Minerva anestesiologica
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Minerva anestesiologica · Jul 2012
Sedation practices in a cohort of critically ill patients receiving prolonged mechanical ventilation.
The aim of this paper was to describe type and amount of sedatives, opioid analgesics and anti- psychotics administered to critically ill patients receiving prolonged mechanical ventilation and identify patient-specific factors associated with their administration. ⋯ In critically ill patients receiving prolonged ventilation, history of substance abuse predicted a 3-fold increase in 14-day cumulative dose of sedatives and opioids used. Conversely, older age was associated with decreased use of sedatives and opioids and history of alcohol abuse was only associated with decreased opioid use. Overall, patients receiving prolonged mechanical ventilation appeared to consume high cumulative doses of sedatives and opioids, with less frequent use of antipsychotics. Accounting for patient characteristics may help identify individuals with varying sedative needs.
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Non-invasive ventilation (NIV) is increasingly used in patients with acute respiratory failure, but few data exist regarding current sedation practices during NIV. Mask intolerance or claustrophobia, and delirium and agitation, may lead to NIV failure, requiring endotracheal intubation. Judicious use of sedation during NIV could be one of the valuable options for some of these patients at risk of intubation. ⋯ Pilot studies suggest that continuous infusion of a single sedative agent may decrease patient discomfort, with no significant effects on respiratory drive, respiratory pattern, or hemodynamics. In addition, gas exchange improved under NIV with sedation. While the current limited data available suggests that sedation during NIV is safe and feasible, more widespread application should await the results of randomized clinical trials.
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Minerva anestesiologica · Jul 2012
ReviewProcalcitonin and sepsis: recent data on diagnostic utility prognostic potential and therapeutic implications in critically ill patients.
Procalcitonin (PCT) has emerged as the most specific biomarker for bacterial infection. As clinicians become more familiar with its use, a multitude of observational studies have reported on its diagnostic potential in distinct types of infections and various clinical situations, such as in neutropenia or in the postoperative period. In the Intensive Care Unit setting, however, the prognostic value of a single PCT measurement at the time of admission on a patient with sepsis is suboptimal. ⋯ The most recent significant development in the field of PCT monitoring, is the publication of several randomized controlled trials that investigated its use as a decision making tool for the initiation and/or the duration of antibiotic treatment. Currently, the available evidence suggests that the incorporation of PCT measurements to assist with the duration of antibiotic stewardship programs may decrease antibiotic use without compromising clinical outcomes. Nevertheless, this strategy still needs further validation in large prospective studies.
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Minerva anestesiologica · Jul 2012
Case ReportsPosterior reversible encephalopathy syndrome in the Intensive Care Unit after liver transplant: a comparison of our experience with the existing literature.
Posterior reversible encephalopathy syndrome (PRES) is a rare disease characterized by altered mental status, seizures, headache, vomiting and visual disturbances, most often described after transplantation and immunosuppressive therapy. PRES is commonly first diagnosed by the neuroradiologist, rather than the clinician, as it is characterized by very typical magnetic resonance imaging (MRI) features, i.e., hyperintense lesions in the territories of the posterior cerebral artery. Here we report our experience in the Intensive Care Unit (ICU) with a case of tacrolimus-related PRES after liver transplant, presenting with sudden neurological deterioration and diffuse and massive hyperintensities upon brain MRI. ⋯ In conclusion, tacrolimus-related brain adverse events need to be promptly recognized, especially during the first months after transplantation. When tacrolimus-related PRES occurs, immunosuppressive therapy may be safely and efficiently switched to everolimus and mycofenolic acid. This strategy may help not only to avoid acute organ rejection but also to reduce the dosage of corticosteroids, which might interfere with proper control of hypertension.