Anaesthesiology intensive therapy
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Anaesthesiol Intensive Ther · Jan 2015
ReviewWhat's new in medical management strategies for raised intra-abdominal pressure: evacuating intra-abdominal contents, improving abdominal wall compliance, pharmacotherapy, and continuous negative extra-abdominal pressure.
In the future, medical management may play an increasingly important role in the prevention and management of intra-abdominal hypertension (IAH). A review of different databases was used (PubMed, MEDLINE and EMBASE) with the search terms 'Intra-abdominal Pressure' (IAP), 'IAH', ' Abdominal Compartment Syndrome' (ACS), 'medical management' and 'non-surgical management'. We also reviewed all papers with the search terms 'IAH', 'IAP' and 'ACS' over the last three years, only extracting those papers which showed a novel approach in the non-surgical management of IAH and ACS. ⋯ Many treatment options are available and are often part of routine daily management in the ICU (nasogastric, rectal tube, prokinetics, enema, sedation, body position). Some of the newer treatments are very promising options in specific patient populations with raised IAP. Future studies are warranted to confirm some of these findings.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewPerioperative goal directed therapy using automated closed-loop fluid management: the future?
Although surgery has become much safer, it has also becoming increasingly more complex and perioperative complications continue to impact millions of patients worldwide each year. Perioperative hemodynamic optimization utilizing Goal Directed Therapy (GDT) has attracted considerable interest within the last decade due to its ability to improve postoperative short and long-term outcomes in patients undergoing higher risk surgeries. The concept of GDT in this context can be loosely defined as collecting data from minimally invasive hemodynamic monitors with the intention of using such data (flow-related parameters and/or dynamic parameters of fluid responsiveness) to titrate therapeutic interventions (intravenous fluids and/or inotropic therapy administration) with the ultimate aim of optimizing end organ tissue perfusion. ⋯ As a result, hospitals and clinicians around the world have become increasingly incentivized to implement perioperative hemodynamic optimization using GDT strategies within their departments. Unfortunately, its adoption continues to be quite limited and a lack of standardized criteria for perioperative fluid administrations has resulted in significant clinical variability among practitioners. This current review will provide a brief up-to-date overview of GDT, discuss current clinical practice, analyze why implementation has been limited and finally, describe the newer closed-loop GDT concept along with its potential risks and benefits.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewAssessment of loading conditions with cardiac ultrasound. A comprehensive review.
Optimization of the preloading conditions and concomitant determination of endpoints of fluid administration are the most frequent therapeutic actions in critically ill patients. Besides a clinical appraisal, reproducible data should be acquired at the bedside to estimate the adequacy of fluid resuscitation. The dynamic assessment and determination of fluid responsiveness plays a major role in this respect. ⋯ Moreover, left sided variables, including aortic flow variation, with intermittent swings of intrathoracic pressure during mechanical ventilation, may be achieved non-invasively with Doppler-echocardiography. Both in terms of resuscitation, as well as correct interpretation of various two-dimensional and Doppler variables, it is essential to acquire a clear understanding of the filling status of a patient. Doppler-echocardiography plays herein a pivotal role.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewAn overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 - avoiding complications by using the right endpoints with a new personalized protocolized approach.
While organ hypoperfusion caused by inadequate resuscitation has become rare in clinical practice due to the better understanding of burn shock pathophysiology, there is growing concern that increased morbidity and mortality related to over-resuscitation induced by late 20th century resuscitation strategies based on urine output, is occurring more frequently in burn care. In order to reduce complications related to this concept of "fluid creep", such as respiratory failure and compartment syndromes, efforts should be made to resuscitate with the least amount of fluid to provide adequate organ perfusion. ⋯ Special reference is made to the role of intra-abdominal hypertension in burn care and adjunctive treatments modulating the inflammatory response. Finally, as urine output has been recognized as a poor resuscitation target, a new personalized stepwise resuscitation protocol is suggested which includes targets and endpoints that can be obtained with modern, less invasive hemodynamic monitoring devices like transpulmonary thermodilution.
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Anaesthesiol Intensive Ther · Jan 2015
ReviewRole of permissive hypotension, hypertonic resuscitation and the global increased permeability syndrome in patients with severe hemorrhage: adjuncts to damage control resuscitation to prevent intra-abdominal hypertension.
Secondary intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are closely related to fluid resuscitation. IAH causes major deterioration of the cardiac function by affecting preload, contractility and afterload. The aim of this review is to discuss the different interactions between IAH, ACS and resuscitation, and to explore a new hypothesis with regard to damage control resuscitation, permissive hypotension and global increased permeability syndrome. ⋯ Novel markers like the capillary leak index, extravascular lung water and pulmonary permeability index may help the clinician in guiding appropriate fluid management. Capillary leak is an inflammatory condition with diverse triggers that results from a common pathway that includes ischaemia-reperfusion, toxic oxygen metabolite generation, cell wall and enzyme injury leading to a loss of capillary endothelial barrier function. Fluid overload should be avoided in this setting.