Critical care : the official journal of the Critical Care Forum
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Cost is a key concern in fluid management. Relatively few data are available that address the comparative total costs of care between different fluid management regimens in particular clinical indications. Relevant costs of fluid-associated morbidity and mortality, including those incurred after intensive care unit or hospital discharge, also need to be considered in evaluating the cost-benefit ratios of administered fluids. Rigorously designed pharmacoeconomic studies are needed to delineate the costs and benefits of various approaches to fluid management.
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Fluid imbalance can arise due to hypovolemia, normovolemia with maldistribution of fluid, and hypervolemia. Trauma is among the most frequent causes of hypovolemia, with its often profuse attendant blood loss. Another common cause is dehydration, which primarily entails loss of plasma rather than whole blood. ⋯ However, entry of fluid into the lungs may also be facilitated by increased vascular permeability in certain pathologic conditions, especially sepsis and endotoxemia, even in the absence of substantially rising hydrostatic pressure. Another condition associated with elevated vascular permeability is systemic capillary leak syndrome. The chief goal of fluid management, based upon current understanding of the pathophysiology of fluid imbalance, should be to ensure adequate oxygen delivery by optimizing blood oxygenation, perfusion pressure, and circulating volume.
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Comparative Study
Emergency airway management by intensive care unit nurses with the intubating laryngeal mask airway and the laryngeal tube.
When using the laryngeal tube and the intubating laryngeal mask airway (ILMA), the medium-size (maximum volume 1100 ml) versus adult (maximum volume 1500 ml) self-inflating bags resulted in significantly lower lung tidal volumes. No gastric inflation occurred when using both devices with either ventilation bag. The newly developed medium-size self-inflating bag may be an option to further reduce the risk of gastric inflation while maintaining sufficient lung ventilation. Both the ILMA and laryngeal tube proved to be valid alternatives for emergency airway management in the experimental model used.
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Physiological background concerning mechanics of the respiratory system, techniques of measurement and clinical implications of pressure-volume curve measurement in mechanically ventilated patients are discussed in the present review. The significance of lower and upper inflection points, the assessment of positive end-expiratory pressure (PEEP)-induced alveolar recruitment and overdistension and rationale for optimizing ventilatory settings in patients with acute lung injury are presented. Evidence suggests that the continuous flow method is a simple and reliable technique for measuring pressure-volume curves at the bedside. In patients with acute respiratory failure, determination of lower and upper inflection points and measurement of respiratory compliance should become a part of the routine assessment of lung injury severity, allowing a bedside monitoring of the evolution of the lung disease and an optimization of mechanical ventilation.
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Clinical Trial
Balloon laryngoscopy reduces head extension and blade leverage in patients with potential cervical spine injury.
Head extension and excessive laryngoscope blade levering motion (LBLM) are undesirable during airway management of trauma patients. We hypothesized that laryngoscopy with a modified blade facilitating glottic exposure by balloon inflation would reduce head extension and LBLM. ⋯ Balloon laryngoscopy reduces head extension and LBLM under simulated cervical spine precautions.