Articles: critical-illness.
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Intensive care patients often require inotropic support to stabilise circulation and to optimise oxygen supply. In this context, the catecholamines norepinephrine (noradrenaline), epinephrine (adrenaline), dopamine and dobutamine are still the mainstay of therapy. They provide, to different extents, a variety of adrenoceptor-mediated actions comprising vasoconstriction (via alpha-receptors) as well as vasodilatation (via beta 1-receptors), and an increase in cardiac output by enhancing inotropy and heart rate (again via beta 1-receptors). ⋯ Depending on the dosage and the speed of intravenous administration, the use of phosphodiesterase inhibitors sometimes results in pronounced decrease of blood pressure which may require vasopressor therapy. Other drugs including histamine H2-agonists are currently under investigation. Their value in the treatment of intensive care patients has still to be evaluated.
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Positioning of critically ill patients affects hemodynamic and cardiopulmonary outcomes. A review of clinical studies indicates that backrest elevations up to 60 degrees do not affect measurement of intracardiac pressures or cardiac output, but PaO2 may diminish in sitting positions following surgical procedures. In lateral positions, measurement of intracardiac pressures and cardiac output is not recommended, since a uniform reference point has not been identified for lateral positions. ⋯ Prone positioning may be beneficial in adult respiratory distress syndrome and in weaning of mechanically ventilated patients. When planning positioning maneuvers, critical care nurses should consider these effects in relation to the specific needs of each patient. Hemodynamic and cardiopulmonary responses to positioning should be evaluated in conjunction with other therapeutic modalities such as those designed to preserve skin integrity and improve comfort.
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Critical care clinics · Apr 1993
ReviewMetabolic and nutritional support of the intensive care patient. Ascending the learning curve.
The learning curve of nutritional support in the critically ill began with the amelioration of the effects of starvation in patients with a disabled intestine. Next, there was an appreciation that feeding formulas could be tailored to support patients with specific organ insufficiencies. Then it was realized that feeding enterally has distinct advantages over feeding parenterally. ⋯ In the future, feeding formulae will be devised that continue to modify the patient's response to illness favorably. Another important consideration is to begin nutritional support as soon as possible--i.e., on the day of admission, if appropriate. The critical care specialist should be expert in these techniques, with the goal of eliminating malnutrition as a confounding variable in the clinical course of the intensive care unit patient.
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Hypoalbuminemia is a common finding in critically ill patients. It has been well documented that hypoalbuminemic patients have a higher morbidity and mortality rate when compared with patients with a normal serum albumin. ⋯ There is, however, very little evidence that this practice is of any benefit. In this article the physiology of albumin in health and disease is reviewed, and those clinical studies that have investigated the use of albumin in acutely ill hypoalbuminemic patients are evaluated.
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This paper reviews presently available techniques for monitoring the adequacy of tissue oxygenation, emphasizing the practical and theoretical problems that exist with presently used measurements. ⋯ In attempting to develop tools to assess adequate tissue oxygenation, emphasis should be placed on the monitoring of individual tissues that are felt to be highly susceptible to reduced oxygen delivery and key to overall survival. Preliminary data involving measurements of the interstitial pH of the gastrointestinal tract suggest that this measurement may be one approach to pursue.