Current opinion in critical care
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Curr Opin Crit Care · Apr 2018
ReviewLong-term outcome following decompressive craniectomy: an inconvenient truth?
There is little doubt that decompressive craniectomy can reduce mortality following malignant middle cerebral infarction or severe traumatic brain injury. However, the concern has always been that the reduction in mortality comes at the cost of an increase in the number of survivors with severe neurological disability. ⋯ Given these results, the time may have come for a nuanced examination of the value society places on an individual life, and the acceptability or otherwise of performing a procedure that converts death into survival with severe disability.
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Curr Opin Crit Care · Apr 2018
ReviewFrom dysmotility to virulent pathogens: implications of opioid use in the ICU.
Gastrointestinal dysmotility occurs frequently in the critically ill. Although the causes underlying dysmotility are multifactorial, both pain and its treatment with exogenous opioids are likely causative factors. The purpose of this review is to describe the effects of pain and opioids on gastrointestinal motility; outline the rationale for and evidence supporting the administration of opioid antagonists to improve dysmotility; and describe the potential influence opioids drugs have on the intestinal microbiome and infectious complications. ⋯ Replication of clinical studies from ambulant populations in critical care is required to ascertain the independent influence of opioid administration on gastrointestinal motility and infectious complications.
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Pain management in neurocritical care is a subject often avoided because of concerns over the side-effects of analgesics and the potential to cause additional neurological injury with treatment. The sedation and hypercapnia caused by opioids have been feared to mask the neurological examination and contribute to elevations in intracranial pressure. Nevertheless, increasing attention to patient satisfaction has sparked a resurgence in pain management. As opioids have remained at the core of analgesic therapy, the increasing attention to pain has contributed to a growing epidemic of opioid dependence. In this review, we summarize the most recent literature regarding opioids and their alternatives in the treatment of acute pain in patients receiving neurocritical care. ⋯ In an era of increasing attention to patient satisfaction mitigated by growing concerns over the harms imposed by opioids, alternative analgesic therapies are being investigated with promising results.
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This review is to discuss the role of autophagy in the critically ill patient population. As the understanding of autophagy continues to expand and evolve, there are certain controversies surrounding whether intensivist should allow the benefit of autophagy to supersede gold standard of insulin therapy or early nutritional support. ⋯ The jury is still out as to how autophagy will play into clinical practice as we review several gold standard therapies for the critically ill.
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Maintaining gut barrier defenses, modulating immune responses, and supporting the role of commensal microbiota are major factors influencing outcome in critical illness. Of these, maintaining a commensal 'lifestyle' and preventing the emergence of a virulent pathobiome may be most important in reducing risk of infection and multiple organ failure. ⋯ FMT has become an attractive option to mitigate multiple organ dysfunction in the ICU. This article discusses the physiology, rationale, early experience, and expectations for such therapy in the critically ill patient.