Pub Date : 2024-12-01Epub Date: 2024-09-04DOI: 10.1097/MCC.0000000000001204
Rosalia Navarro-Perez, Nekane Romero-García, Camilla Paolessi, Chiara Robba, Rafael Badenes
Purpose of review: This review aims to summarize the latest evidence on the role of near-infrared spectroscopy (NIRS) in monitoring cerebral oxygenation in high-risk surgical patients, including both cardiac and noncardiac surgeries, and to present a new algorithm for its application.
Recent findings: NIRS effectively measures brain oxygen saturation noninvasively, proving valuable in cardiac surgeries to reduce neurological complications, though its impact on nonneurological outcomes is less clear. In noncardiac surgeries, NIRS can help prevent complications like postoperative cognitive dysfunction, particularly in high-risk and major surgeries. Studies highlight the variability of cerebral oxygenation impacts based on surgical positions, with mixed results in positions like the beach chair and sitting positions. A structured algorithm for managing cerebral desaturation has been proposed to optimize outcomes by addressing multiple factors contributing to blood oxygen content and delivery.
Summary: Despite its limitations, including spatial resolution and interindividual variability, NIRS is a useful tool for intraoperative cerebral monitoring. Further studies are needed to confirm its broader applicability in noncardiac surgeries, but current evidence supports its role in reducing postoperative complications especially in cardiac surgeries.
{"title":"Cerebral oximetry in high-risk surgical patients: where are we?","authors":"Rosalia Navarro-Perez, Nekane Romero-García, Camilla Paolessi, Chiara Robba, Rafael Badenes","doi":"10.1097/MCC.0000000000001204","DOIUrl":"10.1097/MCC.0000000000001204","url":null,"abstract":"<p><strong>Purpose of review: </strong>This review aims to summarize the latest evidence on the role of near-infrared spectroscopy (NIRS) in monitoring cerebral oxygenation in high-risk surgical patients, including both cardiac and noncardiac surgeries, and to present a new algorithm for its application.</p><p><strong>Recent findings: </strong>NIRS effectively measures brain oxygen saturation noninvasively, proving valuable in cardiac surgeries to reduce neurological complications, though its impact on nonneurological outcomes is less clear. In noncardiac surgeries, NIRS can help prevent complications like postoperative cognitive dysfunction, particularly in high-risk and major surgeries. Studies highlight the variability of cerebral oxygenation impacts based on surgical positions, with mixed results in positions like the beach chair and sitting positions. A structured algorithm for managing cerebral desaturation has been proposed to optimize outcomes by addressing multiple factors contributing to blood oxygen content and delivery.</p><p><strong>Summary: </strong>Despite its limitations, including spatial resolution and interindividual variability, NIRS is a useful tool for intraoperative cerebral monitoring. Further studies are needed to confirm its broader applicability in noncardiac surgeries, but current evidence supports its role in reducing postoperative complications especially in cardiac surgeries.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153281","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-03DOI: 10.1097/MCC.0000000000001201
Prashant Nasa, Robert Wise, Manu L N G Malbrain
Purpose of review: This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications.
Recent findings: Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content).
Summary: Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.
