Current opinion in critical care
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Bleeding and death from hemorrhage remain a leading cause of morbidity and mortality in the trauma population. Early resuscitation of these gravely injured patients has changed significantly over the past several years. The concept of damage control resuscitation has expanded significantly with the experience of the US military in southwest Asia. This review will focus on this resuscitation strategy of transfusing blood products (red cells, plasma, and platelets) early and often in the exsanguinating patient. ⋯ The current evidence supports that the acute coagulopathy of trauma is present in a high percentage of trauma patients. Patients who will require a massive transfusion will have improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells.
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To highlight some of the recent key issues surrounding crystalloid and colloid fluid management of critically ill patients. ⋯ Despite hydration remaining a key principle in fluid management in many patients, volume overload is of considerable concern. Recent evidence also suggests that balanced electrolyte formulations are preferable to saline-based formulations in a variety of clinical settings. Furthermore, alkalinization of fluids is protective in the setting of contrast-induced nephropathy. Oncotic load appears to be the most important factor in acute kidney injury associated with colloid fluid therapy.
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Curr Opin Crit Care · Dec 2009
ReviewPhysician communication with families in the ICU: evidence-based strategies for improvement.
Skilled physician-family communication in the ICU has been shown to improve patient outcomes, but until now little attention has been given to the effect of communication on family satisfaction and bereavement outcomes. The aim of this review is to outline the recent evidence that effective physician communication with families, and proactive palliative care interventions, can improve outcomes for both patients and family members in the ICU. ⋯ Empathic communication, skilful discussion of prognosis, and effective shared decision-making are core elements of quality care in the ICU, represent basic competencies for the ICU physician, and should be emphasized in future educational and clinical interventions.
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Curr Opin Crit Care · Dec 2009
ReviewFluid accumulation and acute kidney injury: consequence or cause.
Fluid accumulation and fluid overload are frequent findings in critically ill patients and in those suffering from severe acute kidney injury. This review focuses on the consequences associated with fluid overload in critically ill patients with or without associated acute kidney injury and discusses the potential mechanisms by which acute kidney injury can contribute to fluid overload and whether fluid overload can also contribute to kidney dysfunction. ⋯ Fluid overload is independently associated with increased mortality in patients with acute kidney injury and contributes to worsen outcomes in critically ill patients. Further studies are required to determine the influence of fluid overload on organ function and overall prognosis.