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Find video protocols related to scientific articles indexed in Pubmed.
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Combination of veno-arterial extracorporeal membrane oxygenation and hypothermia for out-of-hospital cardiac arrest due to Taxus intoxication.
CJEM
PUBLISHED: 11-01-2014
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ABSTRACTA young woman presented with cardiac arrest following ingestion of yew tree leaves of the Taxus baccata species. The toxin in yew tree leaves has negative inotropic and dromotropic effects. The patient had a cardiac rhythm that alternated between pulseless electrical activity with a prolonged QRS interval and ventricular fibrillation. When standard resuscitation therapy including digoxin immune Fab was ineffective, a combination of extracorporeal membrane oxygenation (ECMO) and hypothermia was initiated. The total duration of low flow/no flow was 82 minutes prior to the initiation of ECMO. After 36 hours of ECMO (including 12 hours of electrical asystole), the patient's electrocardiogram had normalized and the left ventricular ejection fraction was 50%. At this time, dobutamine and the ECMO were stopped. The patient had a full neurologic recovery and was discharged from the intensive care unit after 5 days and from the hospital 1 week later.
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Impact of diagnostic criteria on the incidence of ventilator-associated pneumonia.
Chest
PUBLISHED: 10-24-2014
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Background:Ventilator-associated pneumonia (VAP) is a frequent complication of prolonged invasive ventilation. Because VAP is largely preventable, its incidence has been used as an index of quality-of-care in the intensive care unit (ICU). However, the incidence of VAP varies according to which criteria are used to identify it. We compared the incidence of VAP obtained with different sets of criteria. Methods:We collected data from all adult patients admitted to our 35-bed Dept of Intensive Care over a 7-month period who had no pulmonary infection on admission or within the first 48 hours and who required mechanical ventilation for >48 hours. To diagnose VAP, we applied six published sets of criteria and 89 combinations of criteria for hypoxemia, inflammatory response, purulence of tracheal secretions, chest radiography findings and microbiological findings of varying levels of severity. The variables used in each diagnostic algorithm were assessed daily. Results:Of 1,824 patients admitted to the ICU during the study period, 91 were eligible for inclusion. The incidence of VAP ranged from 4% to 42% when using the 6 published sets of criteria, and from 0-44% when using the 89 combinations. The delay before diagnosis of VAP increased from 4 to 8 days with increasingly stringent criteria and mortality from 50 to 80%. Conclusions:Applying different diagnostic criteria to the same patient population can result in wide variation in the incidence of VAP. The use of different criteria can also influence the time of diagnosis and the associated mortality rate.
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High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial.
JAMA
PUBLISHED: 08-07-2014
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Enteral administration of immune-modulating nutrients (eg, glutamine, omega-3 fatty acids, selenium, and antioxidants) has been suggested to reduce infections and improve recovery from critical illness. However, controversy exists on the use of immune-modulating enteral nutrition, reflected by lack of consensus in guidelines.
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Multicenter, Randomized, Placebo-Controlled Phase III Study of Pyridoxalated Hemoglobin Polyoxyethylene in Distributive Shock (PHOENIX).
Crit. Care Med.
PUBLISHED: 08-02-2014
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To compare the effectiveness and safety of the hemoglobin-based nitric oxide scavenger, pyridoxalated hemoglobin polyoxyethylene, against placebo in patients with vasopressor-dependent distributive shock.
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Global prospective epidemiologic and surveillance study of ventilator-associated pneumonia due to Pseudomonas aeruginosa*.
Crit. Care Med.
PUBLISHED: 07-24-2014
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To estimate the prevalence of ventilator-associated pneumonia caused by Pseudomonas aeruginosa in patients at risk for ventilator-associated pneumonia and to describe risk factors for P. aeruginosa ventilator-associated pneumonia.
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Albumin administration in the acutely ill: what is new and where next?
Crit Care
PUBLISHED: 07-16-2014
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Albumin solutions have been used worldwide for the treatment of critically ill patients since they became commercially available in the 1940s. However, their use has become the subject of criticism and debate in more recent years. Importantly, all fluid solutions have potential benefits and drawbacks. Large multicenter randomized studies have provided valuable data regarding the safety of albumin solutions, and have begun to clarify which groups of patients are most likely to benefit from their use. However, many questions remain related to where exactly albumin fits within our fluid choices. Here, we briefly summarize some of the physiology and history of albumin use in intensive care before offering some evidence-based guidance for albumin use in critically ill patients.