{"title":"Fluid management in the septic peri-operative patient.","authors":"Prashant Nasa, Robert Wise, Manu L N G Malbrain","doi":"10.1097/MCC.0000000000001201","DOIUrl":"10.1097/MCC.0000000000001201","url":null,"abstract":"<p><strong>Purpose of review: </strong>This review provides insight into recent clinical studies involving septic peri-operative patients and highlights gaps in understanding fluid management. The aim is to enhance the understanding of safe fluid resuscitation to optimize peri-operative outcomes and reduce complications.</p><p><strong>Recent findings: </strong>Recent research shows adverse surgical and clinical outcomes with both under- and over-hydration of peri-operative patients. The kinetic of intravenous fluids varies significantly during surgery, general anaesthesia, and sepsis with damage to endothelial glycocalyx (EG), which increases vascular permeability and interstitial oedema. Among clinical anaesthesia, neuraxial anaesthesia and sevoflurane have less effect on EG. Hypervolemia and the speed and volume of fluid infusion are also linked to EG shedding. Despite improvement in the antisepsis strategies, peri-operative sepsis is not uncommon. Fluid resuscitation is the cornerstone of sepsis management. However, overzealous fluid resuscitation is associated with increased mortality in patients with sepsis and septic shock. Personalized fluid resuscitation based on a careful assessment of intravascular volume status, dynamic haemodynamic variables and fluid tolerance appears to be a safe approach. Balanced solutions (BS) are preferred over 0.9% saline in patients with sepsis and septic shock due to a potential reduction in mortality, when exclusive BS are used and/or large volume of fluids are required for fluid resuscitation. Peri-operative goal-directed fluid therapy (GDFT) using dynamic haemodynamic variables remains an area of interest in reducing postoperative complications and can be considered for sepsis management (Supplementary Digital Content).</p><p><strong>Summary: </strong>Optimization of peri-operative fluid management is crucial for improving surgical outcomes and reducing postoperative complications in patients with sepsis. Individualized and GDFT using BS is the preferred approach for fluid resuscitation in septic peri-operative patients. Future research should evaluate the interaction between clinical anaesthesia and EG, its implications on fluid resuscitation, and the impact of GDFT in septic peri-operative patients.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-18DOI: 10.1097/MCC.0000000000001213
Daniel De Backer, Rocio Rimachi, Jacques Duranteau
Purpose of review: To discuss the role of hemodynamic management in critically ill patients with acute kidney injury.
Recent findings: Acute kidney injury (AKI) may be associated with persistent alterations in renal perfusion, even when cardiac output and blood pressure are preserved. The effects of interventions aiming at increasing renal perfusion are best evaluated by renal Doppler or contrast enhance ultrasound. However, limited data have been acquired with these techniques and the essential of the literature is based on surrogates of renal function such as incidence of use of renal replacement therapy. Fluids may increase renal perfusion but their effects are quite unpredictable and can be dissociated from their impact on cardiac output and arterial pressure. Inotropes can also be used in selected conditions. At the de-escalation phase, fluid withdrawal should be considered. Safe fluid withdrawal may be achieved when applied in selected patients with preserved tissue perfusion presenting signs of fluid intolerance. When applied, stopping rules should be set. Dobutamine, milrinone and levosimendan increase renal perfusion in AKI associated with cardiac failure or after cardiac surgery. However, the impact of these agents in sepsis is not well defined. Regarding vasopressors, norepinephrine is the first-line vasopressor agent, but vasopressin derivative may limit the requirement of renal replacement therapy. Angiotensin has promising effects in a limited size post-Hoc analysis of a RCT, but these data need to be confirmed. While correction of severe hypotension is associated with improved renal perfusion and function, the optimal mean arterial pressure (MAP) target level remains undefined, Systematic increase in MAP results in variable changes in renal perfusion. It sounds reasonable to individualize MAP target, paying attention to central venous and intraabdominal pressures, as well as to the response to an increase in MAP.
Summary: Recent studies have refined the impact of the various hemodynamic interventions on renal perfusion and function in critically ill patients with AKI. Though several of these interventions improve renal perfusion, their impact on renal function is more variable.
