British medical bulletin
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British medical bulletin · Jan 1999
ReviewThe role of the endothelium in modulating vascular control in sepsis and related conditions.
The majority of deaths amongst critically ill patients requiring intensive care are attributable to sepsis and its sequelae: septic shock, the systemic inflammatory response syndrome (SIRS) and the acute respiratory distress syndrome (ARDS). Patients within the ICU who develop these conditions and fail to survive succumb to multiple organ dysfunction syndrome (MODS). ARDS is considered to be the pulmonary component of MODS and is characterized by pulmonary hypertension, often in the setting of systemic hypotension. ⋯ Pro-thrombotic, pro-inflammatory and vasoactive mediators are released including nitric oxide (NO), endothelins (ETs) and products of cyclo-oxygenase metabolism. It is probably the disordered production of these mediators in vascular beds that results in MODS. This review highlights recent research in this area with particular emphasis on possible therapeutic options.
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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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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.
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Optimising the results of fracture treatment requires a holistic view of both patients and treatment. The nature of the patient determines the priority targets for outcome, which differ widely between the elderly and the young, and between the victims of high and low energy trauma. The efficacy of treatment depends on the overall process of care and rehabilitation as well as the strategy adopted to achieve bone healing. ⋯ The development of systems for early fracture stabilisation has been an advance. However, narrow thinking centred only on the restoration of mechanical integrity leads to poor strategy--the aim is to optimise the environment for bone healing. Future advances may come from the adjuvant use of molecular stimuli to bone regeneration.