Bring on the Remi!

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  • Remifentanil seems to be associated with reductions in the duration of mechanical ventilation, time to extubation after cessation of sedation, and ICU-LOS.
  • No significant differences were identified between remifentanil and other opioids in terms of hospital-LOS, costs, mortality or agitation.

 

More on good old fluid responsiveness!

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  • The PR decreases with a long infusion time. A standard technique for fluid challenge is desirable.

 

Drive, drive, drive!

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  • Airway driving pressure is the difference between plateau pressure and PEEP and represents the cyclic strain to which the lung parenchyma is subjected during each ventilatory cycle.
  • It is a physiological way of adjusting Vt to the residual lung size (respiratory system compliance) of the patient, correlates directly with transpulmonary pressure, and is associated with survival in patients with ARDS.
  • Thus, setting ventilatory parameters to decrease driving pressure may have a role in improving outcomes in patients requiring mechanical ventilation.
  • However, driving pressure is only one of many variables involved in the mechanical power or energy applied to the lung parenchyma. Vt, flow, and respiratory rate have also been identified as causes of VILI. Further research will need to explore how all these factors behave in a particular patient.
  • In the meantime, we suggest adjusting ventilatory support with traditional protective parameters, Vt 6–8 mL/ kg IBW and moderate PEEP levels, and adjusting them according to driving pressure, which should ideally be below 15 cm H2O, although this limit should be tested in future trials.

 

Are we being too harsh on glucose!!?

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  • Given the potential role of autophagy, establishing the effect of glycaemic control could be of great clinical value.
  • More research is urgently needed to provide a complete picture of the effect exerted by intensive insulin therapy on autophagy.

 

Look at it continuously…not just when you feel like it!

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  • We believe that the prevention of severe hyperglycemia and hypoglycemia should be considered a strong object- ive in all settings involving critically ill patients and that CGM can contribute to safe, effective glucose management.
  • CGM, when combined with a validated insulin infusion protocol that minimizes glycemic variability, can help improve patient outcomes and reduce workload, which may be cost-effective.
  • Once reliable devices with acceptable point accuracy are available at reasonable running costs, CGM will be useful in all critically ill patients receiving strict glucose control.
  • The optimal blood glucose target remains unclear and may depend on the studied patient population.
  • As with any monitoring device, CGM cannot per se improve outcomes, but must be combined with an effective algorithm and trained, dedicated staff.