Current opinion in critical care
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Curr Opin Crit Care · Oct 2012
ReviewHeart rescue: the role of mechanical circulatory support in the management of severe refractory cardiogenic shock.
Cardiogenic shock is present in 3.5% of patients presenting with acute decompensated heart failure. Despite advances in therapy, mortality remains high, approaching 70% in some settings. Recent management strategies have incorporated the use of mechanical circulatory support (MCS), which has been associated with better survival in nonrandomized trials. MCS is increasingly used in the acute setting and has become an important treatment modality for cardiogenic shock. ⋯ This article will review novel strategies in the management of cardiogenic shock including percutaneous MCS (intra-aortic balloon pump, Impella, TandemHeart, venoarterial extracorporeal membrane oxygenation) and surgically implanted devices (CentriMag) that are used for short-term management. We will review the mechanisms involved in cardiogenic shock and discuss management and device selection strategies.
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Curr Opin Crit Care · Oct 2012
ReviewWhat is the niche for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome?
This article reviews the results of case series and trials which evaluated venovenous extracorporeal membrane oxygenation (VV-ECMO) for severe respiratory failure. Potential indications of the technique in this setting are discussed. ⋯ Before widespread diffusion of VV-ECMO for severe ARDS, new trials should test the efficacy of early initiation of the technique with tight control of mechanical ventilation in the control group, initiation of ECMO prior to transportation to ECMO centers, and the use of ECMO in every patient randomly assigned to receive it.
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Curr Opin Crit Care · Oct 2012
ReviewInterventions to decrease the morbidity and mortality associated with implantable cardioverter-defibrillator shocks.
Implantable cardioverter-defibrillator (ICD) implantation is the standard of care for secondary prevention in patients with previous cardiac arrest and for primary prevention in appropriately selected patients with cardiomyopathy. However, ICD therapies and the arrhythmias that trigger these therapies cause decreased quality of life as well as increased morbidity and mortality. In this review, we summarize the recent evidence for interventions that may prevent ICD therapies. ⋯ Pharmacologic therapy and appropriate device programming remain essential to the overall care of ICD patients. The role of CRT continues to grow as we gain a better understanding of its benefits. Advancements in the fields of catheter ablation and new understanding of the autonomic nervous system's effects on ventricular arrhythmias allow interventions to decrease the frequency of ICD shocks.
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An appreciation of the post-ICU burden for family members, as well as the ways to prevent and minimize their symptoms of stress, anxiety, and depression. ⋯ A high proportion of family members present with symptoms of anxiety (70%) and depression (35%). Acute stress disorder and posttraumatic stress disorder (PTSD) related symptoms are also common. These symptoms are significantly more frequent when the relative is a spouse, or in bereaved family members. Few long-term data are available. However, in family members of dying patients, 1 year after the loss, up to 40% of them present with criteria for psychiatric illness such as generalized anxiety, major depressive disorders, or complicated grief. Prevention of post-ICU burden, mostly based on communication strategies, has been proposed to assist relatives.