Current opinion in critical care
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Curr Opin Crit Care · Aug 2003
ReviewGoal-oriented shock resuscitation for major torso trauma: what are we learning?
Shock resuscitation is an obligatory intervention for severely injured patients who present in shock. During the past 15 years, with widespread acceptance of "damage control" surgery and early triage to the intensive care unit (ICU) to optimize resuscitation, the lives of many major trauma victims have been saved, and much has been learned about shock resuscitation. Due largely to the work of Shoemaker et al., a resuscitation strategy based on a standardized process using O(2) delivery index (DO(2)I) as an endpoint and physiologic performance goal for interventions has been developed, studied, and refined for resuscitation of shock caused by major trauma. ⋯ Our data analysis indicates that the next challenge will be to develop a similar pre ICU resuscitation process that will use less invasive monitors and different endpoints. Identification of the high-risk resuscitation nonresponders early in the resuscitation process will be needed to redirect their clinical trajectories. As an endpoint for interventions for goal-directed resuscitation in the critically injured trauma patient, systemic O(2) delivery is the current state of the art and the basis for near future development of clinical processes for resuscitation of shock due to major trauma.
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This is a literature review over a time period of the past 2 years concerning glutamine in clinical nutrition. Emphasis is put upon studies of glutamine in clinical settings, but a brief overview of the large range of literature over the role of glutamine in various experimental settings is also included. The most interesting concept for the past 2 years is the suggestion to use plasma glutamine concentration at admission to the intensive care unit as a prognostic marker and as a possible indicator for indication of glutamine supplementation.
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The demand for high-quality care is increasing. A variety of therapies have been shown to improve patient outcomes in critical care. Nevertheless, relatively little research has focused on identifying how to deliver those therapies effectively and efficiently. As a result, the most cost-effective opportunity to improve patient outcomes will likely come not from discovering new therapies but from discovering how to deliver therapies that are known to be effective. ⋯ Because quality is a multidimensional construct, it is unlikely that a single approach will be effective. ICU physicians and hospital leaders must assume a leadership role, implementing a combination of different approaches and developing appropriate systems for patient care.
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The number of critically ill elderly continues to rise, causing health care workers to be faced with decisions regarding aggressiveness of care, rationing of resources, and optimizing outcome. Although survival rates in the critically ill elderly may be lower than those in the younger critically ill, health care workers must focus on customizing treatment to optimize physiologic recovery, quality of life, and functional status. We advocate better research designs incorporating long-term outcomes and genetic predisposition as a means of improving care in the elderly critically ill.
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Curr Opin Crit Care · Aug 2003
ReviewMetabolic alterations in sepsis and vasoactive drug-related metabolic effects.
The main clinical characteristics of sepsis and septic shock are derangements of cardiocirculatory and respiratory function. Additionally, profound alterations in metabolic pathways occur leading to hypermetabolism, enhanced energy expenditure, and insulin resistance. The clinical hallmarks are hyperglycemia, hyperlactatemia, and enhanced protein catabolism. ⋯ Mainstay therapeutic interventions for hemodynamic stabilization are adequate volume resuscitation and vasoactive agents, which, however, have additional impact on metabolic activity. Therefore, beyond hemodynamic effects, specific drug-related metabolic alterations need to be considered for optimal treatment during sepsis. This review gives an overview of the typical metabolic alterations during sepsis and septic shock and highlights the impact of vasoactive therapy on metabolism.