Current opinion in critical care
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Trauma-induced coagulopathy is a frequent complication in severely injured patients. To correct coagulopathy and restore haemostasis, these patients have traditionally been treated with fresh frozen plasma, but in the last decade, there has been a shift from empirical therapy to targeted therapy with coagulation factor concentrates and other haemostatic agents. This review highlights emerging therapeutic options and controversial topics. ⋯ Current evidence in trauma resuscitation indicates a potential role for coagulation factor concentrates and other haemostatic agents in correcting trauma-induced coagulopathy. Despite a shift towards such transfusion strategy, there remains a shortage of data to support this approach.
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Transfusion paradigms and protocols have evolved at a rapid pace in the last few years to ameliorate the adverse effects of trauma-induced coagulopathy (TIC). This has occurred despite fragmented and inadequate knowledge of the underlying pathophysiology that they are supposed to treat. This review will collate and assimilate the most recent data about TIC in order to present our state-of-the-art understanding of this condition. ⋯ Further improvement in the outcome from trauma-haemorrhage is possible with more refined and tailored haemostatic resuscitation. Achieving this will depend upon a better understanding of the haemostatic defects that develop after injury.
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Curr Opin Crit Care · Dec 2012
ReviewFrom persistence to palliation: limiting active treatment in the ICU.
End-of-life care and communication deficits are important sources of conflicts within ICU teams and with patients or families. This narrative review describes recent studies on how to improve palliative care and surrogate decision-making in ICUs and compares the results with previously published literature on this topic. ⋯ Optimizing palliative care and communication skills is the current challenge in ICU end-of-life care. Intervention strategies should be interdisciplinary, multiprofessional and family-centred in order to quickly reach these goals.
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Curr Opin Crit Care · Dec 2012
ReviewRenal replacement therapy in the critically ill: getting it right.
Survival of critically ill patients with severe acute kidney injury is still low. The aim of this review is to describe recent scientific evidence on renal replacement therapy (RRT) and its potential implications for future research and clinical practice. ⋯ Specific research on RRT timing will be mandatory in the next few years: a standard definition of timing will certainly help to shed new light on how to improve RRT patients' outcome. Dialytic dose of continuous RRT has been recently and definitely standardized to 20-25 ml/kg per hour (dialysis or hemofiltration), however, application to clinical practice still needs to be improved and new evidence on net ultrafiltration prescription showed that fluid balance may be as important as blood purification in critically ill patients with renal dysfunction. Special settings such as septic RRT, pediatric RRT, and RRT during extracorporeal membrane oxygenation recently achieved important results and new applications in clinical practice with important consequences for technical improvement and future care of these patients.
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Curr Opin Crit Care · Dec 2012
ReviewRenal blood flow, fractional excretion of sodium and acute kidney injury: time for a new paradigm?
Global renal blood flow is considered pivotal to renal function. Decreased global renal blood flow (decreased perfusion) is further considered the major mechanism of reduced glomerular filtration rate responsible for the development of acute kidney injury (AKI) in critically ill patients. Additionally, urinary biochemical tests are widely taught to allow the differential diagnosis of prerenal (functional) AKI and intrinsic [structural AKI (so-called acute tubular necrosis)]. In this review we will examine recent evidence regarding these two key clinical paradigms. ⋯ Intra-renal microcirculatory changes are likely more important than changes in global blood flow in the development of AKI. Urinary biochemistry is not a clinically useful diagnostic or prognostic tool in critically ill patients at risk of or with AKI.