Critical care : the official journal of the Critical Care Forum
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Comment
Genetic epidemiology of acute lung injury: choosing the right candidate genes is the first step.
In an innovative scientific review in this issue, Grigoryev and colleagues report a method for choosing candidate genes for acute lung injury (ALI) based on gene expression data derived from multiple animal models of mechanical ventilation and shear stress. The authors conclude there are five key biologic processes that warrant further investigation: inflammatory and immune responses, cell proliferation, chemotaxis, and blood coagulation. This review represents an important first step toward studying the genetic epidemiology of ventilator-induced lung injury and ALI. The application of these findings to future human studies of the genetic influence on ALI risks and outcomes is discussed here.
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Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. ⋯ Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.
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This review focuses on mechanical ventilation strategies that allow unsupported spontaneous breathing activity in any phase of the ventilatory cycle. By allowing patients with the acute respiratory distress syndrome to breathe spontaneously, one can expect improvements in gas exchange and systemic blood flow, based on findings from both experimental and clinical trials. In addition, by increasing end-expiratory lung volume, as occurs when using biphasic positive airway pressure or airway pressure release ventilation, recruitment of collapsed or consolidated lung is likely to occur, especially in juxtadiaphragmatic lung legions. ⋯ Recent investigations have questioned the utility of sedation, muscle paralysis and mechanical control of ventilation. Furthermore, evidence exists that lowering sedation levels will decrease the duration of mechanical ventilatory support, length of stay in the intensive care unit, and overall costs of hospitalization. Based on currently available data, we suggest considering the use of techniques of mechanical ventilatory support that maintain, rather than suppress, spontaneous ventilatory effort, especially in patients with severe pulmonary dysfunction.
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For many patients optimal perioperative care may require little or no additional medical management beyond that given by the anaesthetist and surgeon. However, the continued existence of a group of surgical patients at high risk for morbidity and mortality indicates an ongoing need to identify such patients and deliver optimal care throughout the perioperative period. A group of patients exists in whom the risk for death and serious complications after major surgery is in excess of 20%. ⋯ A number of studies have shown that the use of goal-directed haemodynamic therapy during the perioperative period can result in large reductions in morbidity and mortality. Some patients may also benefit from perioperative beta blockade, which in selected patients has also been shown to result in significant mortality reductions. In this review a pragmatic approach to perioperative management is described, giving guidance on the identification of the high-risk patient and on the use of goal-directed haemodynamic therapy and beta blockade.
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There has been renewed interest in quantifying acid-base disorders in the intensive care unit. One of the methods that has become increasingly used to calculate acid-base balance is the Stewart model. This model is briefly discussed in terms of its origin, its relationship to other methods such as the base excess approach, and the information it provides for the assessment and treatment of acid-base disorders in critically ill patients.