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My paper 20 years later: effects of dobutamine on the VO2/DO 2 relationship.
Intensive Care Med
PUBLISHED: 07-07-2014
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Oxygen uptake (VO2) is independent of oxygen delivery (DO2) over a wide range of values, because O2 extraction can readily adapt to changes in DO2. However, VO2 can become DO2-dependent in acute circulatory failure.
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Infections, antibiotic treatment and mortality in patients admitted to ICUs in countries considered to have high levels of antibiotic resistance compared to those with low levels.
BMC Infect. Dis.
PUBLISHED: 07-03-2014
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Antimicrobial resistance is an increasing concern in ICUs worldwide. Infection with an antibiotic resistant (ABR) strain of an organism is associated with greater mortality than infection with the non-resistant strain, but there are few data assessing whether being admitted to an intensive care unit (ICU) with high levels of antimicrobial resistance is associated with a worse outcome than being admitted to an ICU with low rates of resistance. The aim of this study was, therefore, to compare the characteristics of infections and antibiotic treatments and patient outcomes in patients admitted to ICUs in countries considered as having high levels of antibiotic resistance and those admitted to ICUs in countries considered as having low levels of antibiotic resistance.
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C-reactive protein kinetics after major surgery.
Anesth. Analg.
PUBLISHED: 06-01-2014
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Diagnosis of sepsis in the postoperative period is a challenge. Measurements of inflammatory markers, such as C-reactive protein (CRP), have been proposed in medical patients, but the interpretation of these values in surgical patients is more difficult. We evaluated the changes in blood CRP levels and white blood cell count in postoperative patients with and without infection.
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Evolution of insulin sensitivity and its variability in out of hospital cardiac arrest (OHCA) patients treated with hypothermia.
Crit Care
PUBLISHED: 05-25-2014
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IntroductionTherapeutic hypothermia (TH) is often used to treat out of hospital cardiac arrest (OHCA) patients who also often simultaneously receive insulin for stress-induced hyperglycaemia. However, the impact of TH on systemic metabolism and insulin resistance in critical illness is unknown. This study analyses the impact of TH on metabolism, including the evolution of insulin sensitivity (SI) and its variability, in patients with coma after OHCA.MethodsThis study uses a clinically validated, model-based measure of SI. Insulin sensitivity was identified hourly using retrospective data from 200 post-cardiac arrest patients (8,522 hours) treated with TH, shortly after admission to the Intensive Care Unit (ICU). Blood glucose and body temperature readings were taken every one to two hours. Data were divided into three periods: 1) cool (T <35 °C); 2) an idle period of two hours as normothermia was re-established; and 3) warm (T >37 °C). A maximum of 24 hours each for the cool and warm periods were considered. The impact of each condition on SI is analysed per cohort and per patient for both level and hour-to-hour variability, between periods and in 6-hour blocks.ResultsCohort and per patient median SI levels increase consistently by 35% to 70% and 26% to 59% (P <0.001) respectively from cool to warm. Conversely, cohort and per patient SI variability decreased by 11.1% to 33.6% (P <0.001) for the first 12 hours of treatment. However, SI variability increases between the 18th and 30th hours over the cool-warm transition, before continuing to decrease afterward.ConclusionsOCHA patients treated with TH have significantly lower and more variable SI during the cool period, compared to the later warm period. As treatment continues, SI level rises, and variability decreases consistently except for a large, significant increase during the cool-warm transition. These results demonstrate increased resistance to insulin during mild induced hypothermia. Our study might have important implications for glycaemic control during targeted temperature management.
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Infections and use of antibiotics in patients admitted for severe acute pancreatitis: data from the EPIC II study.
Surg Infect (Larchmt)
PUBLISHED: 05-12-2014
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Infectious complications are frequent in severe acute pancreatitis (SAP) but multinational epidemiologic data are lacking. The aim of the study was to analyze the characteristics of the infectious complications and antimicrobial use in this setting.
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Vaccine development and passive immunization for Pseudomonas aeruginosa in critically ill patients: a clinical update.
Future Microbiol
PUBLISHED: 05-10-2014
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Pseudomonas aeruginosa is one of the most common causes of nosocomial infection in intensive care unit patients and is independently associated with worse outcomes. Resistance of P. aeruginosa to antimicrobial agents is increasingly common and treatment of these infections is a growing challenge for intensivists. The development of methods to prevent infection, such as vaccines, is thus of considerable interest. Three agents currently show promise in this population of patients and are undergoing clinical evaluation; however, further vaccine targets are being discovered and more potential agents will likely be developed in the near future.
