Although placement of an intra-cerebral catheter remains the gold standard method for measuring intracranial pressure (ICP), several non-invasive techniques can provide useful estimates. The aim of ...this study was to compare the accuracy of four non-invasive methods to assess intracranial hypertension.
We reviewed prospectively collected data on adult intensive care unit (ICU) patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH) in whom invasive ICP monitoring had been initiated and estimates had been simultaneously collected from the following non-invasive indices: optic nerve sheath diameter (ONSD), pulsatility index (PI), estimated ICP (eICP) using transcranial Doppler, and the neurological pupil index (NPI) measured using automated pupillometry. Intracranial hypertension was defined as an invasively measured ICP > 20 mmHg.
We studied 100 patients (TBI = 30; SAH = 47; ICH = 23) with a median age of 52 years. The median invasively measured ICP was 17 12-25 mmHg and intracranial hypertension was present in 37 patients. Median values from the non-invasive techniques were ONSD 5.2 4.8-5.8 mm, PI 1.1 0.9-1.4, eICP 21 14-29 mmHg, and NPI 4.2 3.8-4.6. There was a significant correlation between all the non-invasive techniques and invasive ICP (ONSD, r = 0.54; PI, r = 0.50; eICP, r = 0.61; NPI, r = - 0.41-p < 0.001 for all). The area under the curve (AUC) to estimate intracranial hypertension was 0.78 CIs = 0.68-0.88 for ONSD, 0.85 95% CIs 0.77-0.93 for PI, 0.86 95% CIs 0.77-0.93 for eICP, and 0.71 95% CIs 0.60-0.82 for NPI. When the various techniques were combined, the highest AUC (0.91 0.84-0.97) was obtained with the combination of ONSD with eICP.
Non-invasive techniques are correlated with ICP and have an acceptable accuracy to estimate intracranial hypertension. The multimodal combination of ONSD and eICP may increase the accuracy to estimate the occurrence of intracranial hypertension.
Objective
Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician ...regarding the diagnosis, management and monitoring of shock.
Methods
The European Society of Intensive Care Medicine invited 12 experts to form a Task Force to update a previous consensus (Antonelli et al.: Intensive Care Med 33:575–590, 2007). The same five questions addressed in the earlier consensus were used as the outline for the literature search and review, with the aim of the Task Force to produce statements based on the available literature and evidence. These questions were: (1) What are the epidemiologic and pathophysiologic features of shock in the intensive care unit? (2) Should we monitor preload and fluid responsiveness in shock? (3) How and when should we monitor stroke volume or cardiac output in shock? (4) What markers of the regional and microcirculation can be monitored, and how can cellular function be assessed in shock? (5) What is the evidence for using hemodynamic monitoring to direct therapy in shock? Four types of statements were used: definition, recommendation, best practice and statement of fact.
Results
Forty-four statements were made. The main new statements include: (1) statements on individualizing blood pressure targets; (2) statements on the assessment and prediction of fluid responsiveness; (3) statements on the use of echocardiography and hemodynamic monitoring.
Conclusions
This consensus provides 44 statements that can be used at the bedside to diagnose, treat and monitor patients with shock.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Management of the patient with sepsis comprises three key branches: control of the underlying infection, haemodynamic stabilization, and modulation of the host response. Each aspect should be ...considered in all patients and, when relevant, managed at the same time. Infection control is applicable to all patients with sepsis and will include antibiotic therapy and often surgical intervention to remove an infectious source. Haemodynamic support involves fluid administration in all patients and vasoactive agents in patients with associated circulatory shock. Noradrenaline is the first choice vasopressor agent; inotropic agents, usually dobutamine, may be added in case of myocardial depression. No interventions directed at individual components of the host response to sepsis have yet been shown to improve outcomes, but glucocorticoids and vasopressin have a global impact on the response and can thus be considered in this category. A move toward more personalized treatment is needed across all three arms of sepsis management.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Recent advances in technology and better understanding of mechanisms underlying disease are beginning to enable us to better characterize critically ill patients. Instead of using nonspecific ...syndromic groupings, such as sepsis or acute respiratory distress syndrome, we can now classify individual patients according to various specific characteristics, such as immune status. This "personalized" medicine approach will enable us to distinguish patients who have similar clinical presentations but different cellular and molecular responses that will influence their need for and responses (both negative and positive) to specific treatments. Treatments will be able to be chosen more accurately for each patient, resulting in more rapid institution of appropriate, effective therapy. We will also increasingly be able to conduct trials in groups of patients specifically selected as being most likely to respond to the intervention in question. This has already begun with, for example, some new interventions being tested only in patients with coagulopathy or immunosuppressive patterns. Ultimately, as we embrace this era of precision medicine, we may be able to offer precision therapies specifically designed to target the molecular set-up of an individual patient, as has begun to be done in cancer therapeutics.
The fluid challenge Vincent, Jean-Louis; Cecconi, Maurizio; De Backer, Daniel
Critical care (London, England),
12/2020, Volume:
24, Issue:
1
Journal Article
Peer reviewed
Open access
...if there is no concurrent fluid loss (for example in hemorrhage), fluid administration can result in an increase in hydrostatic pressures with ensuing edema formation. ...fluid administration can ...be associated with a potential benefit (increase in cardiac output) and a risk of harm (increase in hydrostatic pressure). Importantly, any given CVP value will not accurately predict whether or not a patient will respond to fluids; this is true for all variables, including the cardiac output, capillary refill time, central venous oxygen saturation (ScvO2), urine output or blood lactate level. ...one should remember that use of a fluid challenge technique will result in not more but less fluid being given in total, because fluid administration will be quickly discontinued if there is no clinical benefit. Hemodynamic responses to rapid saline loading: the impact of age, sex, and heart failure.
General illness severity scores are widely used in the ICU to predict outcome, characterize disease severity and degree of organ dysfunction, and assess resource use. In this article we review the ...most commonly used scoring systems in each of these three groups. We examine the history of the development of the initial major systems in each group, discuss the construction of subsequent versions, and, when available, provide recent comparative data regarding their performance. Importantly, the different types of scores should be seen as complementary, rather than competitive and mutually exclusive. It is possible that their combined use could provide a more accurate indication of disease severity and prognosis. All these scoring systems will need to be updated with time as ICU populations change and new diagnostic, therapeutic and prognostic techniques become available.
While guidelines provide important information on how to approach a patient in septic shock, “many challenges remain” for the management of these patients. In this narrative review, the panel ...discusses the challenges in identifying the right hemodynamic target, optimization of fluid therapy, selection of vasopressor agents, identification of patients who may benefit from inotropic agents or on the contrary beta-blockade, and use of steroids. The place for microcirculation-targeted therapy is debated as well as the use of alternative techniques (blood purification) and therapies (vitamin C). The implications of hemodynamic alterations on antibiotic doses is discussed. Finally, the specific challenges in low- and middle-income countries are addressed. Ongoing trials address some of these challenges, but many uncertainties will remain, and individualized therapies based on careful clinical assessment will continue to be essential to optimizing the care of patients with septic shock.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The randomized controlled trial is seen by many as the summit of evidence-based medicine, yet, in the intensive care unit, randomized controlled trials can be challenging to conduct, and results are ...often difficult to interpret and apply. Many randomized controlled trials in intensive care patients have not demonstrated beneficial effects of the intervention under investigation often despite good preclinical and even previous randomized controlled trial evidence. There are many reasons for these negative results including problems with timing, end point selection, and heterogeneous populations. In this article, we will discuss the limitations of randomized controlled trials in the intensive care unit population and highlight the importance of considering other study designs in the challenging intensive care unit environment.
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