1,721,009 research outputs found
Endocrine and Metabolic Disorders in the ICU
No full textThe knowledge of metabolic disorders in critically ill patients has grown in the last decade. Metabolic alterations have been studied for more than a century and are composed of a big number of diseases and conditions. The word metabolism comes from the Greek word μεταβάλλω (meta-ballo), meaning to “change,” and refers to the complex number of chemical processes that happen in a living organism and that allow to change the molecules and use them to support the living process. The endocrine system represents a connection of the organs and allows complex changes in the systemic metabolism to adapt the organism to different conditions. Intensive care unit (ICU) admission is per se a stressful situation that can therefore be a trigger for deep metabolic and endocrine changes. Patients admitted to the ICUs have important physiological derangements that can be caused by the disease that brought the patient to the ICU, e.g., sepsis or acute kidney injury, or by the therapy associated to ICU admission, like sedation or invasive mechanical ventilation.
In this chapter, we will introduce some concept of endocrine and metabolic ICU associated disorders, especially regarding hemoglobin metabolism and glycemic control, and discuss diagnosis and possible therapeutic management
Principles and Management of ARDS
No full textAcute respiratory distress syndrome (ARDS) was described for the first time more than 40 years ago. Since then, several progresses have been made in its definition, management, and in the understanding of the underlying pathophysiology. Despite ARDS is a syndrome of different entities and probably different inflammatory and biomechanical phenotypes, ARDS patients share some common features, like the need of respiratory support and the increased risk of ventilation-induced lung injury (VILI). Mechanical ventilation is an essential tool in supporting gas exchange but can amplify lung damage and increase lung inflammation. Finally, ARDS patients may be exposed to a higher risk of complications, such as delirium and ICU-acquired weakness. In this chapter, we will explore the current knowledge on ARDS definition, classification, pathophysiology, possible therapies, and complications, focusing on open questions being explored in the last years. Moreover, we will discuss the role of adjuvant therapies, such as pharmacological therapy and VV-ECMO, and their current indication
Can Abdominal Muscle Ultrasonography During Spontaneous Breathing and Cough Predict Reintubation in Mechanically Ventilated Patients?
No full textNo abstract availabl
Diabetes Ketoacidosis: New Onset Diabetes with Diabetic Ketoacidosis After SARS-CoV-2 Infection in Adult Critically Ill Patient
No full textPatients affected by diabetes have a higher rate of hospitalization and mortality after a SARS-CoV-2 infection. Diabetes is indeed a negative prognostic factor for coronavirus disease 2019 (COVID-19) and can increase its risk of severity and mortality by more than two times. Furthermore, although on one hand people with diabetes are more at risk of developing complications from COVID-19, the SARS-CoV-2 infection could also act as a diabetic agent by binding to ACE2 in the pancreatic beta-cells and causing their acute dysfunction. To date, there are few data on the impact of the COVID-19 disease on the onset of insulin-dependent diabetes in adult patients. We evaluated the pathophysiological mechanisms binding COVID-19 and diabetes mellitus by discussing the clinical case of a 47-year-old woman admitted to the intensive care unit for coma due to diabetic ketoacidosis secondary to SARS-CoV-2 infection. The patient was successfully treated with acute rehydration, normalization of glycemia, and chronic administration of insulin to maintain normal blood glucose levels
A modified approach to percutaneous ultrasound-guided left stellate ganglion block for drug-refractory electrical storm: a case report
No full textBackground: The use of percutaneous stellate ganglion block (SGB) in the management of drug-refractory electrical storm (ES) has been increasingly reported in the last years. Few data are available on the safety, duration, and dosage of local anaesthetic used. Case summary: A 66-year-old male patient with a history of ischaemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD) presented to the emergency room complaining several ventricular arrhythmias and ICD shocks received in the last 24 h. He was treated with many lines of anti-arrhythmic drugs but his condition deteriorated with cardiovascular instability and respiratory distress, so he was intubated. The ES still worsened (82 episodes of ventricular arrhythmias), so we performed an ultrasound-guided left SGB, using a modified technique, with success in suppressing the ventricular arrhythmias. The patient was then treated with electrophysiological study and catheter ablation. Discussion: The ultrasound approach to SGB is feasible in emergency setting, and it is safe and effective also using a modified and easier technique in patient with difficult sonographic visualization of the neck structures. Moreover, it is possible and safe to use a combination of short-acting rapid-onset local anaesthetic with a long-lasting one with a good outcome
Lung aeration, ventilation, and perfusion imaging
No full textPurpose of review: Lung imaging is a cornerstone of the management of patients admitted to the intensive care unit (ICU), providing anatomical and functional information on the respiratory system function. The aim of this review is to provide an overview of mechanisms and applications of conventional and emerging lung imaging techniques in critically ill patients. Recent findings: Chest radiographs provide information on lung structure and have several limitations in the ICU setting; however, scoring systems can be used to stratify patient severity and predict clinical outcomes. Computed tomography (CT) is the gold standard for assessment of lung aeration but requires moving the patients to the CT facility. Dual-energy CT has been recently applied to simultaneous study of lung aeration and perfusion in patients with respiratory failure. Lung ultrasound has an established role in the routine bedside assessment of ICU patients, but has poor spatial resolution and largely relies on the analysis of artifacts. Electrical impedance tomography is an emerging technique capable of depicting ventilation and perfusion at the bedside and at the regional level. Summary: Clinicians should be confident with the technical aspects, indications, and limitations of each lung imaging technique to improve patient care
Oxygenation Impairment during Anesthesia: Influence of Age and Body Weight.
