Resuscitation
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Many critically ill patients suffer pain which can produce by itself undesirable effects. Consequently, pain must be carefully prevented, or at least, treated early and effectively. ⋯ Computer-assisted intravenous "on demand" analgesia with Fentanyl can also be used. When pain coverage is required during transient events such as active physiotherapy or dressing changes, additional intravenous of a narcotic (1-2 mg morphine e.g.) or inhalation of nitrous oxide with oxygen are usually effective.
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Hyperlactatemia is frequently observed in critically ill patients. A correlation of blood lactate concentrations and outcome of patients has been proven in circulatory shock, circulatory arrest, acute myocardial infarction, acute hypnotic drug poisoning and severe pancreatitis. ⋯ In individual patients, hyperlactatemia is a useful indicator pointing to the severity of illness and to superimposed complications. Blood lactate is of considerable value for the metabolic monitoring of critically ill patients.
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Increase in total cardiac output can improve oxygen delivery to the cells. Although inotropic drugs increase primarily myocardial contractility, they can adversely affect cardiac preload and afterload. Moreover, they can dangerously increase myocardial oxygen requirements. The combined use of vasodilating agents, with fluid challenge represents a challenging but more efficient treatment of acute circulatory failure.
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HFPPV is not a jet technique, as it works without air entrainment. A low-compression ventilator, with a conventional rate of 20/min, provides efficient intrapulmonary gas mixing; however, with higher rates of 60-100/min the high inspiratory flow improves transfer/mixing of gas in the conducting airways. ⋯ It is important to note that enhanced gas mixing and improved gas distribution during HFPPV in acute respiratory failure patients are accomplished with lower mean airway pressure, thereby reducing barotrauma. In the future, versatile low-compression ventilators for volume-controlled IPPV and HFPPV will hopefully improve safety, efficiency and patient acceptance of mechanical ventilation in acute respiratory failure.
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Plasma growth hormone, cortisol, insulin and blood glucose concentrations were measured intra- and postoperatively in ten patients who underwent open heart surgery with moderate hypothermia. Diazepam-ketamine anaesthesia for 10-20 min failed to precipitate any significant alterations in the levels of measured hormones and blood glucose. In the pre-bypass period of surgery, an increase in cortisol and a slight elevation in growth hormone levels was observed; insulin level showed no change in spite of marked hyperglycaemia. ⋯ The post-bypass period with rewarming the restoring spontaneous circulation was characterized by further marked increase in cortisol and growth hormone levels and, in spite of decreasing levels of blood glucose, by a paradoxical elevation in plasma insulin. It is suggested that hypothermia, haemodilution, reduced tissue perfusion affecting endocrine glands, as well as denaturation of some hormones in the oxygenator, participate in the moderate endocrine response, disproportionate to the stress of cardiopulmonary bypass surgery. The rise in hormone levels on terminating bypass seems to be dependent on the improved blood flow to endocrine glands due to recovered spontaneous circulation, rewarming and, as for insulin, presumably even on the reduced inhibitory effect of catecholamines.