Current opinion in critical care
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Curr Opin Crit Care · Apr 2014
ReviewIntracranial pressure after the BEST TRIP trial: a call for more monitoring.
Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI), but whether its management improves the outcome is unclear. In this review, we will examine the implications of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) trial, evidence for an influence of ICP care on outcome, and a need for greater understanding of the pathophysiology than just ICP through multimodal monitoring (MMM) to enhance the outcome. ⋯ ICP-based monitoring and treatment alone may not be enough to enhance TBI outcome, but ICP and cerebral perfusion pressure therapy remain important in TBI care. Although high-quality evidence for MMM is limited, it should be more widely adapted to better understand the complex pathophysiology after TBI, better target care, and identify new therapeutic opportunities.
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Curr Opin Crit Care · Apr 2014
ReviewUpdate in intensive care medicine: acute liver failure. Initial management, supportive treatment and who to transplant.
Acute liver failure (ALF) is associated with significant mortality. Although specific therapies may be available, the evidence base for these and for many aspects of supportive therapy has been slow to emerge. Liver transplantation continues to be a cornerstone of treatment, and the management of ALF, therefore, remains the domain of the specialist ICU. The purpose of this review is to identify and critically appraise the recent evidence and to inspire those who strive to provide excellent care for a difficult patient cohort. ⋯ Increasingly sophisticated prognostication tools are evolving, which have the potential to transform clinical decision-making. A review of the indications for transplantation in acetaminophen toxicity is overdue. The use of therapeutic plasma exchange and extracorporeal liver support in ALF requires further investigation.
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Curr Opin Crit Care · Apr 2014
ReviewFeeding the gut: how, when and with what - the metabolic issue.
To review the literature on feeding critically ill patients with special emphasis on the intestine. ⋯ The use of gastric feeding in critical illness is recommended. Successful gastric feeding is indicative of a functional gastrointestinal tract. Pharmacological effects of nutrients are questionable, but supplementation of deficits (glutamine, selenium, etc.) may be in the patient's best interest. A more individualized prescription of nutrition in the critically ill is advocated.
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Spontaneous intracerebral haemorrhage (ICH) imposes a significant health and economic burden on society. Despite this, ICH remains the only stroke subtype without a definitive treatment. Without a clearly identified and effective treatment for spontaneous ICH, clinical practice varies greatly from aggressive surgery to supportive care alone. This review will discuss the current modalities of treatments for ICH including preliminary experience and investigative efforts to advance the care of these patients. ⋯ ICH lacks a definitive primary treatment as well as a therapy targeting surrounding perihematomal oedema and associated secondary damage. An ongoing phase III trial using MIS techniques shows promise for providing treatment for these patients.
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To review the changing insights in the pathophysiology and management of acute pancreatitis. ⋯ Management of severe acute pancreatitis is changing fundamentally. 'Less is more' is the new paradigm in acute pancreatitis - less antibiotics, less fluids, less surgery, which should eventually lead to less morbidity and mortality.