Current opinion in critical care
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Severe acute respiratory syndrome (SARS) is a new disease that caused large outbreaks in several countries in the first half of 2003, resulting in infection in more than 8000 people and more than 900 deaths. During that time, a large body of literature rapidly emerged describing the clinical disease, the etiologic viral agent, and management options. This paper reviews the current status of this knowledge base, with particular reference to the critically ill patient. ⋯ SARS is a predominantly respiratory illness, spread through droplets from respiratory secretions and possibly via a fecal-oral route. A small number of "super-spreaders" appear to have contributed to the rapid proliferation of the disease. Infection control precautions are an essential component of management. Approximately 20% of patients develop progressive pulmonary infiltrates and respiratory failure, and the mortality rate is as high as 10%. Treatment strategies with antiviral agents such as ribavirin have not clearly demonstrated a benefit, but high-dose corticosteroids appear to be beneficial in patients with progressive disease. The recent outbreaks highlighted the potential for this disease to overwhelm critical care resources, by the volume of patients and loss of healthcare workers to illness and quarantine.
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Management of the patient with traumatic brain injury is a rapidly advancing field, characterized in recent years by an improved understanding of intracranial pathophysiology and ways in which outcomes can be improved. Many traditional therapies, such as fluid restriction and hyperventilation, have been called into question and are no longer recommended. Other proposed therapies, such as deliberate hypothermia, remain controversial. This detailed review of the recent literature helps the reader come to an understanding of current scientific and evidence-based practices in this area, with emphasis on those therapies most likely to be of use to the practicing intensivist. ⋯ Some issues in traumatic brain injury have now been resolved, and specific recommendations can be made. Fluid therapy directed toward a euvolemic state is now universally recommended, for example, as is the role of intracranial pressure monitoring. Other areas, such as the use of hypertonic saline, remain controversial. In both cases the authors have made an effort to cite the most recent literature, so that readers can draw their own conclusions from the original source material.
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The establishment and maintenance of an adequate airway is often the single most important initial therapy provided to a victim of severe injury. This may be accomplished by simple techniques such as placement of an oral or nasopharyngeal airway as well as bag-mask ventilation techniques. ⋯ Although paramedics routinely practice endotracheal intubation in the field, there are increasing reports on the many potential risks associated with these procedures as well as increased morbidity and mortality in both pediatric and adult patients. These data have important implications for field airway management in the critically ill trauma patient.
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Based on the progress made during the last few years in understanding the pathophysiology of acute renal failure, a plethora of therapeutic drug and nondrug interventions have been developed and tested in animal and human forms of this disease. The first part of this article focuses on the role of volume expansion and vasopressors in the prevention and treatment of acute renal failure in the critically ill. From all prophylactic measures that have been proposed, volume expansion, or at least correction of volume depletion, remains the most efficient and most evidence-based intervention in these patients. ⋯ The last few years have seen a number of trials with acetylcysteine in the prevention of mainly radiocontrast nephropathy. Although the results are still conflicting, the majority indicates that acetylcysteine, when applied together with adequate volume expansion, may be a useful drug to incorporate in the standard treatment procedures in patients at risk for acute renal failure. Interventions to stimulate the recovery process of the damaged kidney with growth factors, although theoretically sound, have thus far not led to successful results.