Current Opinion in Critical Care

Jeremy R Beitler
PURPOSE OF REVIEW: Most clinical trials of lung-protective ventilation have tested one-size-fits-all strategies with mixed results. Data are lacking on how best to tailor mechanical ventilation to patient-specific risk of lung injury. RECENT FINDINGS: Risk of ventilation-induced lung injury is determined by biological predisposition to biophysical lung injury and physical mechanical perturbations that concentrate stress and strain regionally within the lung. Recent investigations have identified molecular subphenotypes classified as hyperinflammatory and hypoinflammatory acute respiratory distress syndrome (ARDS), which may have dissimilar risk for ventilation-induced lung injury...
December 6, 2019: Current Opinion in Critical Care
Takeshi Yoshida, Domenico L Grieco, Laurent Brochard, Yuji Fujino
PURPOSE OF REVIEW: The potential risks of spontaneous effort and their prevention during mechanical ventilation is an important concept for clinicians and patients. The effort-dependent lung injury has been termed 'patient self-inflicted lung injury (P-SILI)' in 2017. As one of the potential strategies to render spontaneous effort less injurious in severe acute respiratory distress syndrome (ARDS), the role of positive end-expiratory pressure (PEEP) is now discussed. RECENT FINDINGS: Experimental and clinical data indicate that vigorous spontaneous effort may worsen lung injury, whereas, at the same time, the intensity of spontaneous effort seems difficult to control when lung injury is severe...
December 6, 2019: Current Opinion in Critical Care
Ewan C Goligher, Eddy Fan
No abstract text is available yet for this article.
November 26, 2019: Current Opinion in Critical Care
Robinder G Khemani, Justin C Hotz, Katherine A Sward, Christopher J L Newth
PURPOSE OF REVIEW: Mechanical ventilation of adults and children with acute respiratory failure necessitates balancing lung and diaphragm protective ventilation. Computerized decision support (CDS) offers advantages in circumstances where complex decisions need to be made to weigh potentially competing risks, depending on the physiologic state of the patient. RECENT FINDINGS: Significant variability in how ventilator protocols are applied still exists and clinical data show that there continues to be wide variability in ventilator management...
November 19, 2019: Current Opinion in Critical Care
Steven D Pearson, Bhakti K Patel
PURPOSES OF REVIEW: Critically ill patients frequently require mechanical ventilation as part of their care. Administration of analgesia and sedation to ensure patient comfort and facilitate mechanical ventilation must be balanced against the known negative consequences of excessive sedation. The present review focuses on the current evidence for sedation management during mechanical ventilation, including choice of sedatives, sedation strategies, and special considerations for acute respiratory distress syndrome (ARDS)...
November 19, 2019: Current Opinion in Critical Care
Irene Telias, Savino Spadaro
PURPOSE OF REVIEW: There is increased awareness that derangements of respiratory drive and inspiratory effort are frequent and can result in lung and diaphragm injury together with dyspnea and sleep disturbances. This review aims to describe available techniques to monitor drive and effort. RECENT FINDINGS: Measuring drive and effort is necessary to quantify risk and implement strategies to minimize lung and the diaphragm injury by modifying sedation and ventilation...
November 16, 2019: Current Opinion in Critical Care
Sarina K Sahetya
PURPOSE OF REVIEW: The optimal strategy for setting positive end-expiratory pressure (PEEP) has not been established. This review examines different approaches for setting PEEP to achieve lung-protective ventilation. RECENT FINDINGS: PEEP titration strategies commonly focus either on achieving adequate arterial oxygenation or reducing ventilator-induced lung injury from repetitive alveolar opening and closing, referred to as the open lung approach. Five recent trials of higher versus lower PEEP have not shown benefit with higher PEEP, and one of the five trials showed increased harm for patients treated with the open lung strategy...
November 12, 2019: Current Opinion in Critical Care
Tom Schepens, Jose Dianti
PURPOSE OF REVIEW: Diaphragm weakness can impact survival and increases comorbidities in ventilated patients. Mechanical ventilation is linked to diaphragm dysfunction through several mechanisms of injury, referred to as myotrauma. By monitoring diaphragm activity and titrating ventilator settings, the critical care clinician can have a direct impact on diaphragm injury. RECENT FINDINGS: Both the absence of diaphragm activity and excessive inspiratory effort can result in diaphragm muscle weakness, and recent evidence demonstrates that a moderate level of diaphragm activity during mechanical ventilation improves ICU outcome...
November 12, 2019: Current Opinion in Critical Care
Giacomo Grasselli, Matteo Brioni, Alberto Zanella
PURPOSE OF REVIEW: Accurate monitoring of the mechanical properties of the respiratory system is crucial to understand the pathophysiological mechanisms of respiratory failure in mechanically ventilated patients, to optimize mechanical ventilation settings and to reduce ventilator-induced lung injury. However, although the assessment of respiratory mechanics is simple in patients undergoing fully controlled ventilation, it becomes quite challenging in the presence of spontaneous breathing activity...
November 12, 2019: Current Opinion in Critical Care
Katerina Vaporidi
PURPOSE OF REVIEW: Complications of mechanical ventilation, such as ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD), adversely affect the outcome of critically ill patients. Although mostly studied during control ventilation, it is increasingly appreciated that VILI and VIDD also occur during assisted ventilation. Hence, current research focuses on identifying ways to monitor and deliver protective ventilation in assisted modes. This review describes the operating principles of proportional modes of assist, their implications for lung and diaphragm protective ventilation, and the supporting clinical data...
