摘要:

Purpose of reviewFor years, the field of sepsis research was extremely active; the net result, however, was rather disappointing. Sepsis is still a major problem in intensive care units worldwide. Frustratingly, sepsis is characterized by a high morbidity and mortality. Although multiple (animal) studies with promising results have been published, the clinical situation has changed only a little. However, the recent 2 or 3 years of sepsis research brought significant results that will have a significant impact on clinical routine.Recent findingsIn the last 2 years, three big randomized controlled clinical trials were published on treatment of sepsis, each leading to a significant improvement in outcome: administration of activated protein C, administration of low dose corticosteroids, and maintenance of strict normoglycemia.SummaryA breakthrough in sepsis research was long awaited. Recent clinical studies demonstrated that an improvement in outcome can be achieved even with simple means. This review focuses on these new therapeutic concepts, hopefully helping to transfer scientific advantages into everyday clinical routine.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe past 35 years have provided a wealth of evidence that mechanical ventilation, although potentially life saving, can injure the lungs. Recent evidence suggests that limiting ventilating gas volumes can reduce patient mortality, but may result in progressive parenchymal derecruitment and alveolar hypoventilation, potentially aggravating systemic hypercarbia and hypoxemia. This review summarizes the current recommendations on a controversial, invasive technique termed ‘extracorporeal life support’ as a means to provide temporary pulmonary support during ‘lung-protective’ strategies.Recent findingsExtracorporeal life support has been implemented since the origins of cardiopulmonary bypass in the 1950s, but differs in several important ways from cardiopulmonary bypass, including its prolonged duration of application. Because extracorporeal life support serves only to supplement physiological derangements and is not therapeutic, patient selection critically impacts results. Whereas reversible neonatal processes such as meconium aspiration and persistent fetal circulation have fostered clinical trials demonstrating the efficacy of extracorporeal life support, adult cardiopulmonary failure extracorporeal life support trials have proved less compelling. Despite two prospective randomized trials that failed to demonstrate its efficacy, adult extracorporeal life support continues in limited centers of excellence. Adult extracorporeal life support survival rates for respiratory failure average 50% when strict criteria are met, but it remains unclear whether these results represent improved outcomes.SummaryExtracorporeal life support is an invasive technique that can provide support to the failing lung. Clinical trials have demonstrated its efficacy in neonatal and pediatric patients, but data in adults are less clear. An ongoing trial in the UK will soon address this important issue.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewSedation and analgesia are important means of providing care for the critically ill patient.Recent findingsIt is now clear that posttraumatic stress disorders resulting from an intensive care unit stay may be prevented by the right level of sedation. New drug developments but also recent findings in new ventilation strategies allow for a sedation management that is better tailored to an individual's need. Most importantly, regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level will help to avoid over- and undersedation and may ultimately improve the outcome of the patient and reduce costs.SummarySedation and analgesia are now regarded as an integral part of treatment on the intensive care unit instead of being an unpleasant but necessary and minor issue. The importance of monitoring the level of sedation and analgesia has only recently been realized. It remains to be shown that new management strategies including an evaluation of the patient, planned interventions and the choice of drugs will further improve the care for the critically ill.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewPostoperative pulmonary complications, including pneumonia, bronchospasm, respiratory failure and prolonged mechanical ventilation, occur commonly and are a significant source of morbidity and mortality. This review will discuss the etiology of postoperative pulmonary complications and the interventions that reduce their risk.Recent findingsGeneral anesthesia and surgery produce changes in the respiratory system and are responsible, along with underlying conditions, for postoperative pulmonary complications. Risk factors include upper abdominal or thoracic surgery, cigarette smoking, chronic respiratory disease, emergency surgery, anesthetic time of 180 min or more, age greater than 70 years, renal failure, poor nutritional status, and significant intraoperative blood loss. The inhibition of phrenic nerve output results in postoperative diaphragmatic dysfunction. Sleep-disordered breathing occurs after surgery even in patients without obstructive sleep apnea, but patients with obstructive sleep apnea may have a worsening of their disease after surgery. A clear advantage of one anesthetic technique over another in reducing postoperative pulmonary complications has not been demonstrated. Conflicting results have been obtained regarding the value of epidural analgesia in preventing postoperative pulmonary complications. Incentive spirometry decreases rates of postoperative pulmonary complications and hospital lengths of stay.SummaryUnderstanding risk factors for the development of postoperative pulmonary complications allows targeted interventions aimed at reducing their frequency and severity. Further research is needed to define the role of regional analgesic and anesthetic techniques in reducing postoperative pulmonary complications, and also to define the nature of risk factors and develop better predictive models of patients at risk of developing postoperative pulmonary complications.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewTo summarize current knowledge on pathophysiology and treatment of drowning accidents. Studies and case reports were searched using the keywords drowning, near-drowning, asphyxia, hypoxia and hypothermia in conjunction with organ systems and specific treatment options.Recent findingsDrowning is defined as death by suffocation in a liquid. In contrast, near-drowning is defined as survival beyond 24 h after a drowning accident. Drowning is a frequent preventable accident with a significant morbidity and mortality in a mostly healthy population. In the majority of patients the primary injury is pulmonary, resulting in severe arterial hypoxemia and secondary damage to other organs. Damage to the central nervous system is most critical in terms of patient survival and subsequent quality of life. Therefore, prompt resuscitation and aggressive respiratory and cardiovascular treatment are crucial for optimal survival. Immediate interruption of hypoxia, aggressive treatment of hypothermia and cardiovascular failure are the cornerstones of correct medical treatment. Unfortunately, accurate neurologic prognosis cannot be predicted from initial clinical presentation, laboratory, radiological or electrophysiological examinations.SummarySeveral case studies have convincingly demonstrated that drowning victims may survive neurologically intact even after prolonged submersion times, in particular in cold water. Therefore, aggressive initial therapeutic efforts are indicated in most near-drowning victims.