Hospital practice (1995)
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Hospital practice (1995) · Apr 2012
ReviewThe diabetes paradox: diabetes is not independently associated with mortality in critically ill patients.
Intensive monitoring of blood glucose levels and treatment of hyperglycemia in critically ill patients has become a standard of care over the past decade. Although diabetes is associated with a large burden of illness in outpatients, the "diabetes paradox" suggests that in patients admitted to intensive care units, the presence of diabetes as a comorbidity is not independently associated with increased risk of mortality. This review article 1) describes prospective trial and observational cohort literature addressing this issue, 2) addresses the potential mechanisms underlying the diabetes paradox, and 3) discusses implications for patient care and future research.
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Hospital practice (1995) · Apr 2012
ReviewEvaluating the adequacy of fluid resuscitation in patients with septic shock: controversies and future directions.
Fluid resuscitation is a cornerstone in the treatment of severe sepsis and septic shock. However, there is little evidence to guide clinicians in its administration. Current guidelines recommend targeting fluid therapy based on measurements of cardiac filling pressures, such as central venous pressure. ⋯ Such response can be better predicted by measuring changes in hemodynamic parameters caused by positive pressure ventilation or maneuvers designed to simulate increased preload. These changes can be measured by analysis of arterial waveforms, echocardiography or Doppler, or with emerging noninvasive technologies. This article reviews the current role of fluid replacement strategies and the use of monitoring systems in the overall resuscitation of patients with severe sepsis and septic shock.
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Ventilator-associated pneumonia (VAP) is the most frequent and severe infection acquired in the intensive care unit, leading to prolonged mechanical ventilation and excess mortality. This article reviews the different aspects of VAP, such as risk factors, causative agents, and approaches to diagnosis, treatment, and prevention. Several aspects of VAP are still considered controversial.
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Hospital practice (1995) · Feb 2012
ReviewAn update in options for the treatment of pain: a review of new opioid formulations.
In the past 2 decades, there has been a significant increase in the use of opioids for the management of chronic nonmalignant pain. This increase in usage has led to concerns of misuse and abuse of opioids. ⋯ In addition, alternative delivery systems have been developed to provide physicians with more options to provide adequate pain management for those with chronic pain. This article reviews new opioid options for the treatment of pain management and requirements of the Risk Evaluation and Mitigation Strategies program.
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In the postoperative pain setting, the use of opioid analgesics remains essential in achieving effective analgesia and in avoiding the deleterious sequelae of uncontrolled pain that can worsen patient outcomes. However, postoperative pain remains undertreated in many patients. Choosing the most appropriate use of opioids in the postoperative setting, especially for patients undergoing ongoing opioid treatment for chronic pain, can pose daunting challenges for many clinicians. In this article, we examine the pitfalls that may be encountered when implementing postoperative pain management strategies with opioid analgesics, especially in patients receiving chronic opioid therapy prior to admission, and the critical steps for appropriate and effective analgesia in this setting.