Full text linkWHAT WE ALREADY KNOW ABOUT THIS TOPIC
During anesthesia oxygenation is impaired, especially in the elderly or obese, but the mechanisms are uncertain.
WHAT THIS ARTICLE TELLS US THAT IS NEW
Pooled data were examined from 80 patients studied with multiple inert gas elimination technique and computed tomography. Oxygenation was impaired by anesthesia, more so with greater age or body mass index. The key contributors were low ventilation/perfusion ratio (likely airway closure) in the elderly and shunt (atelectasis) in the obese.
BACKGROUND
Anesthesia is increasingly common in elderly and overweight patients and prompted the current study to explore mechanisms of age- and weight-dependent worsening of arterial oxygen tension (PaO2).
METHODS
This is a primary analysis of pooled data in patients with (1) American Society of Anesthesiologists (ASA) classification of 1; (2) normal forced vital capacity; (3) preoxygenation with an inspired oxygen fraction (FIO2) more than 0.8 and ventilated with FIO2 0.3 to 0.4; (4) measurements done during anesthesia before surgery. Eighty patients (21 women and 59 men, aged 19 to 69 yr, body mass index up to 30 kg/m) were studied with multiple inert gas elimination technique to assess shunt and perfusion of poorly ventilated regions (low ventilation/perfusion ratio [VA/Q]) and computed tomography to assess atelectasis.
RESULTS
PaO2/FIO2 was lower during anesthesia than awake (368; 291 to 470 [median; quartiles] vs. 441; 397 to 462 mm Hg; P = 0.003) and fell with increasing age and body mass index. Log shunt was best related to a quadratic function of age with largest shunt at 45 yr (r =0.17, P = 0.001). Log shunt was linearly related to body mass index (r = 0.15, P < 0.001). A multiple regression analysis including age, age, and body mass index strengthened the association further (r = 0.27). Shunt was highly associated to atelectasis (r = 0.58, P < 0.001). Log low VA/Q showed a linear relation to age (r = 0.14, P = 0.001).
CONCLUSIONS
PaO2/FIO2 ratio was impaired during anesthesia, and the impairment increased with age and body mass index. Shunt was related to atelectasis and was a more important cause of oxygenation impairment in middle-aged patients, whereas low VA/Q, likely caused by airway closure, was more important in elderly patients. Shunt but not low VA/Q increased with increasing body mass index. Thus, increasing age and body mass index impaired gas exchange by different mechanisms during anesthesia
Understanding cardiopulmonary interactions through esophageal pressure monitoring
Full text linkEsophageal pressure is the closest estimate of pleural pressure. Changes in esophageal pressure reflect changes in intrathoracic pressure and affect transpulmonary pressure, both of which have multiple effects on right and left ventricular performance. During passive breathing, increasing esophageal pressure is associated with lower venous return and higher right ventricular afterload and lower left ventricular afterload and oxygen consumption. In spontaneously breathing patients, negative pleural pressure swings increase venous return, while right heart afterload increases as in passive conditions; for the left ventricle, end-diastolic pressure is increased potentially favoring lung edema. Esophageal pressure monitoring represents a simple bedside method to estimate changes in pleural pressure and can advance our understanding of the cardiovascular performance of critically ill patients undergoing passive or assisted ventilation and guide physiologically personalized treatments
Mechanical ventilation and COPD: from pathophysiology to ventilatory management
No full textIn the chronic obstructive pulmonary disease (COPD), lung and chest-wall morphological alterations determine important and peculiar approaches to mechanical ventilation. Lung emphysema and reduced elastic recoil increase expiratory time, thus worsening dynamic hyperinflation, while airways chronic inflammation rises resistances and can determine distal air-trapping. Muscle wasting and fast fibers prevalence can result in weakness and in an earlier onset of muscle fatigue, prolonging the weaning process. In this narrative review, we explored the connection between altered pathophysiology and necessity for respiratory assistance in COPD, focusing on non-invasive and invasive respiratory management, lung monitoring and weaning difficulties
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