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Anestezjologia intensywna terapia [journal]
- What's new in medical management strategies for raised intra-abdominal pressure: evacuating intra-abdominal contents, improving abdominal wall compliance, pharmacotherapy, and continuous negative extra-abdominal pressure. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Nov 25.
In the future, medical management may play an increasingly important role in the prevention and management of intra-abdominal hypertension (IAH). A review of different databases was used (PubMed, MEDLINE and EMBASE) with the search terms 'Intra-abdominal Pressure' (IAP), 'IAH', ' Abdominal Compartment Syndrome' (ACS), 'medical management' and 'non-surgical management'. We also reviewed all papers with the search terms 'IAH', 'IAP' and 'ACS' over the last three years, only extracting those papers which showed a novel approach in the non-surgical management of IAH and ACS.IAH and ACS are associated with increased morbidity and mortality. Non-surgical management is an important treatment option in critically ill patients with raised IAP. There are five medical treatment options to be considered to reduce IAP: 1) improvement of abdominal wall compliance; 2) evacuation of intra-luminal contents; 3) evacuation of abdominal fluid collections; 4) optimisation of fluid administration; and 5) optimisation of systemic and regional perfusion. This paper will review the first three treatment arms of the WSACS algorithm: abdominal wall compliance; evacuation of intra-luminal contents and evacuation of abdominal fluid collections. Emerging medical treatments will be analysed and finally some alternative specific treatments will be assessed. Other treatment options with regard to optimising fluid administration and systemic and regional perfusion will be described elsewhere, and are beyond the scope of this review. Medical management of critically ill patients with raised IAP should be instigated early to prevent further organ dysfunction and to avoid progression to ACS. Many treatment options are available and are often part of routine daily management in the ICU (nasogastric, rectal tube, prokinetics, enema, sedation, body position). Some of the newer treatments are very promising options in specific patient populations with raised IAP. Future studies are warranted to confirm some of these findings.
- Fluid therapy and perfusional considerations during resuscitation in critically ill patients with intra-abdominal hypertension. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Nov 25.
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are consistently associated with morbidity and mortality among the critically ill or injured. Thus, avoiding or potentially treating these conditions may improve patient outcomes. With the aim of improving the outcomes for patients with IAH/ACS, the World Society of the Abdominal Compartment Syndrome recently updated its clinical practice guidelines. In this article, we review the association between a positive fluid balance and outcomes among patients with IAH/ACS and how optimisation of fluid administration and systemic/regional perfusion may potentially lead to improved outcomes among this patient population.Evidence consistently associates secondary IAH with a positive fluid balance. However, despite increased research in the area of non-surgical management of patients with IAH and ACS, evidence supporting this approach is limited. Some evidence exists to support implementing goal-directed resuscitation protocols and restrictive fluid therapy protocols in shocked and recovering critically ill patients with IAH. Data from animal experiments and clinical trials has shown that the early use of vasopressors and inotropic agents is likely to be safe and may help reduce excessive fluid administration, especially in patients with IAH. Studies using furosemide and/or renal replacement therapy to achieve a negative fluid balance in patients with IAH are encouraging. The type of fluid to be administered in patients with IAH remains far from resolved. There is currently insufficient evidence to recommend the use of abdominal perfusion pressure as a resuscitation endpoint in patients with IAH. However, it is important to recognise that IAH either abolishes or increases threshold values for pulse pressure variation and stroke volume variation to predict fluid responsiveness, while the presence of IAH may also result in a false negative passive leg raising test.Correct fluid therapy and perfusional support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension. Controlled studies determining whether the above medical interventions may improve outcomes among those with IAH/ACS are urgently required.
- From therapeutic hypothermia towards targeted temperature management: a decade of evolution. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Nov 25.
