Training in critical care echocardiography

Echocardiography is useful for the diagnosis and management of hemodynamic failure in the intensive care unit so that competence in some elements of echocardiography is a core skill of the critical care specialist. An important issue is how to provide training to intensivists so that they are competent in the field. This article will review issues related to training in critical care echocardiography

Perioperative echocardiography-guided hemodynamic therapy in high-risk patients:a practical expert approach of hemodynamically focused echocardiography

The number of high-risk patients undergoing surgery is growing. To maintain adequate hemodynamic functioning as well as oxygen delivery to the vital organs (DO2) amongst this patient population, a rapid assessment of cardiac functioning is essential for the anesthesiologist. Pinpointing any underlying cardiovascular pathophysiology can be decisive to guide interventions in the intraoperative setting. Various techniques are available to monitor the hemodynamic status of the patient, however due to intrinsic limitations, many of these methods may not be able to directly identify the underlying cause of cardiovascular impairment. Hemodynamic focused echocardiography, as a rapid diagnostic method, offers an excellent opportunity to examine signs of filling impairment, cardiac preload, myocardial contractility and the function of the heart valves. We thus propose a 6-step-echocardiographic approach to assess high-risk patients in order to improve and maintain perioperative DO2. The summary of all echocardiographic based findings allows a differentiated assessment of the patient's cardiovascular function and can thus help guide a (patho)physiological-orientated and individualized hemodynamic therapy

Current concept of abdominal sepsis : WSES position paper

Peer reviewe

AHRC: An Optimized Cache Associativity

© 2016 IEEE. Hardware resources require efficient scaling because the future of computing technology seems to be intensive multithreaded. One of the main challenges in the scalability of computers hardware is the hierarchy of the memory. Chip-multiprocessors (CMPs) rely on large and multi-level hierarchies of caches to reduce cost of resources and improve systems performance. These multi-level hierarchies are the ones, which also help to solve the issue of limited bandwidth and minimize the latency of the main memory. Almost half of the area of the chip and a large percentage of the system energy is used by caches. One of the main problems limiting the scalability of cache hierarchies is called cache associativity. Caches consume a lot of energy to implement associative lookups. This affects the performance of the system by reducing the efficiency of caches. This paper describes a new design of cache that we called - Adaptive Hashing and Replacement Cache (AHRC). This design has the ability of maintaining high associativity with an advanced method of replacement policy. AHRC can improve associativity and maintain the number of possible locations, where each block is kept as small as possible. Several workloads were simulated on a large-scale CMP with AHRC as the last-level cache. We propose an Adaptive Reuse Interval Prediction (ARIP) scheme for AHRC, which is superior to the NRU scheme that was described by Seznec. Results demonstrate that AHRC has better energy efficiency and higher performance as compared to conventional caches. Additionally, large caches that utilize AHRC are the most suitable in many core CMPs to provide a more significant improvement and scalability than the smaller caches. However, AHRC with a higher-level replacement may lead to loss of energy for workloads that are not sensitive to the policy governing the replacement process

End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan

Background:With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit. Methods: This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way anova were used to compare differences in response between the groups. Results:One hundred and thirty-seven physicians and critical care nurses completed the survey. ‘Brain death’ was defined as an ‘irreversible cessation of brainstem function’ by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P-value \u3c 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P-value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to ‘sustain life at all costs’ and only 8% gave religious beliefs as a reason. Conclusions:There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians’ and nurses’ perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula