Current opinion in critical care
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Stress ulcer prophylaxis in critically-ill patients has been a subject of extensive research, with multiple clinical trials attempting to study the best method of stress ulcer prophylaxis with the least adverse effects. Until recently, pharmacologic prophylaxis has prevailed as the primary choice for the prevention of stress ulcers but recent clinical studies have attempted to evaluate the role of enteral nutrition in stress ulcer prophylaxis. ⋯ The results of multiple recent clinical studies call for re-evaluation of the routine use of PPIs in critically ill patients who tolerates enteral nutrition in the ICU. Despite the promising preliminary results, definitive recommendations need larger clinical trials that are powered to evaluate any added benefits of using PPI in critically ill patients who tolerate enteral nutrition given the low incidence of CIGB in the current era.
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Curr Opin Crit Care · Aug 2019
ReviewMechanical circulatory support devices in cardiogenic shock and acute heart failure: current evidence.
The main purpose of this review is to highlight and summarize recently published studies on the usage of short-term mechanical circulatory support devices for treatment of cardiogenic shock. Importantly, this review will focus on percutaneously implanted devices. ⋯ Randomized, controlled trials are utterly needed to guide treatment with mechanical circulatory support for patients with cardiogenic shock. Importantly, such trials should focus patient selection criteria.
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This review provides an update of recently conducted studies and randomized controlled trials evaluating prokinetic drugs. ⋯ It may not be feasible to establish superiority of a prokinetic drug within a randomized controlled trial with a patient-centered event as the primary outcome. The use of metoclopramide and erythromycin as prokinetic drugs is based on observations from trials measuring surrogate physiological outcomes. Randomized controlled trials of alternative drug regimens and novel prokinetic drugs have recently been completed and results outlined.
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Curr Opin Crit Care · Aug 2019
ReviewRevascularization strategies in cardiogenic shock after acute myocardial infarction.
Coronary revascularization compared with medical treatment alone leads to improved survival in patients with myocardial infarction (MI) and cardiogenic shock. Percutaneous coronary intervention (PCI) is the predominant mode of revascularization in clinical practice. This review discusses several aspects relevant to mechanical revascularization such as general indication, the roles of PCI and bypass surgery, percutaneous access site choice, strategy in multivessel disease and adjunctive antithrombotic therapy. ⋯ Coronary revascularization remains the cornerstone in the early management of patients with acute MI and cardiogenic shock. In patients with multivessel disease, a strategy of culprit lesion only PCI is the default approach.
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Curr Opin Crit Care · Aug 2019
ReviewVenoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence.
Temporary circulatory support (TCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of VA-ECMO principles, indications, management, complications, and discusses the results of recent case series and trials. ⋯ TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the place VA-ECMO in cardiogenic shock treatment strategies.