Current opinion in critical care
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Curr Opin Crit Care · Apr 2003
ReviewSedation in neurointensive care: advances in understanding and practice.
To evaluate the rationale and the pharmacologic options for sedating neurointensive care patients. ⋯ The pharmacokinetic and pharmacologic effects of the available sedatives used in neurointensive care patients are reviewed.
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Curr Opin Crit Care · Apr 2003
ReviewEffect of estradiol administration on splanchnic perfusion after trauma-hemorrhage and sepsis.
This review focuses on the latest mechanistic understanding of the effects of estradiol on the splanchnic circulation and the possibility of estradiol treatment as an adjunct for the treatment of trauma-hemorrhage and sepsis. ⋯ Trauma-hemorrhage results in decreased circulating blood volume. In contrast, sepsis is an inflammatory state mainly mediated by bacterial products. However, these divergent insults show similar pathophysiologic alterations in terms of the splanchnic circulation. Because estradiol effectively protects the organs from circulatory failure after various adverse circulatory conditions, many studies are being performed to clarify the molecular mechanism of estradiol action with regard to tissue circulation. Estradiol improves the macro- and microcirculation of the splanchnic organs by multiple mechanisms. Nonetheless, it remains unclear which mechanism plays the most important role in the treatment of trauma-hemorrhage and sepsis. Additional studies are required to elucidate the precise mechanism of estradiol action and to determine the usefulness of estradiol treatment for severe hemorrhage and sepsis in patients.
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Curr Opin Crit Care · Feb 2003
ReviewWhy protect the right ventricle in patients with acute respiratory distress syndrome?
Even a slight increase in pulmonary vascular resistance can overload a normal right ventricle, which ejects blood through a low-pressure circuit. In a clinical setting, a persistent increase in pulmonary vascular resistance produces acute cor pulmonale. From an echocardiographic point of view, may be defined as the combination of a paradoxical septal motion, reflecting systolic overload, with right ventricular enlargement, reflecting diastolic overload. ⋯ This prognosis has greatly improved with protective ventilation. At the same time, the incidence of acute cor pulmonale has diminished in acute respiratory distress syndrome, and the prognosis of this specific complication has also improved, suggesting that the right ventricle may develop some adaptation against persistent overload. Past lessons, however, have taught us that this potential may be limited and lead us to recommend right ventricular protection during mechanical ventilation.
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Curr Opin Crit Care · Feb 2003
ReviewNoninvasive mechanical ventilation in acute cardiogenic pulmonary edema.
Acute cardiogenic pulmonary edema is a frequent life-threatening emergency. During the last 10 years, increasing attention has focused on the use of noninvasive ventilation to treat patients with various forms of acute respiratory failure. ⋯ However, no sustained benefit (, decreased late mortality) or benefit for less severe forms of cardiogenic pulmonary edema has been demonstrated yet. Moreover, there are still few data that support the use of a specific mode of ventilation over the others.
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Curr Opin Crit Care · Feb 2003
ReviewWhere are we with recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome?
Reduction of tidal volume to limit plateau pressure currently is recommended for the ventilatory management of acute respiratory distress syndrome. However, sufficient evidence now exists to support the fact that excessive reduction in tidal volume may result in harmful alveolar derecruitment depending on the level at which positive end-expiratory pressure is set. ⋯ Moreover, apart from physiologic studies suggesting a potential benefit of recruitment maneuver in terms of recruitment and gas exchange, no data are yet available that demonstrate the ability of such a maneuver to improve outcome. In this article, we discuss the physiologic rules governing recruitment and derecruitment and review articles that provide new insights in the field of recruitment maneuver.