Anaesthesiology intensive therapy
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The concept of brain death (BD) was initially described in 1959 and subsequently became widely accepted in the majority of countries. Nevertheless, the diagnostic guidelines for BD markedly differ, especially regarding the apnoea test (AT), a crucial element of clinical BD confirmation. The current basic guidelines recommend preoxygenation rather than disconnection from the ventilator and insertion of an oxygen insufflation catheter into the endotracheal tube. ⋯ Reports concerning the possible pitfalls of AT and confounding situations have inspired attempts to determine the most effective and safe method of AT. The use of CPAP with oxygen supplementation is becoming highly popular. CPAP can be generated in three manners: directly by the ventilator; through the use of a CPAP valve with a reservoir; and through the use of a highly traditional T-piece system with a reservoir bag connected to distal tubing immersed in water.
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Blood loss and subsequent transfusions are associated with major morbidity and mortality. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma, orthopedic surgery, liver surgery and solid organ transplantation, obstetrics and gynecology, neurosurgery and non-surgical diseases. ⋯ This review aims to help acute care physicians navigate through the clinical evidence available for TXA therapy, develop appropriate dose regimens whilst minimizing harm, as well as understand its broadening scope of applications. Many questions remain unanswered regarding other clinical effects of TXA such as anti-inflammatory response to cardiopulmonary bypass, the risk of thromboembolic events, adverse neurological effects such as seizures, and its morbidity and mortality, all of which necessitate further clinical trials on its usage and safety in various clinical settings.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewInitial resuscitation from severe sepsis: one size does not fit all.
Over recent decades many recommendations for the management of patients with sepsis and septic shock have been published, mainly as the Surviving Sepsis Campaign (SSC) guidelines. In order to use these recommendations at the bedside one must fully understand their limitations, especially with regard to preload assessment, fluid responsiveness and cardiac output. In this review we will discuss the evidence behind the bundles presented by the Surviving Sepsis Campaign and will try to explain why some recommendations may need to be updated. ⋯ The use of functional hemodynamics with stroke volume variation or pulse pressure variation may further help to identify patients who will respond to fluid administration or not. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock, one should consider (active) de-resuscitation guided by extravascular lung water index measurements.
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Anaesthesiol Intensive Ther · Jan 2015
Case ReportsSwift recovery of severe acute hypoxemic respiratory failure under non-invasive ventilation.
In the setting of severe acute respiratory distress syndrome (ARDS; PaO2/FiO2 < 100), the cut-off point for switching from non-invasive ventilation to intubation combined to mechanical ventilation is poorly defined. ⋯ Given the complications associated with tracheal intubation and mechanical ventilation on the one hand and with delayed intubation on the other hand, high PEEP-NIV may warrant study in a restricted set of patients closely monitored in a critical care environment.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewHemodynamic monitoring: To calibrate or not to calibrate? Part 1 - Calibrated techniques.
Over recent decades, hemodynamic monitoring has evolved from basic cardiac output monitoring techniques to a broad variety of sophisticated monitoring devices with extra parameters. In order to reduce morbidity and mortality and optimize therapeutic strategies, different monitoring techniques can be used to guide fluid resuscitation and other medical management. Generally, they can be divided in calibrated and non-calibrated techniques. ⋯ However in complex situations or in patients not responding to fluid resuscitation alone, advanced hemodynamic monitoring is recommended with the use of calibrated techniques like transpulmonary thermodilution. Calibrated techniques are preferred in patients with severe shock and changing conditions of preload, afterload and contractility. The use of the pulmonary artery catheter should be reserved for patients with right ventricular failure in order to assess the effect of medical treatment.