综述的目的:讨论血液动力学管理在急性肾损伤重症患者中的作用:急性肾损伤(AKI)可能与肾脏灌注的持续改变有关,即使在心输出量和血压保持不变的情况下也是如此。通过肾脏多普勒或造影剂增强超声波可对旨在增加肾脏灌注的干预措施的效果进行最佳评估。然而,利用这些技术获得的数据有限,大部分文献都是基于肾功能的替代指标,如使用肾脏替代疗法的发生率。输液可增加肾脏灌注,但其效果难以预测,且与对心排血量和动脉压的影响无关。在某些情况下也可以使用肌注药物。在降级阶段,应考虑撤液。如果选定的患者组织灌注得到保留,并出现液体不耐受的迹象,则可安全撤液。使用时应制定停止规则。多巴酚丁胺、米力农和左西孟旦可增加与心力衰竭相关的 AKI 或心脏手术后的肾脏灌注。然而,这些药物对脓毒症的影响尚不明确。关于血管加压药,去甲肾上腺素是一线血管加压药,但血管加压素衍生物可能会限制肾脏替代疗法的需求。在一项规模有限的 RCT 事后分析中,血管紧张素具有良好的效果,但这些数据尚需证实。虽然纠正严重低血压与改善肾脏灌注和功能有关,但最佳平均动脉压(MAP)目标水平仍未确定。根据中心静脉压和腹腔内压以及对 MAP 升高的反应来确定 MAP 目标值是合理的:最近的研究已经完善了各种血流动力学干预措施对 AKI 重症患者肾脏灌注和功能的影响。虽然其中一些干预措施能改善肾脏灌注,但它们对肾功能的影响却不尽相同。
{"title":"Hemodynamic management of acute kidney injury.","authors":"Daniel De Backer, Rocio Rimachi, Jacques Duranteau","doi":"10.1097/MCC.0000000000001213","DOIUrl":"https://doi.org/10.1097/MCC.0000000000001213","url":null,"abstract":"<p><strong>Purpose of review: </strong>To discuss the role of hemodynamic management in critically ill patients with acute kidney injury.</p><p><strong>Recent findings: </strong>Acute kidney injury (AKI) may be associated with persistent alterations in renal perfusion, even when cardiac output and blood pressure are preserved. The effects of interventions aiming at increasing renal perfusion are best evaluated by renal Doppler or contrast enhance ultrasound. However, limited data have been acquired with these techniques and the essential of the literature is based on surrogates of renal function such as incidence of use of renal replacement therapy. Fluids may increase renal perfusion but their effects are quite unpredictable and can be dissociated from their impact on cardiac output and arterial pressure. Inotropes can also be used in selected conditions. At the de-escalation phase, fluid withdrawal should be considered. Safe fluid withdrawal may be achieved when applied in selected patients with preserved tissue perfusion presenting signs of fluid intolerance. When applied, stopping rules should be set. Dobutamine, milrinone and levosimendan increase renal perfusion in AKI associated with cardiac failure or after cardiac surgery. However, the impact of these agents in sepsis is not well defined. Regarding vasopressors, norepinephrine is the first-line vasopressor agent, but vasopressin derivative may limit the requirement of renal replacement therapy. Angiotensin has promising effects in a limited size post-Hoc analysis of a RCT, but these data need to be confirmed. While correction of severe hypotension is associated with improved renal perfusion and function, the optimal mean arterial pressure (MAP) target level remains undefined, Systematic increase in MAP results in variable changes in renal perfusion. It sounds reasonable to individualize MAP target, paying attention to central venous and intraabdominal pressures, as well as to the response to an increase in MAP.</p><p><strong>Summary: </strong>Recent studies have refined the impact of the various hemodynamic interventions on renal perfusion and function in critically ill patients with AKI. Though several of these interventions improve renal perfusion, their impact on renal function is more variable.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142582288","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-23DOI: 10.1097/MCC.0000000000001215
Andres Zorrilla-Vaca, Jimmy J Arevalo, Michael C Grant
Purpose of review: This review aims to provide an updated overview of lung protective strategies in critically ill patients after surgery, focusing on the utility of postoperative open-lung ventilation during the transition from the operating room to the intensive care unit.
Recent findings: Mechanically ventilated patients after surgery represent a challenge in the intensive care unit. Different protective strategies have been proposed to minimize the risk of ventilator-induced lung injury (VILI) and facilitate adequate weaning from mechanical ventilation. Fast-track extubation protocols, increasingly standard in the care of critically ill patients postsurgery, have demonstrated improvements in recovery and reductions in acute lung injury, primarily based on retrospective studies. Open-lung ventilation strategies, such as individualization of positive-end expiratory pressure based on driving pressure and postoperative noninvasive ventilation support with high-flow nasal cannula, are becoming standard of care in high-risk surgical patients after major abdominal or thoracic surgeries.
Summary: Mechanical ventilation in surgical patients should adhere to lung protective strategies (i.e., individualizing positive end expiratory pressure and prioritize alveolar recruitment) during the transition from the operating room to the intensive care unit.
