1,721,039 research outputs found
Reply to Dr Lockey et al.'s remarks on prehospital thoracostomy
No full textBeing respectively the director of the regional HEMS service and the physician-in-charge for the training of this procedure, we very much appreciated Dr Lockey's remarks on our study reporting the experience with prehospital thoracostomy recently published in the journal [1,2]
Controversial Aspects of the Prehospital Trauma Care
No full textDespite decades of studies and experiences, an evidence-based medicine consensus on the more appropriate treatment of trauma patients in the out-of-hospital setting has not yet been achieved. Different approaches exist and no one has been demonstrated clearly superior over the others for all the circumstances and for all patients. A number of factors likely account for this finding. First, just as the very concept of airway-breath-circulation indicates the goals of a treatment and not the treatment by itself, the different levels of training and expertise of professionals trying to achieve it can be associated with different outcomes. Second, the most appropriate approach differs in patients with penetrating or blunt injuries. Third, similar to what has been hypothesized in other fields of critical care medicine, perhaps the mortality rate is a rather rough, albeit unequivocal, marker of either outcome or appropriateness of care, and should be substituted with other indexes, including changes of some biologic variables or the quality of life of survivors. Finally, and most important, the on-scene treatment is the critical link between the out-of-hospital chain-of-survival and the in-hospital system of delivery of care, and weak points of either system can influence the outcome independently from the others. © 2006 Elsevier Inc. All rights reserved
Management of Severe Sepsis and Septic Shock: Challenges and Recommendations
No full textDespite the advances in the knowledge of the basic processes that trigger and sustain the systemic inflammatory response in sepsis, the search for a "magic bullet" to treat this syndrome has been frustrating. The incidence of severe sepsis and septic shock still remains quite high, as does its mortality, which has decreased very little over the past decades. Advances on pathophysiologic aspects of this syndrome are leading to the discovery of new potential therapeutic targets: studies on Toll-like receptor, a surface receptor present in most of the cells of the immune system, and on the high-mobility group box protein 1, a member of the high-mobility group protein super-family, showed the ability to modulate the inflammatory response after contact with a microbial pathogen [44]. Moreover, an endogenous metabolite, adenosine, has been proposed to play an important role in inflammation. Acting on different receptors (A1, A2a, A2b, and A3) it exerts anti-inflammatory effects by multiple mechanisms including modulation of neutrophil function, endothelial permeability, and collagenase production. The use of adenosine and adenosine kinase inhibitors (an enzyme that increases endogenous adenosine concentration significantly) in the management of sepsis and septic shock has not been investigated in humans, but experimental data seem to be encouraging [45]. The fundamental pillar of the management of sepsis still remains its prevention: an elevated standard of care and hygiene, the selective decontamination of the digestive tract and the source control, together with the administration of appropriate antibiotic treatment when an infection is suspected or documented can surely help to reach this purpose and reduce its incidence. Moreover, an early diagnosis of the syndrome, followed by an early goal-directed therapy for hemodynamic optimization, the use of protective lung strategy, the administration of rhAPC to patients with high risk of death, and low-dose corticosteroids to patients suffering adrenal insufficiency can help in reducing its mortality. The complete understanding of this complex syndrome and its final treatment are still far to come, but the research goes on developing new theories, proposing new experimental therapies, and improving the traditional resources: all of this is encouraging and promising. The priority is to apply evidence-based maneuvers in patients suffering sepsis according to valid recommendations; the importance of bundles represents a new critical point in the early phase. The challenge continues [46]. © 2006 Elsevier Inc. All rights reserved
Anticoagulation therapy in ICU patients
No full textMost patients admitted to an ICU have multiple risk factors for thromboembolic complications, which are very often present in the guise of deep venous thrombosis (DVT) and/or pulmonary thromboembolism (PTE). Risks factors may be present before the ICU admission (advanced age, malignancy, major surgery, major trauma), or may be related to the ICU stay (such as mechanical ventilation and central venous catheters). In such settings, there are strong indications for prolonged thromboprophylaxis and/or treatment of thrombotic complications. This is achieved by a number of pharmacological and nonpharmacological provisions, each having specific advantages and shortcomings. To date, heparin and vitamin K antagonists are the two most widely used measures for both prevention and treatment of DVT and PTE. Critically ill patients are peculiar in having altered pharmacokinetic and pharmacodynamic variability. This variability can lead to unpredictable drug effects, greater toxicity, and increased potential for adverse drug effects associated with disorders of coagulation. ICU patients can receive simultaneously several different medications throughout their stay, increasing the potential for drug interactions or a synergistic/enhanced response
Antiphospholipid antibody syndrome
No full textAntiphospholipid antibody (APLA) syndrome (APS) is a heterogeneous disorder defined by the finding of persistent APLA in patients with arterial or venous thrombosis or pregnancy morbidity. APS manifestations range from deep vein thrombosis to stroke and even rapid multiorgan failure (the rare catastrophic APS). APS may be primary or secondary; in both cases, however, the clinical consequences appear to be the same. Although crucial to thrombotic risk assessment and clinical management, current laboratory testing for APLA lacks standardization and data from randomized trials. Consequently, correlating laboratory findings with clinical features is still a challenge for clinicians facing APS. This chapter presents the current definition of APS and discusses its etiopathogenesis and diagnosis and approaches for its treatment
Hypothermia and coagulation disorders
No full textHypothermia describes a state in which the body's mechanism for temperature regulation is overwhelmed in the face of a cold stressor. Hypothermia is classified as accidental or intentional, primary or secondary, and according to its severity
Coagulation disorders after central nervous system injury
No full textAlmost any injury to the brain may initiate disturbances in local and systemic coagulation. This statement is particularly true for subarachnoid hemorrhage, traumatic brain injuries, and cranial and spinal dural arteriovenous fistulae. The pathogenesis of coagulative disorders is highlighted from both a genetic and a structural biology perspective, along with a discussion of predictive biomarkers and clinical risk factors to guide the selection of eligible patients for primary prevention. This comprehensive review allows a better understanding of the coagulative disorders affecting patients harboring CNS diseases and accordingly offers new insights into their pharmacological and surgical treatment
Diffuse aspergillosis in a patient with SARS-CoV-2 pneumonia
Full text linkA 59-year-old man with a severe pneumonia due to coronavirus disease 2019 (COVID-19) died in multiple organ failure caused by a postoperative septic shock subsequent
to a hemicolectomy for a right colon infarction occurred two weeks earlier
[Hyperammoniemia and central pontine myelinolysis in a patient with Sjögren syndrome and chronic valproate use]
No full textPulmonary-renal syndrome
No full textPulmonary-renal syndrome is defined as the combination of diffuse alveolar haemorrhage (DAH) and glomerulonephritis. The majority of cases are initiated by small vessel vasculitides presenting antineutrophil cytoplasmic autoantibodies (ANCA): Wegener's granulomatosis (WG), microscopic polyangiitis (MPA) and Churg-Strauss-syndrome (CSS). Up to 25% of these ANCA-associated vasculitides (AAV) have also an increased venous thromboembolic risk due to circulating anti-plasminogen antibodies. Pulmonary-renal syndrome in AAV is often fatal without treatment, which still relies on immunosuppression by cytotoxic agents. As such therapy may be lethal itself, accurate assessment of disease severity is mandatory. In this scenario, plasma exchange (PLEX) has proven a fast-acting therapeutic adjunct during severe disease as it limits the use of immunosuppressives and their life-threatening side effects. Novel biomarkers of AAV activity, as well as data from randomized trials investigating new agents, will be essential to improve treatment of severe and refractory forms in the future
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