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Current Opinion in Critical Care

Sundar Krishnan, Gregory A Schmidt
PURPOSE OF REVIEW: Hemodynamic monitoring in ECMO patients requires familiarity with the underlying pathophysiology and circulatory mechanics of extracorporeal flow. This review discusses the various monitoring modalities relevant to the management of patients on venovenous ECMO (VV ECMO) and venoarterial (VA ECMO). We emphasize tools to judge the adequacy of perfusion, predict the response to fluid boluses, measure right ventricular function, assess left ventricular distention (for VA ECMO), and monitor the process of weaning from ECMO...
March 5, 2019: Current Opinion in Critical Care
Anthony S McLean
PURPOSE OF REVIEW: Knowledge of the left ventricular pressures throughout the cardiac cycle is of considerable assistance in managing a haemodynamically unstable patient. Invasive pressure measurement is the only accurate way to analyze ventricular diastolic pressures but this is not feasible outside the catheterization laboratory, whereas the use of a pulmonary artery catheter or Doppler echocardiography, using surrogate measurements, is available at the bedside. The ever-increasing trend toward noninvasive monitoring puts echocardiography at the forefront and considerable effort has been made to define its role in this setting...
March 5, 2019: Current Opinion in Critical Care
Evert Christiaan Boerma, Inge Tjitske Bootsma
PURPOSE OF REVIEW: To focus on the missing link between accuracy and precision of monitoring devices and effective implementation of therapeutic strategies. RECENT FINDINGS: Haemodynamic monitoring is generally considered to be an essential part of intensive care medicine. However, randomized controlled trials fail to demonstrate improved outcome unequivocally as a result of hemodynamic monitoring. This absence of solid proof renders doctors to hesitance to apply haemodynamic monitoring in clinical practise...
February 18, 2019: Current Opinion in Critical Care
Francesca M Trovato, Liane Rabinowich, Mark J W McPhail
PURPOSE OF REVIEW: This review describes the current intensive care management of acute liver failure (ALF) and the latest evidence for emerging therapies. RECENT FINDINGS: Mortality from ALF continues to improve and in some cases, medical therapy can negate the need for liver transplantation because of protocolized management in specialist centres. Liver transplantation remains the cornerstone of management for poor prognosis ALF. The reduced use of blood products in ALF reflects growing evidence of balanced haemostasis in severe liver disease...
January 28, 2019: Current Opinion in Critical Care
Andrew J MacDonald, Mitra K Nadim, François Durand, Constantine J Karvellas
PURPOSE OF REVIEW: Acute kidney injury (AKI) in cirrhosis consists of varying phenotypes, with hepatorenal syndrome (HRS) representing a single entity. Prompt recognition and diagnosis of AKI cause identifies appropriate therapeutic measures. This review provides an overview of AKI definitions, highlights challenges in quantifying renal impairment in cirrhosis, lists novel diagnostic AKI biomarkers, and summarizes transplantation implications. RECENT FINDINGS: Biomarkers (neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, interleukin-18, and liver-type fatty acid-binding protein) may assist in the identification of underlying acute tubular necrosis...
January 22, 2019: Current Opinion in Critical Care
Salia Farrokh, Sung-Min Cho, Jose I Suarez
PURPOSE OF REVIEW: To discuss recent updates in fluid management and use of hyperosmolar therapy in neurocritical care. RECENT FINDINGS: Maintaining euvolemia with crystalloids seems to be the recommended fluid resuscitation for neurocritical care patients. Buffered crystalloids have been shown to reduce hyperchloremia in patients with subarachnoid hemorrhage without causing hyponatremia or hypo-osmolality. In addition, in patients with traumatic brain injury, buffered solutions reduce the incidence of hyperchloremic acidosis but are not associated with intracranial pressure (ICP) alteration...
January 22, 2019: Current Opinion in Critical Care
Olivier Opdenakker, Anna Vanstraelen, Veerle De Sloovere, Geert Meyfroidt
PURPOSE OF REVIEW: In this article, the specific and general indications for sedatives in the neurocritical care unit are discussed, together with an overview on current insights in sedative protocols for these patients. In addition, physiological effects of sedative agents on the central nervous system are reviewed. RECENT FINDINGS: In the general ICU population, a large body of evidence supports light protocolized sedation over indiscriminate deep sedation. Unfortunately, in patients with severe acute brain injury, the evidence from randomized controlled trials is scarce to nonexistent, and practice is supported by expert opinion, physiological studies and observational or small interventional trials...
January 21, 2019: Current Opinion in Critical Care
Fin Stolze Larsen
PURPOSE OF REVIEW: Liver failure is a life-threatening condition, and an artificial liver is highly desirable to replace the failing liver-functions in the waiting time for liver regeneration to happen or until liver transplantation can be undertaken. This review focuses on the efficacy of using artificial extracorporeal liver support devices. RECENT FINDINGS: Artificial liver support devices such as the molecular adsorbent recirculating system (MARS), fractionated plasma separation and adsorption, and therapeutic plasma exchange (TPE) are well tolerated...
January 21, 2019: Current Opinion in Critical Care
Fuat H Saner, Dmitri Bezinover
PURPOSE OF REVIEW: This review provides insight into our current understanding of the pathophysiology and treatment of coagulopathy associated with liver failure, and bleeding risk assessment. RECENT FINDINGS: Patients with end-stage liver disease (ESLD) have a rebalanced coagulation profile and are at risk for both excessive clotting and bleeding. Hypercoagulability is associated with profound endothelial dysfunction and an increased concentration of liver-independent coagulation factors...
