British medical bulletin
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Sedation is a process of soothing. The concept of the ideal level of sedation is controversial and has changed over the last decade. ⋯ This change in attitude has been brought about by sophisticated modes of ventilation allowing the ventilator to synchronize with the patient's own breathing pattern. In addition, the increasingly recognised adverse effects of over-sedation have contributed to the reduction in the depth of sedation.
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British medical bulletin · Jan 1999
ReviewVentilatory support in the acute respiratory distress syndrome.
Ventilatory support in the acute respiratory distress syndrome (ARDS) has undergone considerable transformation in the 1990s. Current approaches include lung protective techniques which, while attempting to recruit and maintain lung volume, limit the shear stresses associated with ventilation by avoiding both alveolar overdistension and cyclical end-expiratory collapse. ⋯ Assessment of the inspiratory volume-pressure (V-P) curve provides information which can direct ventilator settings. Recent information from clinical trials has provided new insights into appropriate ventilatory modification and set the foundation for future clinical investigations.
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The majority of patients with polytrauma seen in the UK are victims of blunt injury. The trauma reception team approach, using a predetermined plan for initial assessment and urgent resuscitation, can improve outcome. It is important, therefore, that each member of the team is familiar with both their own role and that of their colleagues. ⋯ Accurate assessment of shock in the victim of trauma is difficult, as the simple clinical indicators are not ideal. Some of the techniques available for advanced assessment of tissue perfusion are discussed in detail. The management of polytrauma provides a considerable clinical challenge, and this chapter emphasises the importance of a team approach.
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British medical bulletin · Jan 1999
ReviewNon-ventilatory treatment of acute hypoxic respiratory failure.
Severe acute hypoxic respiratory failure is uncommon but often fatal. Standard treatment involves high inspired oxygen concentrations, mechanical ventilation and positive end-expiratory pressure. Many other interventions have been used in parallel with conventional treatment or as rescue therapy when it fails, including extracorporeal gas exchange, prone positioning, inhaled vasodilators, exogenous surfactants and drugs which modify the inflammatory process. ⋯ Randomised controlled trials are, therefore, needed to assess the effects of these treatments on mortality. In such trials, extracorporeal oxygenation and extracorporeal carbon dioxide elimination, surfactant, early methylprednisolone, and prostaglandin E1 offer no survival advantage over conventional therapy. Prophylactic ketoconazole and pentoxifylline appear to improve mortality in small studies in surgical and oncology patients respectively, and methylprednisolone improves mortality and morbidity in unresolving disease.
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The gastrointestinal tract is an organ of digestion and absorption which is metabolically active and has specific nutrient requirements. In health, it has an additional function as a major barrier, protecting the body from harmful intraluminal pathogens and large antigenic molecules. ⋯ Therapeutic strategies for such patients in the intensive care unit aim to support general immune function and maintain the structure and function of the gastrointestinal tract. For these therapies to be successful, the underlying septic or necrotic focus must be ablated using appropriate surgical or other invasive techniques.