More than a decade after the first randomised controlled trials with targeted temperature management (TTM), it remains the only treatment with proven favourable effect on postanoxemic brain damage after out-of-hospital cardiac arrest. Other well-known indications include neurotrauma, subarachnoidal haemorrhage, and intracranial hypertension. When possible pitfalls are taken into consideration when implementing TTM, the side effects are manageable. After the recent TTM trials, it seems that classic TTM (32-34°C) is as effective and safe as TTM at 36°C. This supports the belief that fever prevention is one of the pivotal mechanisms that account for the success of TTM. Uncertainty remains concerning cooling method, timing, speed of cooling and rewarming. New data indicates that TTM is safe and feasible in cardiogenic shock, one of its classic contra-indications. Moreover, there are limited indications that TTM might be considered as a therapy for cardiogenic shock per se.
- Common pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Nov 25.
Haemodynamic monitoring with transpulmonary thermodilution (TPTD) is less invasive than a pulmonary artery catheter, and is increasingly used in the Intensive Care Unit and the Operating Room. Optimal treatment of the critically ill patient demands adequate, precise and continuous monitoring of clinical parameters. Little is known about staff knowledge of the basic principles and practical implementation of TPTD measurements at the bedside. The aims of this review are to: 1) present the results of a survey on the knowledge of TPTD measurement among 252 nurses and doctors; and 2) to focus on specific situations and common pitfalls in order to improve patient management in daily practice.Web-based survey on knowledge of PiCCO technology (Pulsion Medical Systems, Feldkirchen, Germany), followed by PubMed and Medline search with review of the relevant literature regarding the use of TPTD in specific situations.In total, 252 persons participated in the survey: 196 nurses (78%) and 56 medical doctors (22%) of whom 17 were residents in training. Knowledge on the use of TPTD appears to be suboptimal, with an average score of 58.3%. Doctors performed better than nurses (62.7% vs 57.0%, P = 0.012). About 190 out of 252 (75.4%) scored at least 50% but only 45 respondents (17.9%) obtained a score of 70% or more. Having five years of PiCCO experience was present in 15.8% of the participants and this was correlated to passing the test, defined as obtaining a test result of ≥ 50% (P = 0.07) or obtaining a test result of ≥ 70% (P = 0.05). There were no other parameters significantly predictive for obtaining a result above 50% or above 70% such as gender or doctor versus nurse or Belgian versus Dutch residency, or years of ICU experience. High quality education of nursing and medical staff is necessary to perform the technique correctly and to analyse and interpret the information that can be obtained. Visual inspection of thermodilution curves is important as this can point towards specific pathology. Interpretation of the parameters that can be obtained with TPTD in specific conditions is discussed. Finally, a practical approach is given in ten easy steps for nurses and doctors.TPTD has gained its place in the haemodynamic monitoring field, but, as with any technique, its virtue is only fully appreciated with correct use and interpretation.
- In memory of Professor Stanisław Nęcek. [Editorial]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):213-4.
- Succesful use of recombinant activated coagulation factor VII in a patient with veno-venous ECMO after lung transplantation. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Nov 23.
- Swift recovery of severe acute hypoxemic respiratory failure under non-invasive ventilation. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Oct 27.
In the setting of severe acute respiratory distress syndrome (ARDS; PaO₂/FiO2 < 100), the cut-off point for switching from non-invasive ventilation to intubation combined to mechanical ventilation is poorly defined.The swift resolution over 10 h of a severe acute hypoxemic respiratory failure (P/F = 57) caused by aspiration following heroin overdose, using non-invasive ventilation (NIV)-high PEEP (15-20 cm H₂O)-low pressure support (8 cm H₂0) is reported. The success in treating non-invasively severe hypoxia was presumably linked to a highly restricted subset: healthy young patient, minimal alteration of consciousness, non-combativeness, absence of severe metabolic acidosis, quick resolution of supraventricular arrhythmia, one-to-one supervision by the intensivist in the critical care unit.Given the complications associated with tracheal intubation and mechanical ventilation on the one hand and with delayed intubation on the other hand, high PEEP-NIV may warrant study in a restricted set of patients closely monitored in a critical care environment.
