Presse Med
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Sedation is a technique widely used in intensive care unit patients. The main objective is to ensure a proper level of analgesia and the best physical and psychical comfort possible. ⋯ Drugs used for sedation are combinations of opioids (fentanyl or sufentanil), benzodiazepines (midazolam) and hypnotic drugs such as propofol. In combination with the pharmacological approach, a psychological approach is of greater interest in conscious patients.
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It is currently accepted that the consequences of sepsis are highly dependent on host response, largely controlled by the inflammatory reaction. Inflammation in response to infection is a continuous process from simple local reaction which regresses rapidly to systemic reaction leading to multiple organ failure. Septic shock is a specific aspect of severe infection dominated by persistent hypotension despite vascular filling. ⋯ Much progress has been made in the methodology in large clinical trials. It is clear that a posteriori analysis of subgroups must be abandoned and that research must continue in this high-mortality pathology. The upcoming clinical trials will benefit from acquired experience.
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Artificial ventilation plays a key role in the treatment of acute respiratory distress syndrome (ARDS). Initially, the goal is to normalize gas exchange compromised by the lung disease. Positive pressure ventilation can however aggravate prior lesions of the pulmonary parenchyma, at least in areas of the lung accessible to ventilation. ⋯ In the most severe cases, extra-corporal gas exchange systems have shown their efficacy for patients whose lungs cannot be ventilated. Thus ventilation should be carefully adapted to each patient based on the severity of the ARDS and its clinical course. We present a practical protocol based on a hierarchy rationale for each ventilation mode and indicate the explorations required to adapt each mode to a specific patient.
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Nosocomial pneumonia is associated with substantial morbidity and mortality. Patients treated with mechanical ventilation have the highest risk for developing this intensive care unit acquired infection. Gram-negative bacilli are the predominant organisms responsible for pneumonia in this setting. ⋯ Nosocomial pneumonia is difficult to diagnose clinically in ventilated patients because fever, lung infiltrate on chest X-ray, leukocytosis are frequent in severely ill patients under mechanical ventilation whatever lung infection is present or not and because lower respiratory tract of such patients is colonized by potentially pathogenic bacteria independently of the presence of true lung infection; thus, different diagnostic strategies are proposed. Our personal bias is that using bronchoscopic techniques to obtain bronchoalveolar lavage and protected-brush specimens permits us to devise a therapeutic strategy that is superior to one based only on clinical evaluation. Measures for prevention of nosocomial infection are essential to decrease the incidence of nosocomial pneumonia and the emergence of multiresistant pathogens.
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Experimental and clinical evidence has led to a revision of conventional techniques used for mechanical ventilation in the treatment of respiratory failure due to severe asthma and acute respiratory distress syndrome. A common feature in these two clinical situations is the heterogeneous nature of the lesions, causing mechanical alterations which vary from one region to another. Thus the tidal volume is not equally distributed throughout the lungs and can lead to overdistension in some regions or functional exclusion in others. ⋯ Controlled hypoventilation-or permissive hypercapnia-is a new approach aimed at preventing complications by supplying adequate oxygen while accepting or provoking a certain degree of hypercapnia by alveolar hypoventilation. The technique is based on restricting tidal volume and respiratory rate as long as is necessary to recover more favorable mechanical conditions. Results obtained with this method have been convincing for the treatment of decompensated asthma but preliminary data obtained in acute respiratory distress syndrome remain to be validated.