Current opinion in critical care
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Recently there has been much interest in the use of hypothermia in the management of the brain-injured patient and its effect on outcome. Most of these studies examine the use of hypothermia compared with normothermia of 37 degrees C and have failed to demonstrate a benefit in the treatment groups, but what is normothermia in the brain-injured patient? Good epidemiologic evidence suggests that the vast majority of patients admitted to an ICU environment will develop a fever. ⋯ Several treatment options for controlling temperature are discussed. Despite a sound physiologic argument for controlling fever in the brain-injured patient, there is no evidence that doing so will improve outcome.
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Curr Opin Crit Care · Apr 2002
ReviewTherapeutic approaches to vasospasm in subarachnoid hemorrhage.
Delayed vasospasm as a result of subarachnoid blood after rupture of a cerebral aneurysm is a major complication. It is seen in over half of patients and causes symptomatic ischemia in about one third. ⋯ The mainstays of treatment are careful maintenance of fluid balance, induced hypervolemia and hypertension, calcium antagonists, balloon or chemical angioplasty, and, in some centers, cisternal fibrinolytic drugs. Promising future lines of treatment include gene therapy, nitric oxide donors, magnesium, sustained release cisternal drugs, and several other drugs that are under experimental or clinical trial.
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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.