{"title":"Protective mechanical ventilation in critically ill patients after surgery.","authors":"Andres Zorrilla-Vaca, Jimmy J Arevalo, Michael C Grant","doi":"10.1097/MCC.0000000000001215","DOIUrl":"10.1097/MCC.0000000000001215","url":null,"abstract":"<p><strong>Purpose of review: </strong>This review aims to provide an updated overview of lung protective strategies in critically ill patients after surgery, focusing on the utility of postoperative open-lung ventilation during the transition from the operating room to the intensive care unit.</p><p><strong>Recent findings: </strong>Mechanically ventilated patients after surgery represent a challenge in the intensive care unit. Different protective strategies have been proposed to minimize the risk of ventilator-induced lung injury (VILI) and facilitate adequate weaning from mechanical ventilation. Fast-track extubation protocols, increasingly standard in the care of critically ill patients postsurgery, have demonstrated improvements in recovery and reductions in acute lung injury, primarily based on retrospective studies. Open-lung ventilation strategies, such as individualization of positive-end expiratory pressure based on driving pressure and postoperative noninvasive ventilation support with high-flow nasal cannula, are becoming standard of care in high-risk surgical patients after major abdominal or thoracic surgeries.</p><p><strong>Summary: </strong>Mechanical ventilation in surgical patients should adhere to lung protective strategies (i.e., individualizing positive end expiratory pressure and prioritize alveolar recruitment) during the transition from the operating room to the intensive care unit.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142582306","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-10-21DOI: 10.1097/MCC.0000000000001214
Markus B Skrifvars, Benjamin S Abella
Purpose of review: Following successful resuscitation from cardiac arrest, a complex set of pathophysiologic processes are acutely triggered, leading to substantial morbidity and mortality. Postarrest management remains a major challenge to critical care providers, with few proven therapeutic strategies to improve outcomes. One therapy that has received substantial focus is the intentional lowering of core body temperature for a discrete period of time following resuscitation. In this review, we will discuss the key trials and other evidence surrounding TTM and present opposing arguments, one 'against' the use of postarrest TTM and another 'for' the use of this therapeutic approach.
Recent findings: Targeted temperature management, has been a topic of enormous controversy, as recently a number of clinical trials show conflicting results on the effect of TTM. Fundamental questions, about the dosing of TTM (e.g. use at 33 °C versus higher temperatures), or the use of TTM at all (as opposed to passive fever avoidance), remain active topics of global discussion. Systematic reviews on this topic also show variable results.
Summary: There are several arguments for and against the use of TTM targeting 33 °C for alleviating brain injury after cardiac arrest. More studies are on the way that will hopefully provide more robust evidence and hopefully allow for consensus on this important topic.
回顾的目的:心脏骤停复苏成功后,一系列复杂的病理生理过程会被迅速触发,导致大量的发病率和死亡率。心脏骤停后的管理仍然是重症监护提供者面临的一大挑战,几乎没有经过验证的治疗策略可以改善预后。其中一种受到广泛关注的疗法是在复苏后的一段时间内有意降低核心体温。在这篇综述中,我们将讨论有关定向体温管理的主要试验和其他证据,并提出对立的观点,一种是 "反对 "使用复苏后定向体温管理,另一种是 "支持 "使用这种治疗方法:有针对性的体温管理一直是一个极具争议的话题,因为最近的一些临床试验显示,TTM 的效果存在相互矛盾的结果。关于定向体温管理的剂量(如在 33 °C 温度下使用与在更高温度下使用)或定向体温管理的使用(相对于被动退热)等基本问题,仍是全球讨论的热门话题。总结:对于在心脏骤停后使用以 33 °C 为目标的 TTM 缓解脑损伤,支持和反对的观点各有不同。更多的研究正在进行中,有望提供更有力的证据,并有望就这一重要课题达成共识。
{"title":"Does targeted temperature management at 33 °C improve outcome after cardiac arrest?","authors":"Markus B Skrifvars, Benjamin S Abella","doi":"10.1097/MCC.0000000000001214","DOIUrl":"10.1097/MCC.0000000000001214","url":null,"abstract":"<p><strong>Purpose of review: </strong>Following successful resuscitation from cardiac arrest, a complex set of pathophysiologic processes are acutely triggered, leading to substantial morbidity and mortality. Postarrest management remains a major challenge to critical care providers, with few proven therapeutic strategies to improve outcomes. One therapy that has received substantial focus is the intentional lowering of core body temperature for a discrete period of time following resuscitation. In this review, we will discuss the key trials and other evidence surrounding TTM and present opposing arguments, one 'against' the use of postarrest TTM and another 'for' the use of this therapeutic approach.