The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

Bein, Thomas; Grasso, Salvatore; Moerer, Onnen; Quintel, Michael; Guerin, Claude; Deja, Maria; Brondani, Anita; Mehta, Sangeeta

The incidence of gastrointestinal stress bleeding in intensive care patients is low, the prognostic importance is ambiguous, but gastrointestinal stress bleeding prophylaxis is widely used in ICUs worldwide. In a systematic review it was demonstrated that sufficient evidence for the use of such a prophylaxis is low [86] . Early and low dose Glucocorticoids (GC) (methylprednisolone 1 mg/ kg/day, then dose tapering) might accelerate the resolution of ARDS and could contribute to reduction of mortality without the risk of increasing infection [87] , but it is still controversially discussed. Deep vein thromboembolism (DVE) prophylaxis is a routine measure in immobilized ICU patients, and in ARDS patients recommendations are similar to other patient groups [60] : daily unfractionated or low molecular weight heparin should be given for DVE prophylaxis according to the institution's algorithm including contraindications and modes of applications (subcutaneously or continuously via the venous route). In ECMO patients a specific strategy in terms of anticoagulation is mandatory [88] . Backrest elevated position (20-45°) is the preferred supine position for ARDS patients, since it may contribute to an improvement of oxygenation and respiratory mechanics [89] compared to "flat" supine, but limitations for backrest elevation (e.g., hemodynamic impairment) must be considered.