Minerva anestesiologica
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Critically ill cirrhotic patients are characterized by unique and complicated clinical scenarios related to some characteristic and clear-cut pathophysiological features of their chronic end-stage liver disease that challenge Intensive Care Unit (ICU) physicians with several management problems. This class of patients may require admission to the ICU because of decompensation of their pre-existing liver disease or due to medical problems independent of cirrhosis as pneumonia, trauma or surgery. ⋯ Despite some improvement that was recently reported, patients with decompensated cirrhosis pose to ICU physicians several and, sometimes, dramatic dilemmas in terms of therapeutic strategies and efficacy of the treatments also due to the lack of large specific studies on this particular class of patients. This review will focus on kidney, cardiopulmonary and cerebral complications of severe cirrhosis as well as those related to portal hypertension and their management.
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Minerva anestesiologica · Jun 2012
ReviewEarly interventions in severe sepsis and septic shock: a review of the evidence one decade later.
The outcomes of acute myocardial infarction, trauma, and stroke have improved by implementing processes that provide early diagnosis and aggressive interventions at the most proximal point of disease presentation. A common feature in these conditions is the implementation of early intervention strategies. One decade ago, a similar approach to sepsis began when a prospective randomized trial compared early goal-directed therapy (EGDT) to standard care using specific criteria for the early identification of high risk patients with infection. ⋯ Since the EGDT study was published a decade ago, significant emphasis worldwide has been placed on a comprehensive approach to the first 6 hours of sepsis management which is commonly referred to as the resuscitation bundle (RB). The RB consists of early diagnosis, risk stratification using lactate levels, hemodynamic response after a fluid challenge, antibiotics, source control and hemodynamic optimization or EGDT. This review will examine one decade of evidence for the components of the RB examining its impact on systemic inflammation, the progression of organ failure, health care resource consumption and mortality in severe sepsis and septic shock.