Current opinion in critical care
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Therapeutic hypothermia (i.e. induced body core temperature ≈ 33-35°C) in neurological patients with cerebrovascular disease and traumatic brain injury is a controversially discussed issue in the literature. In this review, we have included the most recently published research covering the use of therapeutic hypothermia and targeted temperature management in neurologic diseases and translated the results into a clinical decision support for the professional healthcare community. ⋯ There is overwhelming evidence that fever is an independent predictor of morbidity and mortality in patients with acute severe neurologic diseases. Although therapeutic hypothermia has been proven to be a potent neuroprotective measure acting on various levels in animal models, many questions such as optimal depth of target temperature, speed of rewarming, duration of cooling and management of side-effects accompanying therapeutic hypothermia are unresolved in human. Therefore, the application of therapeutic hypothermia outside of strictly supervised clinical trials must be carefully considered.
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Curr Opin Crit Care · Apr 2017
ReviewNew insights into the gut as the driver of critical illness and organ failure.
The gut has long been hypothesized to be the 'motor' of multiple organ dysfunction syndrome. This review serves as an update on new data elucidating the role of the gut as the propagator of organ failure in critical illness. ⋯ All components of the gut are adversely impacted by critical illness. Gut injury can not only propagate local damage, but can also cause distant injury and organ failure. Understanding how the multifaceted components of the gut interact and how these are perturbed in critical illness may play an important role in turning off the 'motor' of multiple organ dysfunction syndrome in the future.
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In light of emerging data from clinical trials, the place of high-frequency oscillatory ventilation (HFOV) in the management of acute respiratory distress syndrome (ARDS) is uncertain. This review provides an overview of these new clinical data and also explores new areas of investigation for HFOV in adults. ⋯ Although not first-line, HFOV remains a tool in the armamentarium of the intensivist managing the patient with severe ARDS and refractory hypoxemia. A refinement in the approach to delivering HFOV is warranted, with more attention paid to its adverse hemodynamic consequences.
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Here, we review the present state-of-the-art of microdialysis for monitoring patients with severe traumatic brain injury, highlighting the newest developments. Microdialysis has evolved in neurocritical care to become an established bedside monitoring modality that can reveal unique information on brain chemistry. ⋯ Microdialysis has matured into being a standard clinical monitoring modality that takes its place alongside intracranial pressure and brain tissue oxygen tension measurement in specialist neurocritical care centres, as well as being a research tool able to shed light on brain metabolism, inflammation, therapeutic approaches, blood-brain barrier transit and drug effects on downstream targets. Recent consensus on microdialysis monitoring is paving the way for improved neurocritical care protocols. Furthermore, there is scope for future improvements both in terms of the catheters and microdialysate analyser technology, which may further enhance its applicability.
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Curr Opin Crit Care · Apr 2017
ReviewIntersection of prognosis and palliation in neurocritical care.
Difficult discussions regarding end-of-life care are common in neurocritical care. Because of a patient's neurological impairment, decisions regarding continuing or limiting aggressive care must often be made by patients' families in conjunction with medical providers. This review provides perspective on three major aspects of this circumstance: prognostication, family-physician discussions, and determination of death (specifically as it impacts on organ donation). ⋯ End-of-life care in patients with severe brain injuries is common and represents a complex intersection of prognostication, family communication, and decision-making. Skills to optimize this should be emphasized in neurocritical care providers.