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Assessment of the worldwide burden of critical illness: the Intensive Care Over Nations (ICON) audit.
Lancet Respir Med
PUBLISHED: 04-14-2014
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Global epidemiological data regarding outcomes for patients in intensive care units (ICUs) are scarce, but are important in understanding the worldwide burden of critical illness. We, therefore, did an international audit of ICU patients worldwide and assessed variations between hospitals and countries in terms of ICU mortality.
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The next generation of sepsis clinical trial designs: what is next after the demise of recombinant human activated protein C?*.
Crit. Care Med.
PUBLISHED: 04-11-2014
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The developmental pipeline for novel therapeutics to treat sepsis has diminished to a trickle compared to previous years of sepsis research. While enormous strides have been made in understanding the basic molecular mechanisms that underlie the pathophysiology of sepsis, a long list of novel agents have now been tested in clinical trials without a single immunomodulating therapy showing consistent benefit. The only antisepsis agent to successfully complete a phase III clinical trial was human recumbent activated protein C. This drug was taken off the market after a follow-up placebo-controlled trial (human recombinant activated Protein C Worldwide Evaluation of Severe Sepsis and septic Shock [PROWESS SHOCK]) failed to replicate the favorable results of the initial registration trial performed ten years earlier. We must critically reevaluate our basic approach to the preclinical and clinical evaluation of new sepsis therapies.
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Abdominal infections in the intensive care unit: characteristics, treatment and determinants of outcome.
BMC Infect. Dis.
PUBLISHED: 04-10-2014
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Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II.
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C-reactive protein levels after cardiac arrest in patients treated with therapeutic hypothermia.
Resuscitation
PUBLISHED: 03-31-2014
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Prognostication of outcome after cardiac arrest (CA) is challenging. We assessed the prognostic value of daily blood levels of C-reactive protein (CRP), a cheap and widely available inflammatory biomarker, after CA.
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The future of observational research and randomized controlled trials in red blood cell transfusion medicine.
Shock
PUBLISHED: 03-26-2014
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Red blood cell (RBC) transfusions are commonplace in the intensive care unit (ICU) with at least 30% of ICU patients receiving a RBC transfusion at some point during their ICU stay. However, which patients should be transfused and what transfusion trigger(s) should be used remains unclear. RBC transfusion can be associated with adverse effects, but anemia is also associated with worse outcomes. Observational studies and randomized controlled trials (RCTs) have been conducted to try and answer some of the questions surrounding blood transfusion in critically ill patients. The need for blood transfusion and the benefit/risk ratio vary according to individual patient characteristics, including age and comorbidities, so large-scale RCTs in heterogeneous groups of patients may not be the most appropriate tool to investigate these issues; smaller RCTs in carefully defined patient groups may provide more useful information. Rigorous statistical analysis of large, carefully conducted observational studies will also help enhance our evidence-base in this field.
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Abandon the mouse research ship? Not just yet!
Shock
PUBLISHED: 02-27-2014
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Many preclinical studies in critical care medicine and related disciplines rely on hypothesis-driven research in mice. The underlying premise posits that mice sufficiently emulate numerous pathophysiologic alterations produced by trauma/sepsis and can serve as an experimental platform for answering clinically relevant questions. Recently, the lay press severely criticized the translational relevance of mouse models in critical care medicine. A series of provocative editorials were elicited by a highly publicized research report in the Proceedings of the National Academy of Sciences (PNAS; February 2013), which identified an unrecognized gene expression profile mismatch between human and murine leukocytes following burn/trauma/endotoxemia. Based on their data, the authors concluded that mouse models of trauma/inflammation are unsuitable for studying corresponding human conditions. We believe this conclusion was not justified. In conjunction with resulting negative commentary in the popular press, it can seriously jeopardize future basic research in critical care medicine. We will address some limitations of that PNAS report to provide a framework for discussing its conclusions and attempt to present a balanced summary of strengths/weaknesses of use of mouse models. While many investigators agree that animal research is a central component for improved patient outcomes, it is important to acknowledge known limitations in clinical translation from mouse to man. The scientific community is responsible to discuss valid limitations without overinterpretation. Hopefully, a balanced view of the strengths/weaknesses of using animals for trauma/endotoxemia/critical care research will not result in hasty discount of the clear need for using animals to advance treatment of critically ill patients.
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Impact of infection on the prognosis of critically ill cirrhotic patients: results from a large worldwide study.