</p><p><strong>Recent findings: </strong>Targeted temperature management, has been a topic of enormous controversy, as recently a number of clinical trials show conflicting results on the effect of TTM. Fundamental questions, about the dosing of TTM (e.g. use at 33 °C versus higher temperatures), or the use of TTM at all (as opposed to passive fever avoidance), remain active topics of global discussion. Systematic reviews on this topic also show variable results.</p><p><strong>Summary: </strong>There are several arguments for and against the use of TTM targeting 33 °C for alleviating brain injury after cardiac arrest. More studies are on the way that will hopefully provide more robust evidence and hopefully allow for consensus on this important topic.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11540270/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142496657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-04DOI: 10.1097/MCC.0000000000001200
Bart Spruijt, Johannes M Huitink
Purpose of review: Airway management is one of the most challenging aspects in the field of anesthesia. This is also the case when an emergency airway situation arises in the postoperative patient. These airway procedures are often classified as advanced with high complexity. This article aims to address emergency airway management in the post anesthesia care unit.
Recent findings: The way in which care and supervision are organized in the post anesthesia care unit (PACU) varies between hospitals. Airway management in the PACU has typical challenges related to the team, the location itself, and assembling the necessary equipment for airway rescue. Crew resource management is an important aspect of care in these situations.
Summary: This article focuses on emergency airway management in the post anesthesia-care unit. A questionnaire for risk assessment and improvement of quality of care is presented. Different types of emergencies are discussed, i.e., due to medication, medical conditions (e.g., obstructive sleep apnea, pulmonary problems, stridor), procedural related emergencies (e.g., neurosurgery, head and neck surgery) and cardiac arrest. Each specific cause of emergency needs a different approach. A PACU airway rescue flowchart is presented.
{"title":"Emergency airway management in the post anesthesia care unit.","authors":"Bart Spruijt, Johannes M Huitink","doi":"10.1097/MCC.0000000000001200","DOIUrl":"10.1097/MCC.0000000000001200","url":null,"abstract":"<p><strong>Purpose of review: </strong>Airway management is one of the most challenging aspects in the field of anesthesia. This is also the case when an emergency airway situation arises in the postoperative patient. These airway procedures are often classified as advanced with high complexity. This article aims to address emergency airway management in the post anesthesia care unit.</p><p><strong>Recent findings: </strong>The way in which care and supervision are organized in the post anesthesia care unit (PACU) varies between hospitals. Airway management in the PACU has typical challenges related to the team, the location itself, and assembling the necessary equipment for airway rescue. Crew resource management is an important aspect of care in these situations.</p><p><strong>Summary: </strong>This article focuses on emergency airway management in the post anesthesia-care unit. A questionnaire for risk assessment and improvement of quality of care is presented. Different types of emergencies are discussed, i.e., due to medication, medical conditions (e.g., obstructive sleep apnea, pulmonary problems, stridor), procedural related emergencies (e.g., neurosurgery, head and neck surgery) and cardiac arrest. Each specific cause of emergency needs a different approach. A PACU airway rescue flowchart is presented.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-07DOI: 10.1097/MCC.0000000000001205
Filippo D'Amico, Giovanni Landoni
Purpose of review: This editorial aims to highlight the evolving concept of protective hemodynamics in the management of critically ill patients.
Recent findings: Recent literature underscores the limitations of rigid blood pressure targets, particularly in the context of critical care and perioperative management. High blood pressure targets, especially when coupled with high-dose vasopressors, can lead to poor outcomes. 'Protective hemodynamics' aims to maintain cardiovascular stability while reducing risks associated with interventions.
