Current opinion in critical care
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Resuscitation with hydroxyethyl starch (HES) is controversial. In this review, we will present the current evidence for the use of HES solutions including data from recent high-quality randomized clinical trials. ⋯ There is no evidence for an overall beneficial effect of HES in any subgroup of critically ill patients, but there are clear signs of harm. As safer alternatives exist, we recommend that HES is no longer used in critically ill patients.
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Curr Opin Crit Care · Aug 2013
ReviewReappraising Starling: the physiology of the microcirculation.
Vascular permeability is traditionally explained by Starling's principle, describing two opposing forces across the endothelial cell line to maintain compartments in balance. Several contradictions to this principle have recently questioned its validity. ⋯ Starling's principle requires an adaptation to recognize that there is no inward-directed oncotic pressure gradient across the whole anatomical vessel wall. The carrier of vascular barrier competence is the intact endothelial surface layer which might be protected by avoiding intravascular hypervolaemia and limiting inflammation.
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The review is focused on the challenge of managing airway and ventilation in the intraoperative and postoperative period. ⋯ The combination of planning extubation of predicted and unpredicted difficult airway, both intraoperative low tidal volume and low FiO2 with LRM and PEEP at different points of surgery and postoperative noninvasive ventilation should be considered in patients undergoing surgery to decrease the rate of postoperative pulmonary complications and major fatal complications such as brain damage and death.
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Fluid resuscitation is a common intervention in acute medical practice. The optimum fluid for resuscitation remains hotly debated and it is likely to vary from one clinical situation to another. Human albumin solutions have been available since the 1940s, but their use varies greatly around the world. This review examines the current evidence for and against the use of albumin as a resuscitation fluid. ⋯ Fluid resuscitation with albumin is well tolerated and produces similar results to resuscitation with saline. Albumin should be avoided in patients with traumatic brain injury; possible benefits in adults with severe sepsis remain to be confirmed.
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This review examines the long-term influence of postoperative complications on survival. Although it is intuitive that complications after surgery worsen short-term outcomes, it is not clear to what extent and why a longer-term relationship may exist. ⋯ Patients that develop postoperative complications and survive the immediate risk period, demonstrate worsened long-term mortality. The field of perioperative medicine is increasingly mandated to identify vulnerable individuals, develop and implement strategies to prevent and treat complications, and provide better care pathways after hospital discharge.