November 12, 2019: Current Opinion in Critical Care
Elena Spinelli, Eleonora Carlesso, Tommaso Mauri
PURPOSE OF REVIEW: Extracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring. RECENT FINDINGS: A recent randomized trial comparing the efficacy of extracorporeal support as a rescue therapy to conventional protective mechanical ventilation was stopped for futility but post hoc analyses suggested that extracorporeal support is beneficial for patients with very severe acute respiratory distress syndrome...
February 2020: Current Opinion in Critical Care
Martin Dres, Alexandre Demoule
PURPOSE OF REVIEW: To review the clinical problem of diaphragm function in critically ill patients and describes recent advances in bedside monitoring of diaphragm function. RECENT FINDINGS: Diaphragm weakness, a consequence of diaphragm dysfunction and atrophy, is common in the ICU and associated with serious clinical consequences. The use of ultrasound to assess diaphragm structure (thickness, thickening) and mobility (caudal displacement) appears to be feasible and reproducible, but no large-scale 'real-life' study is available...
February 2020: Current Opinion in Critical Care
Kamil Hanna, Michael Ditillo, Bellal Joseph
PURPOSE OF REVIEW: The aging surgical population constitutes a unique challenge to clinicians across the spectrum of care. Frailty is a valuable tool for preoperative risk stratification and may guide targeted interventions, such as prehabilitation. The aim of this review is to revise the recent literature on the role of frailty and prehabilitation to optimize geriatric patients undergoing surgery. RECENT FINDINGS: The concept of frailty became more refined over the past couple of decades, and its various dimensions have been operationalized into an array of different frailty scoring systems...
December 2019: Current Opinion in Critical Care
Roberta Fenoglio, Savino Sciascia, Simone Baldovino, Dario Roccatello
PURPOSE OF REVIEW: This review focuses on acute kidney injury (AKI) associated with glomerular diseases and specifically the mechanisms of development of AKI in the wide spectrum of glomerulopathies. RECENT FINDINGS: The immune system and the kidneys are closely linked. In healthy individuals, the kidneys contribute to immune homeostasis, whereas components of the immune system mediate many acute forms of kidney disease. Both crescentic and noncrescentic forms of acute glomerulonephritis can present as AKI...
December 2019: Current Opinion in Critical Care
Muhammad Khan, Rifat Latifi
PURPOSE OF REVIEW: Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes. RECENT FINDINGS: Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications...
December 2019: Current Opinion in Critical Care
Adrian Wong, Antoine Vieillard-Baron, Manu L N G Malbrain
PURPOSE OF REVIEW: The use of bedside or point-of-care ultrasound (POCUS) in medical emergencies is rapidly becoming more established as an effective acute diagnostic tool. The purpose of this review is to provide an overview of the various techniques currently used that are readily available, as well as several in development. Possible caveats are also addressed. RECENT FINDINGS: Despite its widespread use, definitive studies demonstrating improved patient outcomes are limited...
December 2019: Current Opinion in Critical Care
Marcelo A F Ribeiro, Alexandre Z Fonseca, Stephanie Santin
PURPOSE OF REVIEW: The current review aims to discuss the management of surgical patients in an ICU in countries where resources are limited. RECENT FINDINGS: ICU beds in low-income and middle-income countries (LMICs) are limited and also have limited human and structural resources. The working force has been described to be the costliest factor. Nevertheless, costs for intensive care in LMICs are one third from the cost reported from high-income countries. Alternative options have been described, so intensive care can be delivered outside ICU...
December 2019: Current Opinion in Critical Care
Tanya Anand, Lauren K Roller, Gregory J Jurkovich
PURPOSE OF REVIEW: The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock. RECENT FINDINGS: The antioxidant properties of vitamin C are touted to be useful in modulating the inflammatory response, decreasing vasopressor requirements, and improving resuscitation. Current resuscitation practices are focused on addressing the hemodynamic instability and ensuring adequate oxygen delivery to tissues. The conceptual framework of the use of vitamin C during a resuscitation is to modulate in a beneficial fashion the inflammatory response to sepsis while concomitantly resuscitating and treating the infection...
December 2019: Current Opinion in Critical Care
Shawn Tejiram, Kathleen S Romanowski, Tina L Palmieri
PURPOSE OF REVIEW: Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management...
December 2019: Current Opinion in Critical Care
Usman A Tahir, Brett Carroll, Duane S Pinto
PURPOSE OF REVIEW: To highlight updates on the use of extracorporeal membrane oxygenation (ECMO) and surgical embolectomy in the treatment of massive pulmonary embolism. RECENT FINDINGS: Outcomes for surgical embolectomy for massive pulmonary embolism have improved in the recent past. More contemporary therapeutic options include catheter embolectomy, which although offer less invasive means of treating this condition, need further study. The use of ECMO as either a bridge or mainstay of treatment in patients with contraindications to fibrinolysis and surgical embolectomy, or have failed initial fibrinolysis, has increased, with data suggesting improved outcomes with earlier implementation in selected patients...
December 2019: Current Opinion in Critical Care
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