Minerva anestesiologica
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Minerva anestesiologica · Mar 2013
ReviewBrain-lung crosstalk in critical care: how protective mechanical ventilation can affect the brain homeostasis.
The maintenance of brain homeostasis against multiple internal and external challenges occurring during the acute phase of acute brain injury may be influenced by critical care management, especially in its respiratory, hemodynamic and metabolic components. The occurrence of acute lung injury represents the most frequent extracranial complication after brain injury and deserves special attention in daily practice as optimal ventilatory strategy for patients with acute brain and lung injury are potentially in conflict. Protecting the lung while protecting the brain is thus a new target in the modern neurointensive care. This article discusses the essentials of brain-lung crosstalk and focuses on how mechanical ventilation may exert an active role in the process of maintaining or treatening brain homeostasis after acute brain injury, highlighting the following points: 1) the role of inflammation as common pathomechanism of both acute lung and brain injury; 2) the recognition of ventilatory induced lung injury as determinant of systemic inflammation affecting distal organs, included the brain; 3) the possible implication of protective mechanical ventilation strategy on the patient with an acute brain injury as an undiscovered area of research in both experimental and clinical settings.
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Thrombomodulin has a pivotal role in the protein C system that is important in the pathogenesis of sepsis. In sepsis, endothelial cell expression of thrombomodulin is strongly downregulated, causing an impaired activation of protein C that is central in the modulation of coagulation activation and inflammatory processes. ⋯ Several preclinical studies in experimental sepsis models have shown that administration of soluble thrombomodulin is capable of improving the derangement of coagulation, ameliorates inflammatory responses and may restore organ dysfunction. Initial clinical studies in patients with disseminated intravascular coagulation, of whom a significant proportion were patients with sepsis, demonstrate a beneficial effect of recombinant soluble thrombomodulin on restoration of coagulation and improvement of organ failure.
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Acute respiratory distress syndrome (ARDS) is a common entity in critical care medicine and associated with many diagnoses, including trauma and sepsis, which may lead to multiple organ failure and death. Pathophysiologically, increased capillary permeability is the hallmark of ARDS which is characterized by damage of the capillary endothelium and alveolar epithelium in association with impaired fluid removal from the alveolar space and the accumulation of protein-rich fluid inside the alveoli. The clinical management of patients with ARDS is even more difficult, because in the presence of capillary leakage in the lungs, adequate intravascular volume and cardiac preload are required to maintain organ perfusion. ⋯ The transpulmonary thermo-dye dilution technique has been introduced as an instrument to quantify the fluid in the pulmonary capillary bed, i.e., extravascular lung water (EVLW). This technique has shown to be potentially valuable in the management of critically ill patients and has been further developed to be clinically available nowadays as single transpulmonary thermodilution. The following review deals with the measurement of EVLW and its place in the management of critically ill patients with ARDS.
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Minerva anestesiologica · Mar 2013
Comparative StudyA comparison of continuous non-invasive arterial pressure with invasive radial and femoral pressure in patients undergoing cardiac surgery.
Non-invasive continous monitoring of finger arterial pressure has gained increasing interest. The aim of the present study was to compare the accuracy of non-invasive reconstructed brachial artery pressure by the Nexfin™ device (NFAP) with invasive femoral (IFAP) and radial (IRAP) artery pressure before and after cardiopulmonary bypass (CPB). ⋯ Non-invasive, reconstructed brachial artery pressure showed moderate correlation compared with both invasive femoral and radial artery pressure. Furthermore, the non-invasive monitoring system was able to reflect percentage changes in mean arterial pressure in a moderate fashion.