Crit Care Resusc
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Discussions of cardiac physiology and pathophysiology most often emphasise the function of the left heart. However, right heart dysfunction plays an important role in critically ill patients and is often not recognised. This is probably because the role of the right ventricle is for generating flow more than pressure, and flow is not easy to evaluate. ⋯ It has recently become evident that the right ventricle also has different genetic origins and characteristics from the left ventricle. The right and left ventricles interact through series effects, diastolic interactions and systolic interactions. The mechanisms of these, and their physiological and pathological significance are discussed.
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The value of echocardiography in the critically ill patient is well established, yet applying the modality to patients who could benefit presents considerable logistical challenges. Central is a lack of readily available, trained operators. Although many intensive care specialists and trainees are keen to fill this gap, there are numerous hurdles to obtaining the necessary training. ⋯ It is important that, after training, intensivists can be readily credentialed in their home institutions. The intensive care community needs to determine the vehicle for training and credentialling in echocardiography. This could be achieved solely by bodies representing intensive care or in collaboration with the Australasian Society for Ultrasound in Medicine.
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Clozapine-induced neuroleptic malignant syndrome (NMS) may present differently from NMS associated with traditional antipsychotic agents, with fewer clinical features, particularly fewer extrapyramidal manifestations. The risk of developing NMS with clozapine does not appear dose-related. In half of cases, it occurs within 2 weeks of beginning clozapine therapy, but it can develop at any stage, especially with long-term use. We describe a patient who presented with atypical NMS after more than 10 years of clozapine treatment, and who was safely re-challenged with the same drug.
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Review Meta Analysis
Thrombolysis is not warranted in submassive pulmonary embolism: a systematic review and meta-analysis.
Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in hospitalised patients. While the vast majority of patients with PE survive, a subset die, mostly within a few hours of presentation. Anatomically massive pulmonary emboli account for only half these deaths, while submassive or recurrent embolism accounts for the other half. ⋯ There is also evidence to support the use of thrombolysis in patients with massive PE. However, the optimal management of patients with submassive PE is controversial. This article looks at the definition and diagnosis of submassive PE, and systematically reviews the role of thrombolytic therapy in this subgroup of patients.
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Despite the established role of catecholamines for the treatment of circulatory shock in intensive care medicine, these drugs have been subjected to few randomised controlled trials with high methodological quality and patient-centred outcomes. The literature has been dominated by low-quality, case-control studies of the effects of synthetic catecholamines on surrogate haemodynamic end-points. A recent Cochrane systematic review of the effects of vasopressors on mortality from circulatory shock identified seven randomised controlled trials, none of which demonstrated any conclusive evidence of benefit of one inotrope/vasopressor over another. ⋯ Three higher-quality studies of catecholamines (noradrenaline, adrenaline, dopamine and vasopressin) have been completed, the results of which will provide some evidence of efficacy of catecholamines on mortality and resolution of shock. These studies may provide the basis for designing and conducting a large-scale, pragmatic, randomised controlled trial to analyse the effects of these commonly used drugs on patient-centred outcomes, such as mortality, resolution of organ failure and hospital length of stay. The results of such a study would be particularly important in geographical regions where access to inotropes/vasopressors other than adrenaline remains restricted.