Kings College London, Kings Health Partners (Denmark Hill), Institute of Liver Studies, Kings College Hospital, London, UK.
Crit Care Med. 2010 Oct;38(10 Suppl):S590-9. doi: 10.1097/CCM.0b013e3181f20227.
Patients with critical illness are heterogeneous, with differing physiologic requirements over time. Goal-directed therapy in the emergency room demonstrates that protocolized care could result in improved outcomes. Subsequent studies have confirmed benefit with such a "bundle-based approach" in the emergency room and in preoperative and postoperative scenarios. However, this cannot be necessarily extrapolated to the medium-term and long-term care pathway of the critically ill patient. It is likely that the development of mitochondrial dysfunction could result in goal-directed types of approaches being detrimental. Equally, arterial pressure aims are likely to be considerably different as the patient's physiology moves toward "hibernation." The agents we utilize as sedative and pressor agents have considerable effects on immune function and the inflammatory profile, and should be considered as part of the total clinical picture. The role of gut failure in driving inflammation is considerable, and the drive to feed enterally, regardless of aspirate volume, may be detrimental in those with degrees of ileus, which is often a difficult diagnosis in the critically ill. The pathogenesis of liver dysfunction may be, at least in part, related to venous engorgement that will contribute toward portal hypertension and gut edema. This, in association with loss of the hepatosplanchnic buffer response, it is likely to contribute to venous pooling in the abdominal cavity, impaired venous return, and decreased central blood volumes. Therapies such as those used in "small-for-size syndrome" may have a role in the chronic stages of septic vascular failure.
危重症患者存在异质性，其生理需求随时间而变化。急诊室的目标导向治疗表明，规范化护理可能会改善预后。随后的研究证实，这种“基于捆绑的方法”在急诊室以及术前和术后情况下都有获益。然而，这并不一定能外推到危重症患者的中期和长期护理路径。线粒体功能障碍的发展可能导致目标导向型治疗方法产生不利影响。同样，随着患者的生理状态向“冬眠”转变，动脉压目标也可能有很大差异。我们用作镇静和升压药物的药物对免疫功能和炎症特征有很大影响，应将其视为整体临床情况的一部分。肠道衰竭在驱动炎症方面的作用是相当大的，无论抽吸量如何，通过肠内喂养来进食，对于存在不同程度肠梗阻的患者可能是有害的，而在危重症患者中，肠梗阻往往很难诊断。肝功能障碍的发病机制至少部分与静脉充血有关，静脉充血会导致门静脉高压和肠道水肿。这与肝肠缓冲反应的丧失一起，可能导致腹部静脉淤积、静脉回流受损和中心血容量减少。在感染性血管衰竭的慢性阶段，“小肝综合征”等疗法可能具有一定作用。
