Introduction
With the increasing number of critically ill patients being admitted to intensive care units (ICUs), there is a need for newer techniques and treatment modalities to evolve for their adequate management. The article also emphasizes the importance of understanding and utilizing existing tools and resources to achieve better results and decrease morbidity and mortality. The five specific areas of interest that have the potential to improve critical care outcomes: analgosedation, role of colloids, recent advancements in the management of respiratory failure, the role of extracorporeal membrane oxygenation, and newer antimicrobials. Regarding analgosedation, the article highlights its importance in the critically ill and its role in preventing post-ICU syndromes.
Additionally, the use of albumin has re-emerged as a possible repairer of the injured glycocalyx. Colloids are not only noted for their potential for volume expansion, but also the importance of caution due to potential adverse effects. Regarding respiratory failure, the authors discuss recent advancements in ventilator strategies and mechanical support, with a particular focus on the impact of the COVID-19 pandemic. The authors also discuss the role of extracorporeal membrane oxygenation (ECMO) in the management of critically ill patients, including its potential for use in patients with refractory hypoxemia, severe acute respiratory distress syndrome, and cardiopulmonary failure.
Relook at Analgosedation
Pain and discomfort affect many critically ill patients. Analgosedation is a strategy that prioritizes pain relief before sedation to improve outcomes. The ABCDEF bundle and Pain Agitation and Delirium (PAD) guidelines have improved patient outcomes, but patients can still experience pain and be awake during treatment. Analgosedation reduces pain and discomfort, decreases drug-related adverse events, and improves psychological outcomes. However, opioids can cause delirium and other side effects, and there are concerns about tolerance and withdrawal. A variety of drugs and techniques are available for administering analgosedation, and non-opioid and non-pharmacological methods should be considered to reduce side effects. It is recommended to use the lowest possible opioid doses for the shortest time and non-benzodiazepines to prevent delirium. Multimodal analgesia is suggested for optimal recovery. Analgosedation can considered during non-invasive ventilation but with caution. Further research is needed on the analgo-economics of drugs. Finally, the article also addresses the rising issue of antibiotic resistance and the need for newer antimicrobials to combat it.
Comeback colloid: Role of Albumin in the
critically ill
The use of resuscitation fluids in sepsis has been a topic of debate, and recent studies suggest that albumin may improve outcomes in critically ill patients by binding to the glycocalyx layer. The Surviving Sepsis Campaign Guidelines 2021 recommend the use of albumin in patients who received large volumes of crystalloids, and the Chinese Society of Critical Care Medicine recommends HSA infusion in cases of persistent haemodynamic instability in septic shock. However, there is currently no evidence to suggest the superiority of low- or high-concentration HSA for resuscitation in sepsis. Further research is needed to determine if HSA can be used as a therapeutic resuscitation strategy in sepsis and improve clinical outcomes.
Recent advancements in the management
of respiratory failure
High flow nasal oxygen
High-flow nasal oxygen (HFNO) therapy is a method of delivering high flows of oxygen-enriched gas to a patient through non-occlusive nasal prongs, humidified to full saturation, and heated to core temperature. This therapy aids in recruiting and enhancing dynamic lung compliance, reducing rebreathing, reducing inspiratory resistance and work of breathing, and optimising ciliary function, mucous hydration, improving patient comfort, and reducing inflammation.
Non-invasive positive pressure ventilation
Non-invasive positive-pressure ventilation (NPPV) is a method of mechanically ventilating the lungs without an invasive airway. It can reduce treatment failure, patient mortality, and the need for intubation in patients with respiratory failure. Bilevel positive airway pressure (BPAP) and continuous positive airway pressure (CPAP) are the commonly used modes of NPPV, with recent advancements providing self-adjusting variable ventilation modes. Adaptive servo-ventilation and volume-assured pressure support are two such modes that can be useful in managing patients with significant respiratory instability. Automatic expiratory positive airway pressure (EPAP) can maintain upper airway patency during BPAP or volume-assured BPAP and is beneficial in acute settings.
Recruitment manoeuvres
The recruitment process involves reopening airless alveoli through a transient increase in transpulmonary pressures. Recruitment manoeuvres (RM) can be performed by various techniques, including sustained inflation, stepwise increases in peak pressure and/or PEEP, and extended sigh manoeuvres (eSigh). These techniques aim to mitigate the prolonged high transpulmonary pressures used in sustained inflation and effectively improve lung aeration while reducing the risk of haemodynamic compromise and hyperinflation.
Prone ventilation
This refers to delivering mechanical ventilatory support to the patient lying in the prone position. Proning improves lung perfusion and reduces lung compression, reduces difference between the dorsal and ventral transpulmonary pressures, decreases ventral alveolar over-inflation and dorsal alveolar collapse.
Trimethoprim derivatives
SIclaprim belongs to this class which are dihdro-folate reductase inhibitors active against GNB, gram-positive bacteria (GPB), atypical, bacteria, MRSA, and vancomycin-resistant Staphylococcus aureus (VRSA).
Pleuromutilins
Lefamulin derived from this class acts by inhibiting bacterial protein synthesis through interactive binding to peptidyl transferase in the centre of the 50S bacterial ribosome subunit which proved to be sensitive against GPB associated with CAP, MRSA, VRSA.
Oxazolidinones
Linezolid and tedizolid derived from this class act by inhibiting bacterial protein synthesis by binding to 23S ribosomal messenger RNA of the 50S subunit of the ribosome and act on facultative aerobic and anaerobic GPB, MRSA, and methicillin-sensitive Staphylococcus aureus (MSSA).
Polymyxins
Polymyxins include colistin and polymyxin B. These drugs disrupt the bacterial cell membrane. Colistin is also known to exert ant-endotoxin activity, while polymyxin binds and neutralises lipopolysaccharide and inhibits respiration of gram-negative bacterial cells.
Summary
Analgosedation has become increasingly important in caring for critically ill patients. While the debate between colloid and crystalloid has mostly been resolved, albumin has emerged as a potential remedy for glycocalyx damage. The COVID-19 pandemic has prompted a reevaluation of various ventilator strategies and recruitment techniques. The use of mechanical support to address circulatory failure has become more prevalent and precise, with clearly defined endpoints. Due to the growing resistance of microorganisms to existing antibiotics, it is necessary to repurpose and research new antibiotics. While we have the ability to employ these techniques and resources to benefit our patients, it is important to exercise prudence in their use to maximize their efficacy.
Source: Gopal, Palepu B.; Sivapurapu, Vijayalakshmi1; Nag, Deb Sanjay2; Bhatia, Nidhi3; Tandon, Ruchi4; Bhavar, Tushar5. Recent advances in critical care: Part II. Indian Journal of Anaesthesia 67(1):p 110-116, January 2023. | DOI: 10.4103/ija.ija_1006_22.