Liver Int.
PUBLISHED: 02-26-2014
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Infections are a leading cause of death in patients with advanced cirrhosis, but there are relatively few data on the epidemiology of infection in intensive care unit (ICU) patients with cirrhosis.
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Cortisol is an associated-risk factor of brain dysfunction in patients with severe sepsis and septic shock.
Biomed Res Int
PUBLISHED: 02-01-2014
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To investigate cortisol levels in brain dysfunction in patients with severe sepsis and septic shock.
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How to assess prognosis after cardiac arrest and therapeutic hypothermia.
Crit Care
PUBLISHED: 01-14-2014
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The prognosis of patients who are admitted in a comatose state following successful resuscitation after cardiac arrest remains uncertain. Although the introduction of therapeutic hypothermia (TH) and improvements in post-resuscitation care have significantly increased the number of patients who are discharged home with minimal brain damage, short-term assessment of neurological outcome remains a challenge. The need for early and accurate prognostic predictors is crucial, especially since sedation and TH may alter the neurological examination and delay the recovery of motor response for several days. The development of additional tools, including electrophysiological examinations (electroencephalography and somatosensory evoked potentials), neuroimaging and chemical biomarkers, may help to evaluate the extent of brain injury in these patients. Given the extensive literature existing on this topic and the confounding effects of TH on the strength of these tools in outcome prognostication after cardiac arrest, the aim of this narrative review is to provide a practical approach to post-anoxic brain injury when TH is used. We also discuss when and how these tools could be combined with the neurological examination in a multimodal approach to improve outcome prediction in this population.
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?-lactam antibiotic concentrations during continuous renal replacement therapy.
Crit Care
PUBLISHED: 01-10-2014
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The use of standard doses of ?-lactam antibiotics during continuous renal replacement therapy (CRRT) may result in inadequate serum concentrations. The aim of this study was to evaluate the adequacy of unadjusted drug regimens (i.e., similar to those used in patients with normal renal function) in patients treated with CRRT and the influence of CRRT intensity on drug clearance.
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Serial Determinations of Neutrophil CD64 Expression for the Diagnosis and Monitoring of Sepsis in Critically Ill Patients.
Clin. Infect. Dis.
PUBLISHED: 12-20-2013
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Background.?Early identification of sepsis is important to be able to initiate timely therapy and optimize survival. Neutrophil CD64 expression (nCD64) has been proposed as a potential marker of sepsis. Methods.?In this prospective observational study, adult patients admitted to our 34-bed medico-surgical department of intensive care over a 3.5-month period were included. nCD64 expression was measured by flow-cytometry at admission and daily until discharge or death. Blood C-reactive protein (CRP) was measured routinely. Diagnosis of sepsis was recorded and appropriateness of empirical antibiotic treatment was established post-hoc. Results.?Of the 548 patients included, 468 had flow-cytometry measurements within 24 hours after admission, of whom 103 had sepsis. Septic patients had higher admission nCD64 expression than did non-septic patients (p<0.001). A cut-off admission nCD64 expression of 230 MFI (median fluorescence intensity) identified sepsis with a sensitivity of 89% (81-94%) and specificity of 87% (83-90%). When combining CRP and nCD64 expression, an abnormal result for both was associated with a 92% probability of sepsis, whereas sepsis was ruled out with a probability of 99% if both were normal. Septic patients receiving inappropriate empirical antibiotics had persistently elevated nCD64 expression, whereas expression decreased over time in patients receiving appropriate antibiotics. In non-septic patients, an increase in nCD64 expression ?40 MFI predicted ICU-acquired infection (n=29) with a sensitivity of 88% and specificity of 65%. Conclusions.?Measurement of nCD64 expression at ICU admission, especially when combined with CRP concentrations, is useful in diagnosing sepsis. Serial determinations of nCD64 could be used for monitoring purposes.
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Combination of veno-arterial extracorporeal membrane oxygenation and hypothermia for out-of-hospital cardiac arrest due to Taxus intoxication.
CJEM
PUBLISHED: 11-07-2013
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ABSTRACTA young woman presented with cardiac arrest following ingestion of yew tree leaves of the Taxus baccata species. The toxin in yew tree leaves has negative inotropic and dromotropic effects. The patient had a cardiac rhythm that alternated between pulseless electrical activity with a prolonged QRS interval and ventricular fibrillation. When standard resuscitation therapy including digoxin immune Fab was ineffective, a combination of extracorporeal membrane oxygenation (ECMO) and hypothermia was initiated. The total duration of low flow/no flow was 82 minutes prior to the initiation of ECMO. After 36 hours of ECMO (including 12 hours of electrical asystole), the patients electrocardiogram had normalized and the left ventricular ejection fraction was 50%. At this time, dobutamine and the ECMO were stopped. The patient had a full neurologic recovery and was discharged from the intensive care unit after 5 days and from the hospital 1 week later.
