Critical care : the official journal of the Critical Care Forum
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Dual-cannulae tracheostomy tubes with low-pressure cuffs, such as the Shiley LPC, are widely regarded as inherently safer than single lumen tubes with low-volume cuffs. For the patient who undergoes tracheostomy for failure to wean from mechanical ventilation, however, the insertion of a tube that occupies a large amount of space within the trachea can delay subsequent efforts to liberate him from the ventilator. ⋯ This allows caregivers to better exploit the benefits of a functional upper airway early during the weaning process, which may reduce complications associated with prolonged mechanical ventilation. We urge clinical studies to determine how the choice of initial tracheostomy tube can affect rehabilitation strategies and important patient outcomes.
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Comment Review
Further cautions for the use of ventilatory-induced changes in arterial pressures to predict volume responsiveness.
Variations in systemic arterial pressure with positive-pressure breathing are frequently used to guide fluid management in hemodynamically unstable patients. However, because of the complex physiology that determines the response, there are important limitations to their use. Two papers in a previous volume add pulmonary hypertension as limitations. Uncritical use of ventilatory-induced changes in arterial pressure can lead to excessive volume therapy and potential clinical harm, and they must be used with respect and thought.
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Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. ⋯ Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder.
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Fresh frozen plasma (FFP) is indicated for the management of massive bleedings. Recent audits suggest physician knowledge of FFP is inadequate and half of the FFP transfused in critical care is inappropriate. Trauma is among the largest consumers of FFP. ⋯ The supporting studies, however, have bias limiting the interpretation of the results. Furthermore, logistical considerations including need for immediately available universal donor AB plasma, short life after thawing, potential waste and transfusion-associated complications have challenged its implementation. The present review focuses on FFP transfusion in massive bleeding and critically appraises the evidence on formula-driven resuscitation, providing resources to allow clinicians to develop informed opinion, given the current deficient and conflicting evidence.
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General illness severity scores are widely used in the ICU to predict outcome, characterize disease severity and degree of organ dysfunction, and assess resource use. In this article we review the most commonly used scoring systems in each of these three groups. ⋯ It is possible that their combined use could provide a more accurate indication of disease severity and prognosis. All these scoring systems will need to be updated with time as ICU populations change and new diagnostic, therapeutic and prognostic techniques become available.