Current opinion in critical care
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Management of the patient with traumatic brain injury is a rapidly advancing field, characterized in recent years by an improved understanding of intracranial pathophysiology and ways in which outcomes can be improved. Many traditional therapies, such as fluid restriction and hyperventilation, have been called into question and are no longer recommended. Other proposed therapies, such as deliberate hypothermia, remain controversial. This detailed review of the recent literature helps the reader come to an understanding of current scientific and evidence-based practices in this area, with emphasis on those therapies most likely to be of use to the practicing intensivist. ⋯ Some issues in traumatic brain injury have now been resolved, and specific recommendations can be made. Fluid therapy directed toward a euvolemic state is now universally recommended, for example, as is the role of intracranial pressure monitoring. Other areas, such as the use of hypertonic saline, remain controversial. In both cases the authors have made an effort to cite the most recent literature, so that readers can draw their own conclusions from the original source material.
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The establishment and maintenance of an adequate airway is often the single most important initial therapy provided to a victim of severe injury. This may be accomplished by simple techniques such as placement of an oral or nasopharyngeal airway as well as bag-mask ventilation techniques. ⋯ Although paramedics routinely practice endotracheal intubation in the field, there are increasing reports on the many potential risks associated with these procedures as well as increased morbidity and mortality in both pediatric and adult patients. These data have important implications for field airway management in the critically ill trauma patient.
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Based on the progress made during the last few years in understanding the pathophysiology of acute renal failure, a plethora of therapeutic drug and nondrug interventions have been developed and tested in animal and human forms of this disease. The first part of this article focuses on the role of volume expansion and vasopressors in the prevention and treatment of acute renal failure in the critically ill. From all prophylactic measures that have been proposed, volume expansion, or at least correction of volume depletion, remains the most efficient and most evidence-based intervention in these patients. ⋯ The last few years have seen a number of trials with acetylcysteine in the prevention of mainly radiocontrast nephropathy. Although the results are still conflicting, the majority indicates that acetylcysteine, when applied together with adequate volume expansion, may be a useful drug to incorporate in the standard treatment procedures in patients at risk for acute renal failure. Interventions to stimulate the recovery process of the damaged kidney with growth factors, although theoretically sound, have thus far not led to successful results.
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Acute renal failure is a serious condition that affects as many as 20% of ICU patients. The most common causes of acute renal failure in the ICU patient are severe sepsis and septic shock. The mortality of acute renal failure in septic critically ill patients remains high despite our increasing ability to support vital organs. This is partly the result of our poor understanding of the pathogenesis of sepsis-induced renal dysfunction. Accordingly, a review of our current understanding of the pathogenesis of septic acute renal failure is timely and relevant. ⋯ This review suggests that, on the evidence available, septic acute renal failure is more likely to be an immune or toxic state rather than simply a hemodynamic condition. The authors speculate that future insights into its pathogenesis might lead to a paradigm shift away from the concept of acute tubular necrosis, which has never been convincingly shown in sepsis, to that of acute tubular apoptosis.
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Curr Opin Crit Care · Dec 2003
ReviewCommunication with family members of patients dying in the intensive care unit.
In intensive care units the patient is usually unconscious and/or incompetent so that the relationship shifts to the family. Interactions between caregivers and families usually follow one of three models. In the first model, a family representative receives information from the caregivers but does not participate in decisions or physical care. ⋯ In the third model, the family members communicate their own wishes, provide physical care to the patient, and participate in medical decision-making. After a description of the studies that measured the quality of information provided to ICU families and by discussing the extent to which respecting the principle of patient autonomy is feasible in the ICU, we will review the literature on studies that identified specific needs of families of dying patients and specific challenges faced by intensivists as they seek to inform the families of dying patients. The need for family-centered care and for a better communication within the patient-family-caregiver trio is also highlighted.