Hawaiian Islanders inside the Time regarding COVID19 an Disregarded Group in Need

This may result in both over-resuscitation and under-resuscitation leading to increased morbidity and mortality. In this article the principles of coherence and the monitoring of the microcirculation are reviewed.PURPOSE OF REVIEW Severe sepsis with septic shock is the most common cause of death among critically ill patients. Mortality has decreased substantially over the last decade but recent data has shown that opportunities remain for the improvement of early and targeted therapy. This review discusses published data regarding the role of focused ultrasonography in septic shock resuscitation. RECENT FINDINGS Early categorization of the cardiovascular phenotypes with echocardiography can be crucial for timely diagnosis and targeted therapy of patients with septic shock. In the last few years, markers of volume status and volume responsiveness have been investigated, serving as valuable tools for targeting volume therapy in the care of both spontaneously breathing and mechanically ventilated patients. In tandem, investigators have highlighted findings of extravascular volume with ultrasonographic evaluation to compliment de-escalation of resuscitation efforts when appropriate. Furthermore, special attention has been given to resuscitation efforts of patients in septic shock with right ventricular failure. SUMMARY Severe sepsis with septic shock is an insidious disease process that continues to take lives. In more recent years, data have emerged suggesting the utility of bedside ultrasonography for early cardiovascular categorization, goal directed resuscitation, and appropriate cardiovascular support based on its changing phenotypes.PURPOSE OF REVIEW To address the impact of therapeutic hypothermia induced already during cardiopulmonary resuscitation (i.e. intra-arrest cooling) and its association with neurologic functional outcome. RECENT FINDINGS Intra-arrest cooling is superior than post-ROSC cooling to mitigate brain injuries in experimental models of cardiac arrest. The delayed initiation of hypothermia in human studies may not have adequately addressed the underlying pathophysiology of ischemia and reperfusion. The assessment of early initiation of cooling has been complicated by increased rate of hemodynamic adverse events caused by infusion of cold intravenous fluids. These adverse events have been more deleterious in patients with initial shockable rhythms. A recent randomized study shows that an alternative intra-arrest cooling method using trans-nasal evaporative cooling was well tolerated and effective to shorten time to target temperature. However, the neurologic outcomes (CPC 1-2 at 90 days) in favor of intra-arrest cooling compared to hospital cooling (34.8% vs 25.9%, P = 0.11) in patients with initial shockable rhythms did not reach statistical significance. SUMMARY Therapeutic intra-arrest hypothermia can be initiated safely at the scene of the arrest using transnasal evaporative cooling. The potential beneficial effect of intra-arrest cooling on neurologic recovery in patients with initial shockable rhythms should be explored further.PURPOSE OF REVIEW To appraise the basic and more advanced methods available for hemodynamic monitoring, and describe the definitions and criteria for the use of hemodynamic variables. RECENT FINDINGS The hemodynamic assessment in critically ill patients suspected of circulatory shock follows a step-by-step algorithm to help determine diagnosis and prognosis. Determination of accurate diagnosis and prognosis in turn is crucial for clinical decision-making. Basic monitoring involving clinical examination in combination with hemodynamic variables obtained with an arterial catheter and a central venous catheter may be sufficient for the majority of patients with circulatory shock. In case of uncertainty of the underlying cause or to guide treatment in severe shock may require additional advanced hemodynamic technologies, and each is utilized for different indications and has specific limitations. Future developments include refining the clinical examination and performing studies that demonstrate better patient outcomes by targeting hemodynamic variables using advanced hemodynamic monitoring. SUMMARY Determination of accurate diagnosis and prognosis for patients suspected of circulatory shock is essential for optimal decision-making. Numerous techniques are available, and each has its specific indications and value.PURPOSE OF REVIEW The current review will give an overview of different possibilities to monitor quality of cardiopulmonary resuscitation (CPR) from a physiologic and a process point of view and how these two approaches can/should overlap. RECENT FINDINGS Technology is evolving fast with a lot of opportunities to improve the CPR quality. The role of smartphones and wearables are step-by-step identified as also the possibilities to perform patient tailored CPR based on physiologic parameters. The first steps have been taken, but more are to be expected. In this context, the limits of what is possible with human providers will become more and more clear. SUMMARY To perform high-quality CPR, at first, one should optimize rate, depth and pause duration supported by process monitoring tools. Second, the evolving technological evolution gives opportunities to measure physiologic parameters in real-time which will open the way for patient-tailored CPR. The role of ultrasound, cerebral saturation and end-tidal CO2 in measuring the quality of CPR needs to be further investigated as well as the possible ways of influencing these measured parameters to improve neurological outcome and survival.PURPOSE OF REVIEW On the basis of recent literature, we summarized the new advances on the use of available dynamic indices of fluid responsiveness. RECENT FINDINGS Reliability of passive leg raising to assess fluid responsiveness is well established provided that a real-time haemodynamic assessment is available. Recent studies have focused on totally noninvasive techniques to assess its haemodynamic effects with promising results. Presence of intra-abdominal hypertension is associated with false-negative cases of passive leg raising. Use of pulse pressure and stroke volume variations is limited and other heart-lung interaction tests have been developed. The tidal volume challenge may overcome the limitation of low tidal volume ventilation. Preliminary data suggest that changes in pulse pressure variation during this test well predict fluid responsiveness. Growing evidence confirms the good predictive performance of the end-expiratory occlusion test. NSC-2260804 inhibitor All these dynamic tests allow selecting appropriate fluid responders and preventing excessive fluid administration.