Summary: The implications of adopting protective hemodynamics are profound for both clinical practice and research. Clinically, this approach can reduce iatrogenic harm and improve long-term outcomes for critically ill patients. For research, it opens new avenues for investigating individualized hemodynamic management strategies that prioritize overall patient stability and long-term health over rigid target attainment.
{"title":"Protective hemodynamics: a novel strategy to manage blood pressure.","authors":"Filippo D'Amico, Giovanni Landoni","doi":"10.1097/MCC.0000000000001205","DOIUrl":"10.1097/MCC.0000000000001205","url":null,"abstract":"<p><strong>Purpose of review: </strong>This editorial aims to highlight the evolving concept of protective hemodynamics in the management of critically ill patients.</p><p><strong>Recent findings: </strong>Recent literature underscores the limitations of rigid blood pressure targets, particularly in the context of critical care and perioperative management. High blood pressure targets, especially when coupled with high-dose vasopressors, can lead to poor outcomes. 'Protective hemodynamics' aims to maintain cardiovascular stability while reducing risks associated with interventions.</p><p><strong>Summary: </strong>The implications of adopting protective hemodynamics are profound for both clinical practice and research. Clinically, this approach can reduce iatrogenic harm and improve long-term outcomes for critically ill patients. For research, it opens new avenues for investigating individualized hemodynamic management strategies that prioritize overall patient stability and long-term health over rigid target attainment.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-02DOI: 10.1097/MCC.0000000000001203
Hendrik Booke, Alexander Zarbock, Melanie Meersch
Purpose of review: To provide an overview of the current diagnostic criteria for acute kidney injury (AKI) including their limitations and to discuss prevention and treatment approaches in the perioperative setting.
Recent findings: AKI is common in the perioperative period and is associated with worse short- and long-term outcomes. Current definitions of AKI have several limitations and lead to delayed recognition of kidney dysfunction which is why novel diagnostic approaches by using renal biomarkers may be helpful. In general, prevention of the development and progression of AKI is vital as a causal treatment for AKI is currently not available. Optimization of kidney perfusion and avoidance of nephrotoxic drugs reduce the occurrence of AKI in surgical patients. Angiotensin II as a new vasopressor, the use of remote ischemic preconditioning, and amino acids may be approaches with a positive effect on the kidneys.
Summary: Evidence suggests that the implementation of supportive measures in patients at high risk for AKI might reduce the occurrence of AKI. Novel biomarkers can help allocating resources by detecting patients at high risk for AKI.
综述的目的:概述急性肾损伤(AKI)的现行诊断标准,包括其局限性,并讨论围手术期的预防和治疗方法:最近的研究结果:AKI 在围手术期很常见,并与短期和长期预后恶化有关。目前对 AKI 的定义存在一些局限性,导致对肾功能障碍的认识延迟,这就是为什么使用肾脏生物标志物的新型诊断方法可能会有所帮助。一般来说,预防 AKI 的发生和发展至关重要,因为目前还没有治疗 AKI 的因果疗法。优化肾脏灌注和避免使用肾毒性药物可减少手术患者 AKI 的发生。血管紧张素 II 作为一种新的血管抑制剂,使用远程缺血预处理和氨基酸可能是对肾脏有积极影响的方法。摘要:有证据表明,对 AKI 高危患者采取支持性措施可能会减少 AKI 的发生。新型生物标志物可通过检测 AKI 高危患者帮助分配资源。
{"title":"Renal dysfunction in surgical patients.","authors":"Hendrik Booke, Alexander Zarbock, Melanie Meersch","doi":"10.1097/MCC.0000000000001203","DOIUrl":"10.1097/MCC.0000000000001203","url":null,"abstract":"<p><strong>Purpose of review: </strong>To provide an overview of the current diagnostic criteria for acute kidney injury (AKI) including their limitations and to discuss prevention and treatment approaches in the perioperative setting.</p><p><strong>Recent findings: </strong>AKI is common in the perioperative period and is associated with worse short- and long-term outcomes. Current definitions of AKI have several limitations and lead to delayed recognition of kidney dysfunction which is why novel diagnostic approaches by using renal biomarkers may be helpful. In general, prevention of the development and progression of AKI is vital as a causal treatment for AKI is currently not available. Optimization of kidney perfusion and avoidance of nephrotoxic drugs reduce the occurrence of AKI in surgical patients. Angiotensin II as a new vasopressor, the use of remote ischemic preconditioning, and amino acids may be approaches with a positive effect on the kidneys.</p><p><strong>Summary: </strong>Evidence suggests that the implementation of supportive measures in patients at high risk for AKI might reduce the occurrence of AKI. Novel biomarkers can help allocating resources by detecting patients at high risk for AKI.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153357","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-13DOI: 10.1097/MCC.0000000000001210
Sandra L Kane-Gill
Purpose of review: The aim of this review is to provide a discussion of new perspectives for up-to-date definitions, a contemporary classification system, and the potential role of stress and damage biomarkers in the context of drug related kidney diseases and disorders.
