Critical care clinics
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Poor synchrony between the delivery of mechanical breaths, the neural respiratory timing, and needs of patients is relatively frequent under mechanical ventilation in the intensive care unit. This review summarizes the current knowledge on the different types of dyssynchrony described to date, their mechanism, consequences, and potential management. There is still a long way to get to a comprehensive knowledge and uncertainties remain. Ongoing research and development of monitoring tools are urgently needed to allow a better appraisal of this area in a near future.
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Critical care clinics · Jul 2018
ReviewDeterminants and Prevention of Ventilator-Induced Lung Injury.
Ventilator-induced lung injury develops from interactions between the lung parenchyma and applied mechanical power. In acute respiratory distress syndrome, the lung is smaller size with an inhomogeneous structure. ⋯ Volutrauma and atelectrauma harms and benefits, however, seem to be equivalent at 5 to 15 cm H2O. At values greater than 15 cm H2O, the risk of damage outweighs the benefits of major atelectrauma prevention.
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Extracorporeal gas exchange is increasingly used for various indications. Among these are refractory acute respiratory failure, including the acute respiratory distress syndrome (ARDS), and the avoidance of ventilator-induced lung injury (VILI) by enabling lung-protective ventilation. ⋯ These indications are based on a reasonable physiologic rationale but must be weighed against the costs and complications associated with the technique. This article summarizes current evidence and indications for extracorporeal gas exchange.
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Cardiogenic shock is a clinical syndrome characterized by low cardiac output and sustained tissue hypoperfusion resulting in end-organ dysfunction and death. In-hospital mortality rates range from 50% to 60%. ⋯ Aggressive, hemodynamically guided medical management with careful monitoring of clinical and hemodynamic parameters with timely use of appropriate mechanical circulatory support devices is often necessary. As treatment options evolve, prospective randomized controlled trials are needed to define best practices that define superior clinical outcomes.
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Critical care clinics · Jul 2018
ReviewDevice Management and Flow Optimization on Left Ventricular Assist Device Support.
The authors discuss principles of continuous flow left ventricular assist device (LVAD) operation, basic differences between the axial and centrifugal flow designs and hemodynamic performance, normal LVAD physiology, and device interaction with the heart. Systematic interpretation of LVAD parameters and recognition of abnormal patterns of flow and pulsatility on the device interrogation are necessary for clinical assessment of the patient. Optimization of pump flow using LVAD parameters and echocardiographic and hemodynamics guidance are reviewed.