Minerva anestesiologica
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Resuscitation from circulatory and respiratory failure represent mainstays of emergency and critical care management. Importantly, no amount of resuscitative effort will be successful in promoting patient survival if the primary reason for the shock state is not identified and treated, independent of resuscitation. Having said that, aggressive resuscitation to normal functional levels of blood flow and organ perfusion pressure during the first 6 hours following the development of shock improves outcome both in patients with trauma or sepsis. ⋯ Clear initial targets for resuscitation are a mean arterial pressure > 60 mm Hg, and a cardiac output and O(2) transport to the body adequate enough to prevent tissue hypoperfusion. The level of cardiac output needed to achieve this goal is probably different among subjects and within subjects over time. Indirect signposts of adequate perfusion, such as venous O2 saturation, mentation, urine output and local measures of tissue blood flow are useful in monitoring this response.
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After a period of initial enthusiasm, several trials cast serious doubts on the usefulness of corticosteroids for the treatment of patients with severe sepsis. Short course with high doses of steroides should not be given in patients with severe sepsis. The attention is now addressed to low-dose of corticosteroides. ⋯ Low doses of hydrocortisone has been shown to reproduce the normal effects of cortisol: anti-inflammatory properties and an increased in the vasoconstrictor response to cathecolamines. There is no concordance in literature about the role of replacement therapy with hydrocortisone on survival in patients with septic shock. Waiting for the results of the European confirmatory phase III trial, and based on the results of the French phase III trial, one may recommended to treat septic shock patients who have a cortisol increment after ACTH of less than 9 micro g/dl with 50 mg of hydrocortisone every 6 hours for seven days combined with 50 micro g of fludrocortisone once a day for seven days.
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During the cyclic changes in intrathoracic pressure, changes in stroke volume characterize the state at which both ventricles are preload dependant. Determining stoke volume variations may thus help to predict fluid responsiveness in mechanically ventilated patients. Selected review of the articles having investigated the stroke volume variations in critically ill patients. ⋯ However, these index are sensitive to tidal volume. During mechanical ventilation with low tidal volumes, the ventilatory-induced changes in preload may be too small to generate changes in stroke volume, even in preload dependant patients. Stroke volume variations can be useful to detect fluid responsiveness in mechanically ventilated patients.
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Fever is one of the most aspecific marker of disease, it is considered a protective host defense response and it is the result of a reset of the hypothalamic thermostat. Fever is a common problem in ICU patients and it is associated with infective and non infective causes. Fever presenting in ICU should always be a source of concern and the first and immediate priority is to determine its clinical significance.
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ICU nurses hold an important role in the management of septic patients underlining with their ability to recognize SIRS that is the first step in the proinflammatory and procoagulant cascade following an infection. Early and timely approach to organ dysfunction can indeed modify the damages due to hypoperfusion. The ability to recognize organ dysfunction using different monitoring devices available should be part of the nursing attitudes.