Current opinion in critical care
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Ventilator-associated pneumonia usually originates from the patient's oropharyngeal microflora. In selective digestive decontamination, topical antibiotics are applied to the oropharynx and stomach for prevention of pneumonia and other infections, possibly reducing infection-related mortality. Selective digestive decontamination is also used for the prevention of gut-derived infections in acute necrotizing pancreatitis and liver transplantation. ⋯ Mortality was not reduced in most individual trials, but this finding was calculated in meta-analyses, especially for combined use of topical and systemic antibiotics in surgical ICU patients. Some investigators reported increased resistance and a shift to Gram-positive pathogens. Today, it appears that selective means not only selective suppression of pathogenic bacteria but also selection of appropriate groups of patients for underlying diseases and severity of illness, and selection of ICUs, where the endemic resistance patterns might allow the use of selective digestive decontamination at a relatively low risk for increased selection pressure.
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Curr Opin Crit Care · Apr 2002
ReviewModerate hypothermia in severe head injuries: the present and the future.
The use of therapeutic moderate hypothermia for treating severe traumatic brain injury has been reported for more than 50 years. However, the most intense investigation of this treatment has occurred during the last 10 to 15 years. Virtually all preclinical studies have documented a robust treatment effect, not only in terms of reduced excitotoxicity and cerebral acidosis, but also in terms of histologic preservation and improved behavioral outcomes. ⋯ Current investigations, particularly in the preclinical arena, are focusing on combination therapy. To date, however, the addition of fibroblast growth factor, cyclosporine, or interleukin (IL)-10 to therapeutic moderate hypothermia has not been found to provide greater benefit than either therapy when used alone. Future investigations are aimed at further identifying the physiologic mechanisms responsible for secondary brain injury and ways in which other novel combination therapies may be expected to improve outcomes.
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The unique pathophysiology of patients with end-stage liver disease has important implications for their critical care treatment, particularly in the postoperative state. To gauge hemodynamic parameters and responses, each patient must be carefully evaluated for their place in the clinical spectrum of cirrhosis and portal hypertension. Although the data are limited, the biology of the consequences of liver disease is emphasized by novel treatments of hepatorenal syndrome, portopulmonary hypertension, and hepatopulmonary syndrome. These issues become more relevant with increased adult-to-adult living donor liver transplantation, in which technical considerations may further complicate the general treatment of the postoperative transplant patient.
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Curr Opin Crit Care · Apr 2002
ReviewAdvanced monitoring in the neurology intensive care unit: microdialysis.
Cerebral microdialysis is a relatively new technique for measuring the levels of brain extracellular chemicals, which to date has predominantly been used as a research tool. This review considers the technical aspects of microdialysis, the importance of the commonly measured chemicals, and the use of microdialysis to monitor patients with ischemic stroke, head injury, and subarachnoid hemorrhage. The advantages and disadvantages of microdialysis are discussed, as is its future potential.
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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.