Current opinion in critical care
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Curr Opin Crit Care · Apr 2002
ReviewDecompressive surgery in the treatment of traumatic brain injury.
According to European Brain Injury Consortium (EBIC) and American Brain Injury Consortium (ABIC) guidelines for severe head injuries, decompressive craniectomy is one therapeutic option for brain edema that does not respond to conventional therapeutic measures. As a result of the failure of all recently developed drugs to improve outcome in this patient group, decompressive craniectomy has experienced a revival during the last decade. ⋯ Decompressive craniectomy may, however, be the only method available in developing countries with limited ICU and monitoring resources. Prospectively controlled and randomized studies to definitively evaluate the effect of this old neurosurgical method on outcome in patients with traumatic brain injury (TBI) are forthcoming.
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Curr Opin Crit Care · Apr 2002
ReviewLung injury in acute pancreatitis: mechanisms, prevention, and therapy.
Lung injury is the most pertinent manifestation of extra-abdominal organ dysfunction in pancreatitis. The propensity of this retroperitoneal inflammatory condition to engender a diffuse and life-threatening lung injury is significant. ⋯ The variability in the clinical course of pancreatitis renders it a vexing entity and makes demonstration of the efficacy of any specific intervention difficult. The distinct pathologic entity of pancreatitis-associated lung injury is reviewed with a focus on etiology and potential therapeutic maneuvers.
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Curr Opin Crit Care · Feb 2002
ReviewReinterpreting the pressure-volume curve in patients with acute respiratory distress syndrome.
New evidence requires a reinterpretation of the inflation pressure-volume curve and suggests that neither the lower nor the upper inflection point provides reliable information to determine safe ventilator settings in the acute respiratory distress syndrome. Recruitment probably continues throughout the inflation pressure-volume curve, and studies of the deflation pressure-volume curve, reinflations after partial deflation, or decremental positive end-expiratory pressure trials after a recruitment maneuver are probably needed to determine open-lung positive end-expiratory pressure.
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The clinical relevance of experimental ventilator-induced lung injury has recently received a resounding illustration by the Acute Respiratory Distress Syndrome Network trial that showed a 22% reduction of mortality in patients with acute respiratory disease syndrome when lung mechanical stress was lessened by tidal volume reduction during mechanical ventilation. This clinical confirmation of the concept of ventilator-induced lung injury has also undisputedly substantiated the experimental observation that excessive tidal volume and/or end-inspiratory lung volume is the main determinant of ventilator-induced lung injury. More recently, attention has focused on the roles and implication in the pathogenesis of ventilator-induced lung injury of inflammatory cells and mediators that may be activated and released either in the alveolar space or in the systemic circulation because of the rupture of the alveolar-capillary barrier and on the cellular response to mechanical stress.
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Curr Opin Crit Care · Feb 2002
ReviewReduced tidal volumes and lung protective ventilatory strategies: where do we go from here?
Three major determinants of lung injury associated with mechanical ventilation have been clearly identified: high pressure/high volume, the shear forces caused by intratidal collapse and decollapse leading to barotrauma/volotrauma/biotrauma. The lung protective strategy aims to reduce the impact of all three determinants. A groundbreaking study showed that reduced tidal volume is less dangerous than high tidal volume, but the researchers did not apply "full" lung protective strategy and did not take into account the shear forces. "Full" protective lung strategy was tested in only one study and in a limited number of patients. Several physiologic studies strongly suggest the advantages of the lung protective strategy.