Critical care : the official journal of the Critical Care Forum
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Comment Review
Preventing severe hypoxia during emergent intubation: is nasopharyngeal oxygenation the answer?
Critically ill patients requiring emergent endotracheal intubation are at risk for life-threatening hypoxemia during the intubation procedure, particularly when the patient is apneic and not receiving any supplemental oxygen. In a current study, Engström and colleagues investigated the effect of nasopharyngeal oxygenation in eight anesthetized pigs with induced acute lung injury. The investigators confirmed, even in this model, that pharyngeal oxygenation significantly prolonged the time to desaturation during periods of apnea. Recognizing the limitations of directly extrapolating these experimental results to critically ill human subjects, the findings do support the contention that, until proven otherwise, nasopharyngeal oxygenation should at least be considered as one technique to diminish hypoxemic complications in very sick patients, particularly those with underlying pulmonary impairment.
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Sedative and analgesic medications are routinely used in mechanically ventilated patients. The aim of this review is to discuss epidemiologic data that suggest a relationship between infection and sedation, to review available data for the potential causes and pathophysiology of this relationship, and to identify potential preventive measures. ⋯ Prolongation of exposure to risk factors for infection, microaspiration, gastrointestinal motility disturbances, microcirculatory effects, and immunomodulatory effects are main mechanisms by which sedation may favour infection in critically ill patients. Future studies should compare the effect of different sedative agents, and the impact of progressive opioid discontinuation compared with abrupt discontinuation on ICU-acquired infection rates.
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Critically ill patients are frequently prescribed sedatives and analgesics to ensure patient safety, to relieve pain and anxiety, to reduce stress and oxygen consumption, and to prevent patient ventilator dysynchrony. Recent studies have revealed that these medications themselves contribute to worsening clinical outcomes. An evidence-based organizational approach referred to as the ABCDE bundle (Awakening and Breathing Coordination of daily sedation and ventilator removal trials; Choice of sedative or analgesic exposure; Delirium monitoring and management; and Early mobility and Exercise) is presented in this commentary.
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Lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1), the major endothelial receptor for oxidized low-density lipoprotein, is also involved in leukocyte recruitment. Systemic leukocyte activation in sepsis represents a crucial factor in the impairment of the microcirculation of different tissues, causing multiple organ failure and subsequently death. The aim of our experimental study was to evaluate the effects of LOX-1 inhibition on the endotoxin-induced leukocyte adherence and capillary perfusion within the intestinal microcirculation by using intravital microscopy (IVM). ⋯ Inhibition of LOX-1 reduced leukocyte activation in experimental endotoxemia. LOX-1 represents a novel target for the modulation of the inflammatory response within the microcirculation in sepsis.
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Development of organ dysfunction associated with sepsis is now accepted to be due at least in part to oxidative damage to mitochondria. Under normal circumstances, complex interacting antioxidant defense systems control oxidative stress within mitochondria. ⋯ Antioxidants can be targeted selectively to mitochondria by several means. This review describes the in vitro studies and animal models of several diseases involving oxidative stress, including sepsis, in which antioxidants targeted at mitochondria have shown promise, and the future implications for such approaches in patients.