Current opinion in critical care
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Severe sepsis and septic shock are common causes of morbidity and mortality in critically ill patients. The complexities of the septic cascade continue to emerge and may identify new targets for innovative patient management. This review will highlight some of the recent advances in our management of the patient with sepsis. ⋯ Significant advances have been made in our understanding of the septic cascade and our ability to manage patients with severe sepsis and septic shock. Despite these advances, significant morbidity and mortality continue. In addition, there is also considerable impact on the financial and overall function of the patient.
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Atrial fibrillation, atrial flutter, AV-nodal reentry tachycardia with rapid ventricular response, atrial ectopic tachycardia, and preexcitation syndromes combined with atrial fibrillation or ventricular tachyarrhythmias are typical arrhythmias in intensive care patients. Most frequently, the diagnosis of the underlying arrhythmia is possible from the physical examination, the response to maneuvers or drugs, and the 12-lead surface electrocardiogram. In all patients with unstable hemodynamics, immediate DC-cardioversion is indicated. Conversion of atrial fibrillation to sinus rhythm is possible using antiarrhythmic drugs. Amiodarone has a conversion rate in atrial fibrillation of up to 80%. However, caution in the use of short-term administration of intravenous amiodarone in critically ill patients with recent-onset atrial fibrillation is absolutely necessary, and the duration of therapy should not exceed 24 to 48 hours. Ibutilide represents a relatively new class III antiarrhythmic agent that has been reported to have conversion rates of 50% to 70%; it seems that ibutilide is even successful when intravenous amiodarone failed to convert atrial fibrillation. ⋯ There is general agreement that bystander first aid, defibrillation, and advanced life support is essential for neurologic outcome in patients after cardiac arrest due to ventricular tachyarrhythmias. The best survival rate from cardiac arrest can be achieved only when (1) recognition of early warning signs, (2) activation of the emergency medical services system, (3) basic cardiopulmonary resuscitation, (4) defibrillation, (5) management of the airway and ventilation, and (6) intravenous administration of medications occurs as rapidly as possible. Public access defibrillation, which places automatic external defibrillators in the hands of trained laypersons, seems to be an ideal approach in the treatment of ventricular fibrillation. The use of automatic external defibrillators by basic life support ambulance providers or first responder in early defibrillation programs has been associated with a significant increase in survival rates. Drugs such as lidocaine, procainamide, sotalol, amiodarone, or magnesium were recommended for treatment of ventricular tachyarrhythmias in intensive care patients. Amiodarone is a highly efficacious antiarrhythmic agent for many cardiac arrhythmias, ranging from atrial fibrillation to malignant ventricular tachyarrhythmias, and seems to be superior to other antiarrhythmic agents.
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Curr Opin Crit Care · Oct 2003
ReviewIs there an optimal hemoglobin value in the cardiac intensive care unit?
Anemia is common in patients admitted to the cardiac intensive care unit. Many unique issues must be considered in the treatment of the anemic cardiac patient. Coronary artery disease and left ventricular dysfunction may significantly increase the risk of anemia. ⋯ Pending definitive clinical trials in cardiac patients, we suggest a more aggressive transfusion trigger (9-10 g/dL) in patients with active cardiac disease. Pulmonary edema may be precipitated by transfusion in patients with left ventricular dysfunction. Large clinical trials are urgently needed to determine optimal transfusion thresholds in patients with cardiovascular disease.
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Curr Opin Crit Care · Oct 2003
ReviewAntimicrobial resistance among gram-negative organisms in the intensive care unit.
We review the hospital-acquired gram-negative organisms commonly encountered among patients in the intensive care unit and discuss pertinent surveillance data, resistance mechanisms and patterns, and optimal treatment regimens for these pathogens. ⋯ Antibiotic resistance continues to rise among hospital-acquired gram-negative pathogens. Optimal management of these infections requires knowledge of local epidemiology and practices to control their spread.
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Curr Opin Crit Care · Oct 2003
ReviewThe role of Ca++-sensitizers for the treatment of heart failure.
For increasing myocardial contractility in patients with cardiac failure, catecholamines, phosphodiesterase-III (PDE) inhibitors, and calcium sensitizers are available. Improving myocardial performance with catecholamines and PDE inhibitors leads to increased intracellular calcium concentration as an unavoidable side effect. An increase in intracellular calcium can induce harmful arrhythmias and increases the energetic demands of the myocardium. ⋯ Levosimendan is a calcium sensitizer with no major inhibition of PDE at clinically relevant doses. It opens ATP-dependent potassium channels and thus has vasodilating and cardioprotective effects. The most important studies of the long-term treatment of stable cardiac failure with pimobendan and on the short-term treatment of unstable cardiac failure with levosimendan are presented.