Journal of critical care
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Journal of critical care · Oct 2013
ReviewAssessment and management of cerebral edema and intracranial hypertension in acute liver failure.
Acute liver failure is uncommon but not a rare complication of liver injury. It can happen after ingestion of acetaminophen and exposure to toxins and hepatitis viruses. The defining clinical symptoms are coagulopathy and encephalopathy occurring within days or weeks of the primary insult in patients without preexisting liver injury. ⋯ Intracranial pressure monitoring, transcranial Doppler, and jugular venous oximetry provide valuable information for monitoring ICP and guiding therapeutic measures in patients with encephalopathy grade III or IV. Osmotic therapy using hypertonic saline and mannitol, therapeutic hypothermia, and propofol sedation are shown to improve ICPs and stabilize the patient for liver transplantation. In this article, diagnosis and management of hepatic encephalopathy and cerebral edema in patients with acute liver failure are reviewed.
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Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. ⋯ These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.
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Journal of critical care · Oct 2013
ReviewHow to select an antifungal agent in critically ill patients.
Fungal infections are common in critically ill patients and are associated with increased morbidity and mortality. Candida spp are the most commonly isolated fungal pathogens. The last 2 decades have seen an increased incidence of fungal infections in critical illness and the emergence of new pathogenic fungal species and also the development of more effective (better bioavailability) and safer (less toxicity, fewer drug interactions) drugs. ⋯ The antifungal agents that are most frequently used in the intensive care unit are the first- and second-generation azoles and the echinocandins; amphotericin B derivatives (mainly the liposomal agents) are less widely used because of adverse effects. The choice of antifungal agent in critically ill patients will depend on the aim of therapy (prophylaxis, pre-emptive, empiric, definitive), as well as on local epidemiology and specific properties of the drug (antifungal spectrum, efficacy, toxicity, pharmacokinetic/pharmacodynamic properties, cost). In this article we will review all these aspects and propose an algorithm to guide selection of antifungal agents in critically ill patients.
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Journal of critical care · Oct 2013
ReviewA review of current agents for anticoagulation for the critical care practitioner.
There has been a tremendous boom in the arena of anticoagulant therapy recently. Although the indications for these agents reside in the noncritical care environment, over time, the impact of these agents have infiltrated the critical care environment particularly due to devastating complications with associated use. ⋯ It is important that the critical care practitioner does not ignore these agents but becomes familiar with them to better prepare for the management of patients on one or more anticoagulant agents in the intensive care unit. To equip the critical care practitioners with the knowledge about commonly used anticoagulants, we provide an extensive review of the pharmacology, indications, and adverse effects related to these agents as well as suggestions on preventing or managing complications.
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Journal of critical care · Oct 2013
ReviewReporting the methodology of height and weight acquisition in studies of body mass index-based prognosis in critically ill patients.
Conflicting findings were reported on the body mass index (BMI)-based prognosis of critically patients. Errors in source weight and height data can confound BMI group allocation. The aim of the present work was to examine investigators' reporting on the methods of height and weight acquisition (HWA). ⋯ These findings demonstrate the prevalent risk for BMI group misallocation in the reviewed studies, which may confound BMI-based prognosis, raising concerns about the validity of reported BMI-related prognostic impact.