Best practice & research. Clinical anaesthesiology
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Echography has developed as an indispensable tool in diagnosis and subsequent therapy in the critically ill. Although pulmonary and abdominal ultrasounds play a major role in their management, this article will discuss the advantages and indications of echocardiography in the intensive care unit (ICU). ⋯ Actually, besides contractility, several preload and even afterload indicators can also be assessed. In short, this bedside tool rapidly provides insight in the haemodynamics without invasive pressure estimations.
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Best Pract Res Clin Anaesthesiol · Sep 2009
ReviewLimited transthoracic echocardiography assessment in anaesthesia and critical care.
The use of echocardiography in anaesthesia and critical care started with transoesophageal echocardiography, whereas transthoracic echocardiography was largely the domain of the cardiologist. In recent times, there has been a change in focus towards transthoracic echocardiography owing to the development of small and portable, yet high-fidelity, echocardiography machines. The cost has reduced, thereby increasing the availability of equipment. ⋯ All of these require a limited knowledge base, and are designed for the clinician to recognise patterns consistent with haemodynamic or anatomical abnormalities. They range from very limited two-dimensional assessments of ventricular function to more complex (yet presently limited) studies such as HEART (haemodynamic echocardiography assessment in real time) scan, which is designed to provide haemodynamic state, as well as basic valvular and pericardial assessment. It is suitable for goal-directed examination in the operating theatre, emergency department or intensive care unit (ICU) and for preoperative screening.
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For decades, the 'third space' was looked upon as an actively consuming compartment. Therefore, perioperative fluid regimens were traditionally based on a generous replacement of this assumed primary loss, in addition to deficits due to insensible perspiration and fasting. The practical consequence was an extremely positive fluid balance in order to maintain blood volume during major surgery. ⋯ Such shifting is related to a destruction of the endothelial glycocalyx, a key structure of the vascular barrier, by traumatic inflammation and iatrogenic hypervolaemia. This explains why patients undergoing major surgical interventions benefit significantly from an infusion regimen which does not substitute but avoids 'third-space shifting'. In summary, eradicating this notion from our minds could be a further key to achieving perioperative fluid optimisation.
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Best Pract Res Clin Anaesthesiol · Jun 2009
ReviewRelevance of albumin in modern critical care medicine.
The relevance of albumin administration in the critical care setting remains controversial. We know that albumin has numerous important physiological effects and many potentially beneficial effects in critical illness. ⋯ Albumin may be useful in some patients, especially those with hypoalbuminaemia at risk of complications or those with liver insufficiency. Further studies are needed to clarify what precise role albumin has in today's ICU.