Current opinion in critical care
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Curr Opin Crit Care · Dec 2019
ReviewStatus epilepticus - time is brain and treatment considerations.
Status epilepticus is a neurological emergency associated with high morbidity and mortality. There is a lack of robust data to guide the management of this neurological emergency beyond the initial treatment. This review examines recent literature on treatment considerations including the choice of continuous anesthetics or adjunctive anticonvulsant, the cause of the status epilepticus, and use of nonpharmacologic therapies. ⋯ Randomized clinical trials are needed to determine the role for newer generation anticonvulsants and nonpharmacologic modalities for the treatment of epilepticus remains and evaluate the long-term outcomes associated with continuous anesthetics.
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Patients with severe burn injuries pose significant challenges for the intensivist. Though average burn sizes have decreased over time, severe burn injuries involving greater than 20% of the total body surface area still occur. Verified burn centers are limited, making the management of severely burn injured patients at nonspecialized ICUs likely. Current practices in burn care have increased survivability even from massive burns. It is important for intensivists to be aware of the unique complications and therapeutic options in burn critical care management. This review critically discusses current practices and recently published data regarding the evaluation and management of severe burn injury. ⋯ Initial evaluation and treatment of acute severe burn injury remains an ongoing area of study. This manuscript reviews current practices and considerations in the acute management of the severely burn injured patient.
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The current review discusses the supplemental use of vitamin C as an adjunct in the management of sepsis and septic shock. ⋯ Although there are large number of animal studies, only a few small prospective and retrospective studies in humans address the use of vitamin C to treat sepsis. Further research in a controlled and randomized fashion is needed to determine if vitamin C is effective in this role. While there is a promise of ascorbate's addition to the sepsis bundle as an adjunct to resuscitation, the evidence is not conclusive.
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Curr Opin Crit Care · Dec 2019
ReviewReview of massive transfusion protocols in the injured, bleeding patient.
Massive haemorrhage is a significant cause of mortality and morbidity in a variety of clinical settings, although most research has been related to trauma patients. Military studies from recent conflicts found that higher ratios of plasma to red blood cells (RBCs) were associated with increased survival in injured soldiers, and subsequent trials in civilian populations showed similar decreased mortality. Over the last decade, massive transfusion protocols (MTPs) have become an important component in the treatment of the massively bleeding patient. This review is intended to summarize the more recent findings and trends in massive transfusion. ⋯ The absence of a universal definition of massive bleeding or massive transfusion, heterogeneity in patients suffering from massive bleeding, and the difficulty in predicting which patients will require a massive transfusion all contribute to the difficulty of studying massive transfusion. However, there is evidence that higher plasma : RBC ratios correlate with improved survival, and that adjuncts to transfusion play a key role. Furthermore, recent validations of massive haemorrhage scoring systems should allow more consistent and appropriate triggering of massive transfusions.
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The aging surgical population constitutes a unique challenge to clinicians across the spectrum of care. Frailty is a valuable tool for preoperative risk stratification and may guide targeted interventions, such as prehabilitation. The aim of this review is to revise the recent literature on the role of frailty and prehabilitation to optimize geriatric patients undergoing surgery. ⋯ Frailty is a valuable risk stratification tool that better captures the state of augmented vulnerability of older adults. Frail patients benefit from targeted interventions, such as multimodal prehabilitation. Thus, the implementation of nationwide geriatric surgery standards can address ongoing challenges in performing surgery on older, frail patients.