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewDrug abuse, especially with designer drugs, continues to grow, involving a wide demographic range. Consequently, anesthesiologists may be involved in the care of patients under the acute and chronic influence of a myriad of substances. In addition to the usual physiological damage to vital organs (heart, lungs, kidneys, and immune system) new evidence of permanent damage in regions of the brain responsible for memory and pain mediation is emerging. As drug use continues to increase, anesthesiologists must learn to detect drug abusing patients and avoid known interactions. This article will attempt to review the recent literature on this subject.Recent findingsCocaine, marijuana, ethanol, and heroin top the list of abused drugs, alone and in combination. The combined effects of these drugs can be synergistic in creating cardiovascular instability and toxicity. Because combinations create synergy in dopamine and serotonin transmission, addiction is possibly faster, more entrenched, and more difficult to treat. Anesthesiologists are now becoming involved in many of the rapid detoxification procedures to combat/treat addiction. Only limited research has addressed the newer designer drugs, but case reports regarding hyperthermia, cerebral edema, cerebral vasospasm, and lethal interactions with commonly used medications such as beta-blockers implicate the need for awareness in anesthesia personnel.SummaryDrug abuse continues to be a major problem facing our society. Anesthesiologists encounter emergency cases in which ‘party drugs’ have clearly been used, and may also be anesthetizing patients in whom abuse is present but unrecognized. Understanding how illicit drugs interact with anesthetic agents is of paramount importance.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe purpose of this review is to assess literature pertinent to outcomes benefits accrued by the use of helicopter emergency medical services for trauma transport. A previous annotated bibliography assessed literature published between 1980 and 2000. The goal of this paper is to address developments since fall 2001, and to cast recent studies in the light of earlier work in an attempt to provide a long-range overview of the relevant literature.Recent findingsIn the year covered by this review, we identified four papers that directly assessed the association between the helicopter emergency medical services utilization and trauma outcome, and three that addressed the closely related issue of the helicopter emergency medical services triage appropriateness. An Italian study found no benefit associated with advanced prehospital care for patients with severe head injury. A US multicenter trial assessing blunt trauma transports found a substantial mortality reduction associated with helicopter use. Two other US studies, characterized by a similar ‘natural experiment’ design of assessing mortality changes on either side of a timepoint at which the helicopter emergency medical services availability ceased, reached opposite conclusions about the benefits of the service. Recent studies addressing the helicopter emergency medical services utilization in terms of triage were characterized by varying levels of agreement with the widely held belief that this service is characterized by overtriage.SummaryThe preponderance of recent and previously extant evidence supports an argument that the helicopter emergency medical services transport is associated with significant benefit for some injured patients. The primary challenges at this time include the determination of which patients benefit and the elucidation of which aspects of the helicopter emergency medical services are responsible for any salutary effects of its utilization.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThere is growing evidence that in end-stage shock or during cardiac arrest, inappropriately low endogenous vasopressin plasma levels may be responsible for pathologic vasodilatation, inadequate organ perfusion, and poor outcome. The purpose of this article is to review recent publications featuring arginine vasopressin as a potent vasoconstrictor in various shock states such as systemic vasodilatation, severe hypovolemia, or cardiac arrest.Recent findingsSeveral retrospective investigations give evidence that vasopressin at a dosage of 2-6 U/h is effective in reversing catecholamine-resistant vasodilatory shock due to sepsis or after cardiopulmonary bypass, but prospective randomized controlled trials are warranted. In experimental hypovolemic cardiac arrest or therapy-resistant (irreversible) hypovolemic shock, vasopressin may be an intriguing therapy, although human evidence is not available. Animal data gives strong evidence that vasopressin given during cardiopulmonary resuscitation improves both return of spontaneous circulation and neurological outcome. Clinical experience on the use of vasopressin for in-hospital cardiopulmonary resuscitation with short response time showed equipotency with epinephrine; in patients with out-of-hospital ventricular fibrillation, vasopressin showed improved 24 h survival in comparison with epinephrine. After the large European multicenter study completed in summer 2002, we will hopefully be able to better determine the role of vasopressin versus epinephrine in the management of adult cardiac arrest.SummaryVasopressin administration is emerging as a rational and promising therapy in the management of various shock states and cardiac arrest.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe worldwide burden of trauma is increasing, but is unequal between nations. Trauma targets the young and productive in society and imposes a major burden on the health infrastructure. This review provides a distillation of practice in a busy urban trauma centre dealing with large volumes of penetrating trauma.Recent findingsThe anaesthetist holds a pivotal role in the management of penetrating injury; the requirements of prompt airway control, early delivery to theatre and control of a physiologically brittle patient can be challenging. Recognition that attempts at definitive surgery in exsanguinating patients may do more harm than good has made surgery a tool of resuscitation rather than an end in itself.SummaryDepending on where they practice, clinicians are more or less likely to encounter patients with gunshot wounds. However, adherence to basic principles and attention to the details of temperature control, invasive haemodynamic monitoring, blood product therapy and effective communication should translate to improved outcomes for patients after penetrating trauma.

ISSN:0952-7907    

出版商:OVID    

年代:2003

数据来源: OVID