Articles: function.
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The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. ⋯ Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.
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Semin Respir Crit Care Med · Feb 2014
ReviewHigh-Resolution CT of Interstitial Lung Disease: A Continuous Evolution.
Before the advent of high-resolution computed tomography (HRCT), the role of imaging, chest radiography in particular, in the management of patients with interstitial lung disease was limited. In the past 25 years, this has radically changed. HRCT has transformed the diagnostic landscape by providing detailed cross-sectional imaging of the lungs, which permit ready identification of a variety of different interstitial lung diseases. ⋯ Recently, HRCT data have been integrated with pulmonary function in staging models to predict prognosis particularly in idiopathic fibrosing lung disease. This article reviews these stages of evolution. The emergence of the multidisciplinary approach to diagnosis will also be considered.
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Anasthesiol Intensivmed Notfallmed Schmerzther · Feb 2014
Review[Update glutamine and antioxidants in critically ill patients].
Critical illness leads to oxidative stress and can induce or exacerbate nutrient deficiencies. This predisposes patients in the intensive care unit to impaired immune function and increased risk of developing infectious complications, organ dysfunction, and therefore worsens clinical outcome. ⋯ The following article summarizes the rationale and provides an update on recent clinical studies with special focus on the use of glutamine and antioxidants in critically ill patients. It further provides recommendations for the clinical use of these substrates in this particular patient population.
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Curr Opin Anaesthesiol · Feb 2014
ReviewCerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients.
Spinal cord ischemia after thoracoabdominal aortic interventions is a devastating complication because it significantly worsens the perioperative morbidity and mortality. Long-term outcome is also affected because of medical complications which are directly related to the neural deficits. Paraplegia has significant medical, social, and financial aspects. Limited mobility, the need for assistance in activities of daily living, makes paraplegia an important target for prevention. An understanding of spinal cord blood supply, risk factors for spinal ischemia, and strategies for spinal cord rescue in this setting can help minimize the negative outcome effects of this important complication. ⋯ The progression of spinal cord ischemia after thoracoabdominal aortic interventions can frequently be arrested before irreversible infarction results. This spinal cord rescue depends on the early detection and immediate multimodal intervention to maximize spinal cord oxygen supply. The devastating outcomes associated with spinal infarction in this setting offset the risks and knowledge gaps currently associated with contemporary interventions.
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Review Historical Article
Clinical applications of targeted temperature management.
Targeted temperature management (TTM) has been investigated experimentally and used clinically for over 100 years. The initial rationale for the clinical application of TTM, historically referred to as therapeutic hypothermia, was to decrease the metabolic rate, allowing the injured brain time to heal. Subsequent research demonstrated the temperature dependence of diverse cellular mechanisms including endothelial dysfunction, production of reactive oxygen species, and apoptosis. ⋯ Additionally, TTM has been demonstrated to improve outcomes for neonatal patients with anoxic brain injury secondary to hypoxic ischemic encephalopathy. Trials are currently under way, or have yielded conflicting results in, examining the utility of TTM for the treatment of ischemic stroke, traumatic brain injury, and acute myocardial infarction. In this review, we place TTM in historic context, discuss the pathophysiologic rationale for its use, review the general concept of a TTM protocol for the management of brain injury, address some of the common side effects encountered when lowering human body temperature, and examine the data for its use in diverse disease conditions with in-depth examination of TTM for postarrest care and pediatric applications.