Current opinion in critical care
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The sympathetic-parasympathetic balance may be altered in critically ill patients. Assessment of autonomic function provides information concerning prognosis, pathogenesis, and treatment strategies in ICU-relevant disorders. Proven tools are heart rate variability, baroreflex sensitivity, and, with limitations, cardiac chemoreflex sensitivity. ⋯ In addition, a model is introduced for investigating the impaired autonomic function in multiple organ dysfunction syndrome and sepsis, integrating extrinsic mechanisms and factors that are intrinsic to the cardiac tissue. By this combined approach, the authors hope to gain insight into the pathogenesis of multiple organ dysfunction syndrome. New pathophysiologic concepts are needed for the development of treatment strategies for this life-threatening disease.
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Bone marrow transplantation and stem cell transplantation have become standard therapies offering potential cures for a number of hematologic malignancies and immunologic disorders. Severe infection remains a life threatening complication after transplantation, contributes significantly to morbidity, and may necessitate admission to the ICU. It is estimated that between 20 and 40% of patients receiving bone marrow transplant will require ICU admission in the initial posttransplantation phase. ⋯ Moreover, risk factors identifying patients who will benefit most from intensive support are poorly defined. However, it is generally accepted that respiratory failure requiring invasive mechanical ventilation is associated with a poor prognosis in this patient group. Early involvement of intensivists in the management of critical illness in transplant recipients is likely to continue to improve survival in this group of patients.
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The abdominal compartment syndrome is an increasingly recognized complication of both medical and surgical patients in the ICU setting. This syndrome has been described in a wide variety of clinical scenarios and results from a persistent elevation in intra-abdominal pressure characterized by graded organ system dysfunction. Manifestations of abdominal compartment syndrome include cardiovascular, pulmonary, renal, splanchnic, and neurologic impairment. ⋯ Patients at risk for abdominal compartment syndrome warrant close monitoring and we recommend prompt abdominal decompression following documentation of increased intra-abdominal pressure in the setting of physiologic compromise. Abdominal compartment syndrome can significantly contribute to the morbidity and mortality of both medical and surgical patients alike in the ICU. The signs and symptoms of abdominal compartment syndrome should become familiar to all critical care practitioners.
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Effective use of sedative-hypnotic and analgesic agents is an integral part of providing patient comfort and safety. Of the numerous drugs administered, benzodiazepines, propofol, and narcotics are the most popular. Even these proven, time-tested sedative-hypnotics and analgesics are not perfect, however, and modern intensive care demands a more ideal product. ⋯ Slower bolus loading over 20 minutes results in minimally decreased heart rate and blood pressure. Continuous infusion maintains unique sedation (patients appear to be asleep, but are readily roused), analgesic sparing effect, and minimal depression of respiratory drive. More experience with dexmedetomidine infusion in medical ICU patients and patients with complex end-organ dysfunction such as respiratory failure or systemic inflammatory response syndrome is needed before conclusions can be drawn about the drug's potential for wider application and its long-term (> 24 h) safety and effectiveness.