Current opinion in critical care
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Curr Opin Crit Care · Apr 2015
ReviewRecommendations for management of large hemispheric infarction.
Large hemispheric infarction is a devastating disease that continues to be associated with significant mortality and morbidity. Most often these patients are admitted to the ICU requiring significant physician and nursing resources. This review will address some of the ICU management issues and review the evidence supporting medical and surgical management of malignant cerebral edema. ⋯ Large hemispheric infarcts continue to have significant morbidity and mortality. Recent guidelines have provided an excellent framework to help intensivists manage these complicated patients. Recent surgical data continue to support early hemicraniectomy even in elderly patients.
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Curr Opin Crit Care · Apr 2015
ReviewRecommendations for the use of multimodal monitoring in the neurointensive care unit.
Multimodal monitoring (MMM) is routinely applied in neurointensive care. Unfortunately, there is no robust evidence on which MMM-derived physiologic variables are the most clinically relevant, how and when they should be monitored, and whether MMM impacts outcome. The complexity is even higher because once the data are continuously collected, interpretation and integration of these complex physiologic events into targeted individualized care is still embryonic. ⋯ MMM allows comprehensive exploration of the complex pathophysiology of acute brain damage and, depending on the different configuration of the pathological condition we are treating, the application of targeted individualized care. Unfortunately, we still lack robust evidence on how to better integrate MMM-derived information at the bedside to improve patient management. Advanced informatics is promising and may provide us a supportive tool to interpret physiologic events and guide pathophysiological-based therapeutic decisions.
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Curr Opin Crit Care · Apr 2015
ReviewLiver transplantation in the context of organ shortage: toward extension and restriction of indications considering recent clinical data and ethical framework.
The scarcity of liver grafts requires to optimize the results of transplantation. Extensions and alternatives of liver transplantation have to be regularly evaluated. ⋯ Before implementation of these potential changes into decisional algorithms for listing and organ allocation, their consequences, either for patient's individual benefit or for global transplant outcomes, should be closely evaluated using objective long-term end points and taking into account the ethical recommendations for organ transplantation.
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Although advances in critical care management and liver transplantation have improved survival in acute liver failure (ALF), mortality remains significant. An evidence base to support management has been lacking, due to the condition's rarity, severity and heterogeneity. The purpose of this review is to critically appraise the latest evidence, updating clinicians on the current understanding of the best management. ⋯ Traditional dogma in ALF management is questioned: transplant thresholds for acetaminophen overdose, steroid use in autoimmune ALF, routine antimicrobial prophylaxis, the coagulopathy of liver disease, the value of intracranial pressure monitoring and extracorporeal liver support.
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To summarize existing evidence on definition, epidemiology, mechanisms, risk factors, consequences, outcome and management of diarrhoea in the critically ill. ⋯ A definition of diarrhoea and a practical approach to identify the precipitant and to manage diarrhoea in critically ill patients are proposed.