Critical care : the official journal of the Critical Care Forum
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Until relatively recently, critical illness was considered as a separate entity and the intensive care unit (ICU), often a little cut-off from other areas of the hospital, was in many cases used as a last resort for patients so severely ill that it was no longer possible to care for them on the general ward. However, we are increasingly realizing that critical illness should be seen as just one part of the patient's disease trajectory and how the patient is managed before and after ICU admission has an important role to play in optimizing outcomes. Identifying critical illness early, before it reaches a stage where it is life-threatening, is a challenge and requires a combination of improved and more frequent or continuous monitoring of at-risk patients, staff training to recognize when a patient is deteriorating, a system to "call for help," and an effective response to that call. ⋯ Early intensivist input may also be important for patients undergoing interventions that are likely to result in ICU admission, e.g., transplantation or cardiac surgery. The patient's continuum after ICU discharge must also be taken into account during their ICU stay, with attempts made to limit the longer-term physical and psychological consequences of critical illness as much as possible. Minimal sedation, good communication, and early mobilization are three factors that can help patients survive their ICU stay with minimal sequelae.
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Review
Host-pathogen interaction during mechanical ventilation: systemic or compartmentalized response?
Patients admitted to the intensive care unit (ICU) often require invasive mechanical ventilation. Ventilator-associated lower respiratory tract infections (VA-LRTI), either ventilator-associated tracheobronchitis (VAT) or ventilator-associated pneumonia (VAP), are the most common complication among this patient cohort. VAT and VAP are currently diagnosed and treated as separate entities, viewed as binary disease elements despite an inherent subjectivity in distinguishing them clinically. ⋯ Taking this model from the realm of theory to the bedside will require a greater understanding of inflammatory and immune pathways, and the development of novel disease-specific biomarkers and diagnostic techniques. Advances will lead to early initiation of optimal bespoke antimicrobial therapy, where the intensity and duration of therapy are tailored to clinical, immune and biomarker response. This approach will benefit towards a personalized treatment.
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Catecholamines are used to increase cardiac output and blood pressure, aiming ultimately at restoring/improving tissue perfusion. While intuitive in its concept, this approach nevertheless implies to be effective that regional organ perfusion would increase in parallel to cardiac output or perfusion pressure and that the catecholamine does not have negative effects on the microcirculation. ⋯ Alternative approaches would be either to minimize exposure to vasopressors, tolerating hypotension and trying to prioritize perfusion but this may be valid as long as perfusion of the organ is preserved, or to combine moderate doses of vasopressors to vasodilatory agents, especially if these are predominantly acting on the microcirculation. In this review, we will discuss the pros and cons of the use of catecholamines and alternative agents for improving tissue perfusion in septic shock.
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Critically ill patients require adequate nutritional support to meet energy requirements both during and after intensive care unit (ICU) stay to protect against severe catabolism and prevent significant deconditioning. ICU patients often suffer from chronic critical illness causing an increase in energy expenditure, leading to proteolysis and related muscle loss. Careful supplementation and modulation of caloric and protein intake can avoid under- or overfeeding, both associated with poorer outcomes. ⋯ Physical exercise may have favorable effects on muscle preservation and should be considered even early in the hospital course of a critically ill patient. After liberation from the ventilator or during non-invasive ventilation, oral intake should be carefully evaluated and, in case of severe dysphagia, should be avoided and replaced by enteral of parenteral nutrition. Upon transfer from the ICU to the ward, adequate nutrition remains essential for long-term rehabilitation success and continued emphasis on sufficient nutritional supplementation in the ward is necessary to avoid a suboptimal nutritional state.
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The founding tenet of evidence-based medicine is to combine best evidence with clinical expertise. As David Sackett opined 'Without clinical expertise, practice risks becoming tyrannised by evidence'. Rigid protocols and mandates, based on an inconclusive and low-level evidence base, cannot suit the physiological, biochemical and biological heterogeneity displayed by the individual septic patient. ⋯ Therapy thus needs to be tailored to meet the individual patient's needs. The same principle should be applied to clinical trials; the continued disappointments of multiple investigational strategies trialled over three decades, despite (often) a sound biological rationale, suggest a repeated methodological failure that does not account for the marked heterogeneity within the septic patient's biological phenotype and thus marked variation in their host response. The increasing availability of rapid point-of-care diagnostics and theranostics should facilitate better patient selection and titrated optimization of the therapeutic intervention.