Recent findings: Acute kidney disease (AKD) is a term recently introduced in the literature describing an abnormality in kidney structure and function that lasts for less than 3 months. Drugs in the context of AKD is described as a new perspective; referred to as drug induced AKD. A framework that includes drugs into the 2X2 classification schema for acute kidney injury (AKI) is provided. Finally, stress and damage biomarkers are examined to assess risk of drug associated AKI (D-AKI), differentiate which drugs cause AKI, differentiate drugs from other etiologies and assess the prognosis of D-AKI.
Summary: Consistent definitions should be adopted with consideration to drug related diseases and disorders. Drug management can be guided using novel biomarkers to isolate a possible drug cause in the presence of more than one nephrotoxin or a nondrug cause, assisting with the diagnosis of pseudo-AKI, and deciding the likelihood AKI recovery. Furthermore, stress and damage kidney biomarkers provide the opportunity to detect subclinical AKI for early intervention in patients at high-risk for severe AKI.
综述的目的:本综述旨在讨论最新定义的新视角、当代分类系统以及应激和损伤生物标志物在药物相关肾脏疾病和紊乱中的潜在作用:急性肾脏病(AKD)是最近出现在文献中的一个术语,描述持续时间少于 3 个月的肾脏结构和功能异常。药物在急性肾脏病中被描述为一个新的视角;被称为药物诱发的急性肾脏病。本文提供了一个将药物纳入急性肾损伤(AKI)2X2 分类模式的框架。最后,研究了应激和损伤生物标志物,以评估药物相关性 AKI(D-AKI)的风险,区分哪些药物会导致 AKI,将药物与其他病因区分开来,并评估 D-AKI 的预后。可使用新型生物标志物指导药物管理,以在存在一种以上肾毒素或非药物原因的情况下分离出可能的药物原因,协助诊断假性 AKI,并决定 AKI 恢复的可能性。此外,应激和损伤肾脏生物标志物为检测亚临床 AKI 提供了机会,以便对严重 AKI 高危患者进行早期干预。
{"title":"New perspectives of drug related kidney diseases and disorders.","authors":"Sandra L Kane-Gill","doi":"10.1097/MCC.0000000000001210","DOIUrl":"10.1097/MCC.0000000000001210","url":null,"abstract":"<p><strong>Purpose of review: </strong>The aim of this review is to provide a discussion of new perspectives for up-to-date definitions, a contemporary classification system, and the potential role of stress and damage biomarkers in the context of drug related kidney diseases and disorders.</p><p><strong>Recent findings: </strong>Acute kidney disease (AKD) is a term recently introduced in the literature describing an abnormality in kidney structure and function that lasts for less than 3 months. Drugs in the context of AKD is described as a new perspective; referred to as drug induced AKD. A framework that includes drugs into the 2X2 classification schema for acute kidney injury (AKI) is provided. Finally, stress and damage biomarkers are examined to assess risk of drug associated AKI (D-AKI), differentiate which drugs cause AKI, differentiate drugs from other etiologies and assess the prognosis of D-AKI.</p><p><strong>Summary: </strong>Consistent definitions should be adopted with consideration to drug related diseases and disorders. Drug management can be guided using novel biomarkers to isolate a possible drug cause in the presence of more than one nephrotoxin or a nondrug cause, assisting with the diagnosis of pseudo-AKI, and deciding the likelihood AKI recovery. Furthermore, stress and damage kidney biomarkers provide the opportunity to detect subclinical AKI for early intervention in patients at high-risk for severe AKI.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142582295","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-09-26DOI: 10.1097/MCC.0000000000001216
Rory McDonald, James Watchorn, Sam Hutchings
Purpose of review: Acute kidney injury (AKI) is common in critical illness and associated with adverse outcomes. Imaging, specifically ultrasound, is increasingly finding a role in AKI diagnostics. This includes the assessment of arterial and venous blood flow, tissue perfusion and the condition of the renal parenchyma. This review provides an update on ultrasound techniques and their application to AKI in critical care.
