to improve the certainty of evidence. ⋯ POCUS findings might indicate a particular diagnosis or encourage the continuation of resuscitation, but absence of the same is not sufficient in isolation to exclude a particular diagnosis or cease resuscitation. Until the evidence to support POCUS during cardiac arrest is more certain, it is best characterized as a diagnostic and prognostic adjunct.