Minerva anestesiologica
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Mortality and morbidity postcardiac surgery with cardiopulmonary bypass (CPB) remain relative stable over the last decades, while the number of patients with increased comorbidity and more complex cardiac disease increases. Nevertheless, end-organ dysfunction and/or failure remain an issue. Multiple perioperative variables, such as non-optimal oxygen delivery, manipulation of the aorta, hyperlactatemia, type of anesthesia, surgical procedure and myocardial protection can be hold responsible for end-organ failure postcardiac surgery. ⋯ Therefore, therapy should focus on controlling perioperative variables that, in combination with the predisposing factors, will further exacerbate organ dysfunction. In order to achieve this, more emphasis should be given to a patient-specific, goal-directed perfusion approach. This review will mainly focus on the impact of perioperative variables.
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Minerva anestesiologica · Mar 2013
ReviewBrain-lung crosstalk in critical care: how protective mechanical ventilation can affect the brain homeostasis.
The maintenance of brain homeostasis against multiple internal and external challenges occurring during the acute phase of acute brain injury may be influenced by critical care management, especially in its respiratory, hemodynamic and metabolic components. The occurrence of acute lung injury represents the most frequent extracranial complication after brain injury and deserves special attention in daily practice as optimal ventilatory strategy for patients with acute brain and lung injury are potentially in conflict. Protecting the lung while protecting the brain is thus a new target in the modern neurointensive care. This article discusses the essentials of brain-lung crosstalk and focuses on how mechanical ventilation may exert an active role in the process of maintaining or treatening brain homeostasis after acute brain injury, highlighting the following points: 1) the role of inflammation as common pathomechanism of both acute lung and brain injury; 2) the recognition of ventilatory induced lung injury as determinant of systemic inflammation affecting distal organs, included the brain; 3) the possible implication of protective mechanical ventilation strategy on the patient with an acute brain injury as an undiscovered area of research in both experimental and clinical settings.
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Acute respiratory distress syndrome (ARDS) is a common entity in critical care medicine and associated with many diagnoses, including trauma and sepsis, which may lead to multiple organ failure and death. Pathophysiologically, increased capillary permeability is the hallmark of ARDS which is characterized by damage of the capillary endothelium and alveolar epithelium in association with impaired fluid removal from the alveolar space and the accumulation of protein-rich fluid inside the alveoli. The clinical management of patients with ARDS is even more difficult, because in the presence of capillary leakage in the lungs, adequate intravascular volume and cardiac preload are required to maintain organ perfusion. ⋯ The transpulmonary thermo-dye dilution technique has been introduced as an instrument to quantify the fluid in the pulmonary capillary bed, i.e., extravascular lung water (EVLW). This technique has shown to be potentially valuable in the management of critically ill patients and has been further developed to be clinically available nowadays as single transpulmonary thermodilution. The following review deals with the measurement of EVLW and its place in the management of critically ill patients with ARDS.
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Thrombomodulin has a pivotal role in the protein C system that is important in the pathogenesis of sepsis. In sepsis, endothelial cell expression of thrombomodulin is strongly downregulated, causing an impaired activation of protein C that is central in the modulation of coagulation activation and inflammatory processes. ⋯ Several preclinical studies in experimental sepsis models have shown that administration of soluble thrombomodulin is capable of improving the derangement of coagulation, ameliorates inflammatory responses and may restore organ dysfunction. Initial clinical studies in patients with disseminated intravascular coagulation, of whom a significant proportion were patients with sepsis, demonstrate a beneficial effect of recombinant soluble thrombomodulin on restoration of coagulation and improvement of organ failure.
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Minerva anestesiologica · Mar 2013
Comparative StudyValidation of predisposition, infection, response and organ dysfunction score compared with standard severity scores in predicting hospital outcome in septic shock patients.
The aim of this study was to validate and compare the performance of Simplified Acute Physiology Score 3 Predisposition, Infection, Response and Organ failure (SAPS 3 PIRO) score with Acute Physiology and Chronic Health Evaluation (APACHE) II, SAPS II and SAPS 3 scores in predicting hospital outcome in septic shock patients. ⋯ The SAPS 3 PIRO score provided better discrimination than the APACHE II, SAPS II and SAPS 3 but had poor calibration in our septic shock patients. SAPS 3 PIRO could be used regarding risk stratification in septic shock patients, however, this score needed to be adapted and modified with new parameters for improving the performance.