Minerva anestesiologica
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The concept of analgo-sedation in intensive care medicine has changed considerably since the last decades. Deep sedation, keeping patients artificially unconscious, is not necessary anymore, it postpones weaning from mechanical ventilation, it provokes complications, and prolongs the length of ICU stay. On the other hand, recent surveys have shown that patients recall their intensive care experience still as stressing and painful. ⋯ Regularly repeated assessment of the sedation level (e.g. by Ramsay score) is mandatory; a sedation protocol seems advantageous. To avoid inadvertent accumulation and overdose, it is recommended to keep the patient at a sedation level at which communication is still possible. A daily interruption of the sedation has shown to shorten the duration of mechanical ventilation and the length of ICU stay.
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Minerva anestesiologica · Apr 2004
ReviewMicrovasculature in ventilator-induced lung injury: target or cause?
Clinicians managing acute lung injury must reconcile the competing objectives of ensuring adequate oxygen delivery and minimizing the adverse effects of ventilatory support. Judging from our experimental work, microvascular stresses appear to be a potent cofactor in the development of pulmonary edema as well as in the expression of lung damage resulting from an injurious pattern of ventilation. ⋯ Raising ventilation frequency may also have cost. Such observations imply that reducing the demands for blood flow and ventilation are important considerations in formulating a lung protective approach to mechanical ventilation of ARDS.
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Maintenance of adequate cardiac preload is of paramount importance in the treatment of patients undergoing major surgical surgery and in the critically ill setting. The end point is to maintain the organ perfusion through volume replacement and therapy to optimize cardiac output, oxygen deliver. ⋯ We briefly review the intra thoracic blood volume index as a preload index and the fluid responsiveness indexes, stroke volume variation and pulse pressure variation, available as novel parameters at the bed-side. The optimization of fluid balance and vasoactive drugs administration based on volumetric monitoring makes the transpulmonary indicator dilution technique a new option as an effective monitoring system where intravascular volume management is a primary objective.
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Minerva anestesiologica · Apr 2004
ReviewThe pulmonary artery catheter in critically ill patients. Does it change outcome?
Initially described more than 30 years ago, the Pulmonary Artery Catheter (PAC) technique was becoming more and more used in the following years. This hemodynamic monitoring device can be used according 2 different therapeutic attitudes. The first one strives to achieve supranormal hemodynamic values, particularly in terms of cardiac index and oxygen consumption. ⋯ Furthermore, because it is an invasive procedure, the safety of the PAC has been seriously questioned for several years. However, the recent study of Richard and coworkers clearly demonstrated that the use of PAC was not responsible for increased mortality in severely ill patients with circulatory shock and/or acute respiratory distress syndrome. The development of educational programs would allow to improve the quality of the collection and interpretation of hemodynamic parameters with the hope to enhance the efficiency of the PAC for the management of critically ill patients.
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Minerva anestesiologica · Apr 2004
Review[Moderate hypothermia in traumatic brain injury: results of clinical trials].
The concept of neuroprotection' by hypothermia dates back to ancient times. This paper reviews the results of clinical trials using mild hypothermia (3235 degrees C) in patients with severe traumatic brain injury over the past decade. Induced hypothermia has been used in experimental models mostly to prevent or attenuate secondary neurological injury and has been used to provide neuroprotection in traumatic brain injury, both in animal models and clinical trials. ⋯ These differences may be explained by differences in study protocols (i.e. speed and duration of cooling, speed of re-warming), prevention of side effects and various supportive measures in the ICU. Although induced hypothermia appears to be a highly promising treatment in various forms of neurological injury including traumatic brain injury, the difficulties in realising its therapeutic potential are underscored by the negative results from a large multi-center trial. Routine usage of hypothermia in traumatic brain injury can not currently be recommended.