Critical care : the official journal of the Critical Care Forum
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Changes in hemodynamic monitoring over the past 10 years have followed two paths. First, there has been a progressive decrease in invasive monitoring, most notably a reduction in the use of the pulmonary artery catheter because of a presumed lack of efficacy in its use in the management of critically ill patients, with an increased use of less invasive monitoring requiring only central venous and arterial catheterization to derive the same data. Second, numerous clinical trials have documented improved outcome and decreased costs when early goal-directed protocolized therapies are used in appropriate patient populations, such as patients with septic shock presenting to Emergency Departments and high-risk surgical patients before surgery (pre-optimization) and immediately after surgery (post-optimization). Novel monitoring will be driven more by its role in improving outcomes than in the technical abilities of the manufacturers.
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As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. ⋯ Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.
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The use of controlled mechanical ventilation (CMV) in patients who experience weaning failure after a spontaneous breathing trial or after extubation is a strategy based on the premise that respiratory muscle fatigue (requiring rest to recover) is the cause of weaning failure. Recent evidence, however, does not support the existence of low frequency fatigue (the type of fatigue that is long-lasting) in patients who fail to wean despite the excessive respiratory muscle load. This is because physicians have adopted criteria for the definition of spontaneous breathing trial failure and thus termination of unassisted breathing, which lead them to put patients back on the ventilator before the development of low frequency respiratory muscle fatigue. ⋯ The mechanisms of VIDD are not fully elucidated, but include muscle atrophy, oxidative stress and structural injury. Partial modes of ventilatory support should be used whenever possible, since these modes attenuate the deleterious effects of mechanical ventilation on respiratory muscles. When CMV is used, concurrent administration of antioxidants (which decrease oxidative stress and thus attenuate VIDD) seems justified, since antioxidants may be beneficial (and are certainly not harmful) in critical care patients.
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Despite studies clearly demonstrating significant benefit from increasing oxygen delivery in the peri-operative period in high risk surgical patients, the technique has not been widely accepted. This is due to a variety of reasons, including non-availability of beds, particularly in the pre-operative period, and the requirement of inserting a pulmonary artery catheter. There are now data that suggest that increasing oxygen delivery post-operatively using a nurse-led protocol based on pulse contour analysis leads to a major improvement in outcome with reduction in infection rate and length of hospital stay.
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An increasing body of evidence from laboratory and clinical studies suggests that vasopressin may represent a promising alternative vasopressor for use during cardiac arrest and resuscitation. Current guidelines for cardiopulmonary resuscitation recommend the use of adrenaline (epinephrine), with vasopressin considered only as a secondary option because of limited clinical data. ⋯ The greater 24-hour survival rate in vasopressin-treated patients suggests that consideration of combined vasopressin and adrenaline is warranted for the treatment of refractory ventricular fibrillation or pulseless ventricular tachycardia. This is especially the case for those patients with myocardial infarction, for whom vasopressin treatment is also associated with a higher hospital discharge rate.