Recent findings: Advances have been made in arterial and venous Doppler, contrast enhanced ultrasound (CEUS) and shear wave elastography (SWE). Doppler and CEUS techniques offer benefit in terms of AKI diagnosis and in identifying patients at risk. In addition, through the demonstration of altered flow or impaired perfusion, these techniques provide information on the pathophysiology of AKI, offering potential for targeted intervention. Renal SWE, an emerging technique, assesses tissue stiffness potentially allowing exploration of the role of venous congestion in the pathogenesis of AKI.
Summary: Ultrasound continues to demonstrate great promise in the diagnosis and management of AKI, offering a noninvasive means to diagnose perfusion deficits and assess response to treatments. Further research, with standardization of techniques, may allow multifaceted renal ultrasound assessment in the critically ill for more accurate diagnosis and tailored intervention in AKI.
审查目的:急性肾损伤(AKI)是危重病中的常见病,与不良预后有关。影像学,尤其是超声波,在急性肾损伤诊断中的作用越来越大。这包括评估动脉和静脉血流、组织灌注和肾实质状况。本综述介绍了超声技术的最新进展及其在重症监护中肾脏缺血的应用:最近的研究结果:动脉和静脉多普勒、造影剂增强超声(CEUS)和剪切波弹性成像(SWE)技术都取得了进展。多普勒和造影剂增强超声(CEUS)技术有助于诊断 AKI 和识别高危患者。此外,通过显示血流改变或灌注受损,这些技术还能提供有关 AKI 病理生理学的信息,为有针对性的干预提供可能。肾脏 SWE 是一项新兴技术,可评估组织僵硬度,从而探索静脉充血在 AKI 发病机制中的作用。随着技术的标准化,进一步的研究可能会对重症患者进行多方面的肾脏超声评估,从而对 AKI 进行更准确的诊断和有针对性的干预。
{"title":"New ultrasound techniques for acute kidney injury diagnostics.","authors":"Rory McDonald, James Watchorn, Sam Hutchings","doi":"10.1097/MCC.0000000000001216","DOIUrl":"10.1097/MCC.0000000000001216","url":null,"abstract":"<p><strong>Purpose of review: </strong>Acute kidney injury (AKI) is common in critical illness and associated with adverse outcomes. Imaging, specifically ultrasound, is increasingly finding a role in AKI diagnostics. This includes the assessment of arterial and venous blood flow, tissue perfusion and the condition of the renal parenchyma. This review provides an update on ultrasound techniques and their application to AKI in critical care.</p><p><strong>Recent findings: </strong>Advances have been made in arterial and venous Doppler, contrast enhanced ultrasound (CEUS) and shear wave elastography (SWE). Doppler and CEUS techniques offer benefit in terms of AKI diagnosis and in identifying patients at risk. In addition, through the demonstration of altered flow or impaired perfusion, these techniques provide information on the pathophysiology of AKI, offering potential for targeted intervention. Renal SWE, an emerging technique, assesses tissue stiffness potentially allowing exploration of the role of venous congestion in the pathogenesis of AKI.</p><p><strong>Summary: </strong>Ultrasound continues to demonstrate great promise in the diagnosis and management of AKI, offering a noninvasive means to diagnose perfusion deficits and assess response to treatments. Further research, with standardization of techniques, may allow multifaceted renal ultrasound assessment in the critically ill for more accurate diagnosis and tailored intervention in AKI.</p>","PeriodicalId":10851,"journal":{"name":"Current Opinion in Critical Care","volume":null,"pages":null},"PeriodicalIF":3.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142582296","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}