Brain injury is frequently associated with the development of brain edema and the development of intracranial hypertension. However, with a coordinated, stepwise, and aggressive approach to management, focusing on control of intracranial pressure without adversely affecting cerebral perfusion pressure, outcomes can be good.
Sepsis and cirrhosis are both characterised by a hyperdynamic state associated with a low systemic vascular resistance, and the release of many mediators. The haemodynamic characteristics are so similar that sepsis is difficult to recognise in cirrhotic patients. Nevertheless, the occurrence of sepsis in cirrhotic patients is associated with high mortality rates. The resemblance of the two conditions may be in part related to the common translocation of bacterial products in cirrhosis. This article reviews the similarities and differences between sepsis and cirrhosis and defines the basis for the treatment of severe sepsis in cirrhotic patients.
info:eu-repo/semantics/published
SCOPUS: le.j
Depuis quelques années, la revalidation précoce a pris une place prépondérante dans la prise en charge des malades de réanimation. Bien que des séquelles neuromusculaires aient été décrites depuis bien longtemps, on n’imaginait pas assez le rôle de l’alitement prolongé et de l’inactivité sur cette fonte et faiblesse musculaires. Actuellement, on comprend mieux les effets délétères des facteurs inflammatoires sur le muscle ainsi que les effets positifs de l’exercice sur ces mêmes facteurs. La revalidation doit être entreprise au plus tôt et, pour assurer la collaboration active du patient, la sédation doit être interrompue au plus vite. Cependant, même chez les patients comateux ou peu collaborant, on peut pratiquer sans crainte des mobilisations passives afin de préserver les amplitudes articulaires. La participation active apporte bien sûr beaucoup plus de bénéfice, ce d’autant plus qu’on peut aussi y ajouter des supports instrumentaux qui permettent de varier les programmes d’exercices. Avant de prendre en charge le malade, le kinésithérapeute devra s’assurer que le patient pourra tolérer le programme. Pour cela, il faut prendre en considération l’état respiratoire, hémodynamique et neurologique avant de fixer une intensité, une longueur et une fréquence de traitement. Souvent, cette prise en charge ne peut se faire que par la collaboration d’une équipe pluridisciplinaire motivée et si possible par la présence d’un nombre plus important de kinésithérapeutes au sein des unités de soins intensifs.
The last events before death were analyzed in 258 patients who died in our ICU. Deepening coma (104 patients) and acute circulatory failure (90 patients) were the most common events preceding death. Catastrophic events accounted for only 12% of deaths. In 168 (65%) of 258 patients, death was considered inevitable and CPR was not performed. Furthermore, 22 (9%) patients were allowed to die after withdrawal of intensive care support. These observations indicate that most deaths are expected in the ICU and that "do-not-resuscitate" orders can be reasonably given in the majority of fatal cases. Moreover, complete withdrawal of intensive care support should be considered as a reasonable option in hopeless patients. Since circulatory shock was identified as the most common potentially reversible problem, better prevention and management of acute circulatory failure are needed to improve survival.
Targeted temperature management (TTM) is a complex intervention used with the aim of minimizing post-anoxic injury and improving neurological outcome after cardiac arrest. There is large variability in the devices used to achieve cooling and in protocols (e.g., for induction, target temperature, maintenance, rewarming, sedation, management of post-TTM fever). This variability can explain the limited benefits of TTM that have sometimes been reported. We therefore propose the concept of "high-quality TTM" as a way to increase the effectiveness of TTM and standardize its use in future interventional studies.
Hydroxyethyl starch (HES) solutions can represent an alternative to human albumin solutions in intensive care unit (ICU) patients, but their effects on the plasma colloid osmotic pressure (COP) have not been well defined. We studied the changes in COP in 61 critically ill patients; 39 patients received 500 ml HES 6% (Elo-Haes Fresenius solution) and 22 received 400 ml of a human albumin solution (4% albumin Belgian Red Cross) over 60 to 90 min. COP was determined with an oncometer, using a semi-permeable membrane at 30 Kd, before the infusion, at the end of the infusion, and one hour and four hours after the end of the infusion. COP increased in the HES group from 20.7 +/- 3.1 to 22.5 +/- 3.1 mmHg (p < 0.05), and this increase in COP was sustained throughout the 4 hours of the study. COP did not increase in the human albumin group (from 19.5 +/- 2.4 to 19.9 +/- 2.0 mmHg, NS). Hence, this standard HES solution has greater effects on COP than natural colloids. In view of their lower costs, HES solutions can represent a valuable alternative to human albumin. However, it is necessary to consider the secondary effects of HES and the physiologic functions of albumin.
