Critical care : the official journal of the Critical Care Forum
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The benefit of albumin administration in the critically ill patient is unproven. Epidemiological evidence suggests that there is an increase in death among patients with burns, hypoalbuminaemia, and hypotension treated with human albumin solution (HAS). ⋯ When treating patients with hypoalbuminaemia, efforts must be centred around correction of the underlying disorder rather than reversal of hypoalbuminaemia. Problems with using albumin arise because it is an expensive blood product, and can result in systemic changes that include cardiovascular, haematological, renal, pulmonary, and immunological effects.
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According to the Frank-Starling relationship, a patient is a 'responder' to volume expansion only if both ventricles are preload dependent. Mechanical ventilation induces cyclic changes in left ventricular (LV) stroke volume, which are mainly related to the expiratory decrease in LV preload due to the inspiratory decrease in right ventricular (RV) filling and ejection. In the present review, we detail the mechanisms by which mechanical ventilation should result in greater cyclic changes in LV stroke volume when both ventricles are 'preload dependent'. We also address recent clinical data demonstrating that respiratory changes in arterial pulse (or systolic) pressure and in Doppler aortic velocity (as surrogates of respiratory changes in LV stroke volume) can be used to detect biventricular preload dependence, and hence fluid responsiveness in critically ill patients.
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Cost is a key concern in fluid management. Relatively few data are available that address the comparative total costs of care between different fluid management regimens in particular clinical indications. Relevant costs of fluid-associated morbidity and mortality, including those incurred after intensive care unit or hospital discharge, also need to be considered in evaluating the cost-benefit ratios of administered fluids. Rigorously designed pharmacoeconomic studies are needed to delineate the costs and benefits of various approaches to fluid management.
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Although many promising objective methods (measuring systems) are available, there are no truly validated instruments for monitoring intensive care unit (ICU) sedation. Auditory evoked potentials can be used only for research in patients with a deep level of sedation. Other measuring systems require further development and validation to be useful in the ICU. ⋯ The Glasgow Coma Score modified by Cook and Palma (GCSC) achieves good face validity and reliability, which assures its clinical utility for routine practice and research. Other scales, in particular the Ramsay Scale, can be recommended preferably for clinical use. An accurate use of available instruments can improve the sedative treatment that we deliver to our patients.
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Clinical Trial
Balloon laryngoscopy reduces head extension and blade leverage in patients with potential cervical spine injury.
Head extension and excessive laryngoscope blade levering motion (LBLM) are undesirable during airway management of trauma patients. We hypothesized that laryngoscopy with a modified blade facilitating glottic exposure by balloon inflation would reduce head extension and LBLM. ⋯ Balloon laryngoscopy reduces head extension and LBLM under simulated cervical spine precautions.