Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2015
ReviewControversies in the Management of Severe ARDS: Optimal Ventilator Management and Use of Rescue Therapies.
Groundbreaking research into the pathophysiology of the adult acute respiratory distress syndrome (ARDS) and the prevention of ventilator-induced lung injury has led to dramatic improvements in survival. Investigations over the last two decades have revolved around the development of rescue therapies that can be used for patients with severe ARDS and refractory hypoxemia. To date, the techniques of using high levels of positive end-expiratory pressure (PEEP), prompt institution of neuromuscular blockade, and early prolonged prone positioning have been shown to reduce mortality in patients with severe ARDS. ⋯ A major randomized controlled trial conducted during this period showed a significant mortality benefit for patients with severe ARDS who were referred to a center with ECMO capabilities. The routine use of inhaled nitric oxide for patients with severe ARDS has not been shown to lead to more than a transient and limited improvement in oxygenation, which may hinder its use as a sole rescue therapy. Finally, recent studies have found that the routine use of high-frequency oscillatory ventilation in severe ARDS does not result in decreased mortality, although the technique has not been specifically investigated as rescue therapy for severe refractory hypoxemia.
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Semin Respir Crit Care Med · Dec 2015
ReviewAwake or Sedated: Trends in the Evaluation and Management of Agitation in the Intensive Care Unit.
Critically ill intensive care unit (ICU) patients often require sedation to tolerate life-saving interventions such as mechanical ventilation. Pain, anxiety, and delirium all contribute to patient distress and agitation which can interfere with ICU medical care if not addressed and treated appropriately. Sedation practices to treat pain, anxiety, and delirium that deviate from established practice guidelines affect mechanical ventilation duration, ICU and hospital length of stay, functional impairment, and mortality. ⋯ This review will focus on changes in sedation practice in the ICU over the past three decades. With the implementation of validated sedation assessment scales, a multidisciplinary treatment model, and development of daily awakening protocols, no or minimal sedation can be achieved in the majority of ICU patients. Frequent, careful consideration of the environmental stimuli that contribute to patient discomfort and agitation and judicious use of sedative medications individualized to each patient are important in achieving this goal.
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Semin Respir Crit Care Med · Dec 2015
ReviewBedside Ultrasound in the Intensive Care Unit: Where Is the Evidence?
Interest in bedside ultrasound in the intensive care unit and emergency department has exploded in recent years. This interest is driven in part by the utility of ultrasound for procedural guidance. In most cases, enthusiasm outstrips current evidence. ⋯ Other possibilities include ventilator titration and guidance of diuresis. While the literature is more complicated, there is some early evidence that lung ultrasound may improve the diagnosis of dyspnea, although these results have not been well validated. Centers should avoid premature loss of equipoise and participate in studies of explicit protocols that incorporate ultrasound.
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Semin Respir Crit Care Med · Dec 2015
Review Meta AnalysisMetabolic Management during Critical Illness: Glycemic Control in the ICU.
Hyperglycemia is a commonly encountered metabolic derangement in the ICU. Important cellular pathways, such as those related to oxidant stress, immunity, and cellular homeostasis, can become deranged with prolonged and uncontrolled hyperglycemia. There is additionally a complex interplay between nutritional status, ambient glucose concentrations, and protein catabolism. ⋯ In this review, we will explore the impact of hyperglycemia upon critical cellular pathways and how nutrition provided in the ICU affects blood glucose. Additionally, important clinical trials to date will be summarized. A practical and comprehensive approach to glucose management in the ICU will be outlined, touching upon important issues such as glucose variability, target population, and hypoglycemia.
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Semin Respir Crit Care Med · Dec 2015
ReviewTo Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill.
The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. ⋯ In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.