Annals of intensive care
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Annals of intensive care · Jan 2012
Near infrared spectroscopy (NIRS) of the thenar eminence in anesthesia and intensive care.
Near infrared spectroscopy of the thenar eminence (NIRSth) is a noninvasive bedside method for assessing tissue oxygenation. The NIRS probe emits light with several wavelengths in the 700- to 850-nm interval and measures the reflected light mainly from a predefined depth. Complex physical models then allow the measurement of the relative concentrations of oxy and deoxyhemoglobin, and thus tissue saturation (StO2), as well as an approximation of the tissue hemoglobin, given as tissue hemoglobin index. ⋯ In contrast, NIRS parameters during VOT increase the diagnostic and prognostic accuracy in both hypovolemic and septic shock. Minimal data are available on static or dynamic StO2 used to guide therapy. Although the available data are promising, further studies are necessary before NIRSth can become part of routine clinical practice.
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Noninvasive ventilation (NIV) is frequently used for the management of acute respiratory failure (ARF) in very old patients (≥ 80 years), often in the context of a do-not-intubate order (DNI). We aimed to determine its efficacy and long-term outcome. ⋯ Very old patients managed using NIV have an overall satisfactory 6-month survival and functional status, except for endotracheal intubation after NIV failure.
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Delirium is characterized by a disturbance of consciousness with accompanying change in cognition. Delirium typically manifests as a constellation of symptoms with an acute onset and a fluctuating course. Delirium is extremely common in the intensive care unit (ICU) especially amongst mechanically ventilated patients. ⋯ Pharmacological treatment for delirium traditionally includes haloperidol; however, more data for haloperidol are needed given the paucity of placebo-controlled trials testing its efficacy to treat delirium in the ICU. Second-generation antipsychotics have emerged as an alternative for the treatment of delirium, and they may have a better safety profile. Dexmedetomidine may prove to be a valuable adjunctive agent for patients with delirium in the ICU.
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Annals of intensive care · Jan 2012
A fresh look at paralytics in the critically ill: real promise and real concern.
Neuromuscular blocking agents (NMBAs), or "paralytics," often are deployed in the sickest patients in the intensive care unit (ICU) when usual care fails. Despite the publication of guidelines on the use of NMBAs in the ICU in 2002, clinicians have needed more direction to determine which patients would benefit from NMBAs and which patients would be harmed. Recently, new evidence has shown that paralytics hold more promise when used in carefully selected lung injury patients for brief periods of time. ⋯ It also is increasingly recognized that NMBAs can cause harm, particularly critical illness polyneuromyopathy (CIPM), when used for prolonged periods or in septic shock. In this review, we address several practical considerations for clinicians who use NMBAs in their practice. Ultimately, we conclude that NMBAs should be considered a lung protective adjuvant in early ARDS and that clinicians should consider using an alternative NMBA to the aminosteroids in septic shock with less severe lung injury pending further studies.
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Annals of intensive care · Jan 2012
The transition from acute to chronic pain: might intensive care unit patients be at risk?
Pain remains a significant problem for patients hospitalized in intensive care units (ICUs). As research has shown, for some of these patients pain might even persist after discharge and become chronic. ⋯ The purpose of this paper is to: 1) review cutting-edge theories regarding pain and mechanisms that underlie the transition from acute to chronic pain, such as increases in membrane excitability of peripheral and central nerve fibers, synaptic plasticity, and loss of the function of descending inhibitory pain fibers; 2) provide information on the association between the immune system and pain and its crucial contribution to development of chronic pain syndromes, and 3) discuss mechanisms at brain levels in the nervous system and their contribution to affective (i.e., emotional) states associated with chronic pain conditions. Finally, we will offer suggestions for ICU clinical interventions to attempt to prevent the transition from acute to chronic pain.