Current opinion in critical care
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Curr Opin Crit Care · Jun 2010
ReviewApproaches to improving cardiac arrest resuscitation performance.
The survival rate from cardiac arrest remains poor despite advances in cardiopulmonary resuscitation (CPR) and postresuscitation therapies. Recent studies have documented many shortcomings during the performance of resuscitation care. We will review the various methods to improve the delivery of resuscitation care described in the current literature. ⋯ By adopting techniques such as simulation, automated feedback, training refreshers, debriefing and CCR, the quality of resuscitation performance can be increased. Future work needs to demonstrate that improved resuscitation performance correlates with decreased mortality.
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Curr Opin Crit Care · Jun 2010
ReviewUsing oxygen delivery targets to optimize resuscitation in critically ill patients.
The use of fluid and inotropic therapies to optimize global haemodynamic variables, in particular oxygen delivery, in critically ill patients has been a controversial area of research for more than 25 years. The aim of this review is to describe the current evidence base for this treatment and how concepts of haemodynamic optimization have evolved in recent years. ⋯ These advances in our understanding have now informed the design of large randomized trials in various patient groups. The true value of haemodynamic optimization is likely to be confirmed or refuted within the next 5 years.
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We report on the evolution of airway pressure and flow monitoring from a pathophysiological tool to the cornerstone of ventilator-induced lung injury (VILI) prevention. ⋯ Airway pressure and flow monitoring is essential for VILI prevention and for an appropriate setting of mechanical ventilation.
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The physiology of the venous part of the human circulation seems to be a forgotten component of the circulation in critical care medicine. One of the main reasons, probably, is that measures of right atrial pressure (Pra) do not seem to be directly linked to blood flow. This perception is primarily due to an inability to measure the pressure gradient for venous return. The upstream pressure for venous return is mean systemic filling pressure (Pmsf) and it does not lend itself easily to be measured. Recent clinical studies now demonstrate the basic principles underpinning the measure of Pmsf at the bedside. ⋯ Measurement of Pmsf is essential to describe the control of vascular capacitance. It is the key to distinguish between passive and active mechanisms of blood volume redistribution and partitioning total blood volume in stressed and unstressed volume.
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Successful resuscitation requires potentially reversible causes to be diagnosed and reversed, and many of these can readily be diagnosed using echocardiography. Although members of the resuscitation team routinely use adjuncts to their clinical examination in order to differentiate these causes, the use of echocardiography is not yet considered standard. The purpose of this review is to discuss the potential for echocardiography to aid diagnosis and treatment during resuscitation, together with some of the perceived challenges that currently limit its widespread use. ⋯ Persistent and worsening haemodynamic instability are regarded as clear indications for echocardiography. The focused application of this well established technique within the ALS algorithm provides the resuscitation team with a potentially powerful diagnostic tool that can be used to diagnose/exclude some of the potentially treatable causes of cardiac arrest as well as to guide therapeutic interventions. The impact of routine periresuscitation echocardiography on patient outcomes both for in-hospital and prehospital care remains an exciting avenue for future research.