April 2019: Current Opinion in Critical Care
Takehiko Oami, Deena B Chihade, Craig M Coopersmith
PURPOSE OF REVIEW: The present review aims to describe the relationship between nutrition and the gut microbiome in critical illness. RECENT FINDINGS: Critical illness disrupts not only cells of human origin but also the intestinal microbiome, with a decrease in bacterial diversity and transformation into a pathobiome. Under basal conditions, nutrition profoundly alters microbial composition with significant salutatory effects on human health. In critical illness, enteral nutrition is recommended and has theoretical (but not proven) advantages towards improved inner microbial health and diminution of bacterial translocation...
April 2019: Current Opinion in Critical Care
Mark P Plummer, Annika Reintam Blaser, Adam M Deane
PURPOSE OF REVIEW: To provide a comprehensive update of diagnosis and treatment of gastrointestinal dysmotility in the critically ill, with a focus on work published in the last 5 years. RECENT FINDINGS: Symptoms and clinical features consistent with upper and/or lower gastrointestinal dysmotility occur frequently. Although features of gastrointestinal dysmotility are strongly associated with adverse outcomes, these associations may be because of unmeasured confounders...
April 2019: Current Opinion in Critical Care
Ségolène Mrozek, David Rousset, Thomas Geeraerts
PURPOSE OF REVIEW: To describe the pathophysiology and pharmacotherapy of dysnatremia in neurocritical care patients. RECENT FINDINGS: Sodium disorders may affect approximately half of the neurocritical care patients and are associated with worse neurological outcome and increased risk of death. Pharmacotherapy of sodium disorders in neurocritical care patients may be challenging and is guided by a careful investigation of water and sodium balance. SUMMARY: In case of hyponatremia, because of excessive loss of sodium, fluid challenge with isotonic solution, associated with salt intake is the first-line therapy, completed with mineralocorticoids if needed...
April 2019: Current Opinion in Critical Care
Hervé Quintard, Carole Ichai
PURPOSE OF REVIEW: Energy dysfunction is increasingly recognized as a key factor in the pathogenesis of acute brain injury (ABI). This one characterized by a high metabolic rate and nitrogen loss is often associated with an undernutrition support. We review the metabolism evolution and nutritional status in brain injured patient and summarize evidence on nutritional support in this condition. RECENT FINDINGS: The role of nutrition support for improving prognosis in brain injured patient has been underlined recently...
April 2019: Current Opinion in Critical Care
Baxter Allen, Paul M Vespa
PURPOSE OF REVIEW: Seizures and status epilepticus are very common diagnoses in the critically ill patient and are associated with significant morbidity and mortality. There is an abundance of research on the utility of antiseizure medications in this setting, but limited randomized-controlled trials to guide the selection of medications in these patients. This review examines the current guidelines and treatment strategies for status epilepticus and provides an update on newer antiseizure medications in the critical care settings...
April 2019: Current Opinion in Critical Care
Luzius A Steiner, Martin Siegemund
PURPOSE OF REVIEW: This review highlights the aspects of pathophysiology that make it difficult to predict the effects of any attempt to improve brain perfusion and reviews the options to improve brain perfusion according to the needs of an individual patient, focusing on the choice of a suitable threshold for cerebral perfusion pressure. RECENT FINDINGS: Typically, vasopressors or vasodilators that do not directly influence the cerebral vascular bed are used to improve cerebral perfusion...
April 2019: Current Opinion in Critical Care
Elisabeth De Waele, Manu L N G Malbrain, Herbert D Spapen
PURPOSE OF REVIEW: To review recent literature on the management of patients with severe acute pancreatitis (SAP) admitted to an ICU. RECENT FINDINGS: SAP is a devastating disease associated with a high morbidity and mortality. Recent evidence advocates adequate risk assessment and severity prediction (including intra-abdominal pressure monitoring), tailored fluid administration favoring balanced crystalloids, withholding prophylactic antibiotic therapy, and early detection and treatment of extra-pancreatic and fungal infections...
April 2019: Current Opinion in Critical Care
Takeshi Yoshida, Marcelo B P Amato, Brian P Kavanagh, Yuji Fujino
PURPOSE OF REVIEW: Facilitating spontaneous breathing has been traditionally recommended during mechanical ventilation in acute respiratory distress syndrome (ARDS). However, early, short-term use of neuromuscular blockade appears to improve survival, and spontaneous effort has been shown to potentiate lung injury in animal and clinical studies. The purpose of this review is to describe the beneficial and deleterious effects of spontaneous breathing in ARDS, explain potential mechanisms for harm, and provide contemporary suggestions for clinical management...
April 2019: Current Opinion in Critical Care
Mauro Oddo
No abstract text is available yet for this article.
April 2019: Current Opinion in Critical Care
Jody C Olson
PURPOSE OF REVIEW: Hospitalizations due to complications of cirrhosis continue to rise. Patients with chronic liver disease who suffer acute decompensation [acute-on-chronic liver failure (ACLF)] often require intensive care support and are at high risk for short-term mortality. Given the high mortality rate associated with this condition is incumbent on intensive care providers who care for this patient population to have a working knowledge of ACLF with its associated complications, management strategies and prognosis...
April 2019: Current Opinion in Critical Care
Rebecca Inglis, Emmanuel Ayebale, Marcus J Schultz
PURPOSE OF REVIEW: This review focuses on the emerging body of literature regarding the management of acute respiratory failure in low- and middle-income countries (LMICs). The aim is to abstract management principles that are of relevance across a variety of settings where resources are severely limited. RECENT FINDINGS: Mechanical ventilation is an expensive intervention associated with considerable mortality and a high rate of iatrogenic complications in many LMICs...
February 2019: Current Opinion in Critical Care
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