- Role of permissive hypotension, hypertonic resuscitation and the global increased permeability syndrome in patients with severe hemorrhage: adjuncts to damage control resuscitation to prevent intra-abdominal hypertension. [JOURNAL ARTICLE]
- Anaesthesiol Intensive Ther 2014 Oct 8.
Secondary Intra-abdominal hypertension : (IAH) and : Abdominal compartment syndrome (ACS) are closely related to fluid resuscitation. IAH causes major deterioration of the cardiac function by affecting preload, contractility and afterload. The aim of this review is to discuss the different interactions between IAH, ACS and resuscitation and to explore new hypothesis with regard to damage control resuscitation, permissive hypotension and global increased permeability syndrome. : METHODS: Review of the relevant literature via PubMed search. : RESULTS: Damage Control Resuscitation (DCR) is a concept that has recently been introduced in the critical care setting. DCR differs from current resuscitation approaches by attempting an earlier and more aggressive correction of coagulopathy as well as metabolic derangements like acidosis and hypothermia, often referred to as the deadly triad or the bloody vicious cycle. Permissive hypotension involves keeping the blood pressure low enough to avoid exacerbating uncontrolled hemorrhage while maintaining perfusion to vital end organs. The potential detrimental mechanisms of early, aggressive crystalloid resuscitation have been described. Limitation of fluid intake by using colloids, hypertonic saline (HTS) or hyperoncotic albumin solutions have been associated with favorable effects. HTS allows not only for rapid restoration of circulating intravascular volume with less administered fluid but also attenuates post-injury edema at the microcirculatory level and may improve microvascular perfusion. Capillary leak represents the maladaptive, often excessive, and undesirable loss of fluid and electrolytes with or without protein into the interstitium that generates edema. The global increased permeability syndrome (GIPS) has been articulated in patients with persistent systemic inflammation failing to curtail transcapillary albumin leakage and resulting in increasingly positive net fluid balances. GIPS may represent a third hit after the initial insult and the ischemia reperfusion injury. Novel markers like the capillary leak index, extravascular lung water and pulmonary permeability index may help the clinician in guiding appropriate fluid management. : CONCLUSIONS: Capillary leak is an inflammatory condition with diverse triggers that results from a common pathway that includes ischemia-reperfusion, toxic oxygen metabolite generation, cell wall and enzyme injury leading to a loss of capillary endothelial barrier function. : Fluid overload should be avoided in this setting. :
- Drug administration via enteral feeding tubes in intensive therapy - terra incognita? [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):307-11.
The use of enteral feeding tubes has become more frequent, both in hospital settings and in home care. The feeding tubes serve not only to deliver nutrients, but also as a route for medication provision. Nonetheless, the pharmaceutical, legal and technical implications of medication delivery via enteral feeding tubes are not widely understood by doctors and nurses. Not only is the type of medication relevant, but also the type of feeding tube. Crushing tablets may have detrimental effects for a patient and a staff member too. Administering a drug via enteral feeding tubes usually falls outside the terms of the licence (off-label), so burdening medical staff with the entire responsibility for potential adverse reactions.
- Cardiogenic shock - diagnostic and therapeutic options in the light of new scientific data. [Journal Article]
- Anaesthesiol Intensive Ther 2014 Sep-Oct; 46(4):301-6.
Shock is a manifestation of circulatory failure related to an inadequate supply of oxygenated blood to the tissues. One type of shock is cardiogenic shock resulting from abnormalities of myocardial structure and function, impairment of mechanical function of the heart, or arrhythmia. Most commonly, cardiogenic shock is due to an acute myocardial infarction, particularly involving the anterior wall. However, establishing the diagnosis of cardiogenic shock and determining its aetiology is not always easy. Techniques of invasive haemodynamic monitoring, measurements of specific biomarkers, and noninvasive bedside echocardiography may be helpful. The effectiveness of shock management depends on the ability to institute appropriate therapy rapidly and to remove the underlying aetiologic factor(s). We present a state-of-the-art review of basic approaches used for the diagnosis and management of cardiogenic shock.