Critical care : the official journal of the Critical Care Forum
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Microcirculatory perfusion is disturbed in sepsis. Recent research has shown that maintaining systemic blood pressure is associated with inadequate perfusion of the microcirculation in sepsis. Microcirculatory perfusion is regulated by an intricate interplay of many neuroendocrine and paracrine pathways, which makes blood flow though this microvascular network a heterogeneous process. ⋯ Therapy in shock is aimed at the optimization of cardiac function, arterial hemoglobin saturation and tissue perfusion. This will mean the correction of hypovolemia and the restoration of an evenly distributed microcirculatory flow and adequate oxygen transport. A practical clinical score for the definition of shock is proposed and a novel technique for bedside visualization of the capillary network is discussed, including its possible implications for the treatment of septic shock patients with vasodilators to open the microcirculation.
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There has been renewed interest in quantifying acid-base disorders in the intensive care unit. One of the methods that has become increasingly used to calculate acid-base balance is the Stewart model. This model is briefly discussed in terms of its origin, its relationship to other methods such as the base excess approach, and the information it provides for the assessment and treatment of acid-base disorders in critically ill patients.
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This review focuses on mechanical ventilation strategies that allow unsupported spontaneous breathing activity in any phase of the ventilatory cycle. By allowing patients with the acute respiratory distress syndrome to breathe spontaneously, one can expect improvements in gas exchange and systemic blood flow, based on findings from both experimental and clinical trials. In addition, by increasing end-expiratory lung volume, as occurs when using biphasic positive airway pressure or airway pressure release ventilation, recruitment of collapsed or consolidated lung is likely to occur, especially in juxtadiaphragmatic lung legions. ⋯ Recent investigations have questioned the utility of sedation, muscle paralysis and mechanical control of ventilation. Furthermore, evidence exists that lowering sedation levels will decrease the duration of mechanical ventilatory support, length of stay in the intensive care unit, and overall costs of hospitalization. Based on currently available data, we suggest considering the use of techniques of mechanical ventilatory support that maintain, rather than suppress, spontaneous ventilatory effort, especially in patients with severe pulmonary dysfunction.
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The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. ⋯ Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completely replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.
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Critical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. ⋯ Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing length of stay and need for admission. Future critical care policies and health services research should include both the ED and ICU in their analyses.