British medical bulletin
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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.
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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.
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Appropriate fluid replacement is an essential component of trauma patient resuscitation. Once haemorrhage is controlled, the restoration of normovolaemia is a priority. In the presence of uncontrolled haemorrhage, aggressive fluid resuscitation may be harmful. ⋯ A number of haemoglobin solutions are under development but one of the most promising of these has been withdrawn recently. It is highly likely that at least one of these solutions will eventually become routine therapy for trauma patient resuscitation. In the mean time, contrary to traditional teaching, recent data suggest that a restrictive strategy of red cell transfusion may improve outcome in some critically ill patients.
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Inter-individual variability in drug response is a major clinical problem. Adverse drug reactions (ADRs) are common, are responsible for a number of debilitating side effects following drug therapy and are a significant cause of death. It is now clear that much of the observed variability in drug response has a genetic basis, arising as a result of genetically-determined differences in drug absorption, disposition, metabolism or excretion. ⋯ Individuals at risk of developing ADRs as a result of genetically-determined variation in genes such as CYP2D6 can now be identified using DNA-based tests. A detailed knowledge of the genetic basis of individual drug response is potentially of major clinical and economic importance and could provide the basis for a rational approach to drug prescription. This would have significant benefits for human health.