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Should hydroxyethyl starch solutions be totally banned?
Crit Care
PUBLISHED: 10-01-2013
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The choice of which intravenous solution to prescribe remains a matter of considerable debate in intensive care units around the world. Trends have been moving away from using hydroxyethyl starch solutions following concerns about safety. But are the available data sufficient to clearly assess the risk-benefit balance for all patients, and is there enough evidence of harm to justify removing these drugs completely from our hospitals?
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Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock.
Virulence
PUBLISHED: 09-25-2013
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Multiple experimental and human trials have shown that microcirculatory alterations are frequent in sepsis. In this review, we discuss the various mechanisms that are potentially involved in their development and the implications of these alterations. Endothelial dysfunction, impaired inter-cell communication, altered glycocalyx, adhesion and rolling of white blood cells and platelets, and altered red blood cell deformability are the main mechanisms involved in the development of these alterations. Microcirculatory alterations increase the diffusion distance for oxygen and, due the heterogeneity of microcirculatory perfusion in sepsis, may promote development of areas of tissue hypoxia in close vicinity to well-oxygenated zones. The severity of microvascular alterations is associated with organ dysfunction and mortality. At this stage, therapies to specifically target the microcirculation are still being investigated.
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A new regimen for continuous infusion of vancomycin during continuous renal replacement therapy.
J. Antimicrob. Chemother.
PUBLISHED: 06-25-2013
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Continuous infusion (CI) of high-dose vancomycin is often used to treat life-threatening infections caused by less-susceptible Gram-positive bacteria. However, this approach has not been well studied in patients on continuous renal replacement therapy (CRRT). The aim of this study was to evaluate the adequacy of a new CI vancomycin regimen in septic patients undergoing CRRT.
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Outcome of elderly patients with circulatory failure.
Intensive Care Med
PUBLISHED: 06-23-2013
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The proportion of elderly patients admitted to the ICU is increasing. Mortality rates are known to increase with age but the impact of age on outcomes after circulatory shock has not been well defined.
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Design of the PRINCESS trial: pre-hospital resuscitation intra-nasal cooling effectiveness survival study (PRINCESS).
BMC Emerg Med
PUBLISHED: 05-23-2013
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Therapeutic hypothermia (TH, 32-34°C) has been shown to improve neurological outcome in comatose survivors of out-of-hospital cardiac arrest (OHCA) with ventricular tachycardia or fibrillation. Earlier initiation of TH may increase the beneficial effects. Experimental studies have suggested that starting TH during cardiopulmonary resuscitation (CPR) may further enhance its neuroprotective effects. The aim of this study was to evaluate whether intra-arrest TH (IATH), initiated in the field with trans nasal evaporative cooling (TNEC), would provide outcome benefits when compared to standard of care in patients being resuscitated from OHCA.
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Soluble urokinase-type plasminogen activator receptor as a prognostic biomarker in critically ill patients.
J Crit Care
PUBLISHED: 05-22-2013
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The aim of this study was to assess the role of blood soluble urokinase-type plasminogen activator receptor (suPAR) levels in the diagnosis and prognostication of sepsis in critically ill patients.
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Control of hypertension in the critically ill: a pathophysiological approach.
Ann Intensive Care
PUBLISHED: 05-14-2013
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Severe acute arterial hypertension can be associated with significant morbidity and mortality. After excluding a reversible etiology, choice of therapeutic intervention should be based on evaluation of a number of factors, such as age, comorbidities, and other ongoing therapies. A rational pathophysiological approach should then be applied that integrates the effects of the drug on blood volume, vascular tone, and other determinants of cardiac output. Vasodilators, calcium channel blockers, and beta-blocking agents can all decrease arterial pressure but by totally different modes of action, which may be appropriate or contraindicated in individual patients. There is no preferred agent for all situations, although some drugs may have a more attractive profile than others, with rapid onset action, short half-life, and fewer adverse reactions. In this review, we focus on the main mechanisms underlying severe hypertension in the critically ill and how using a pathophysiological approach can help the intensivist decide on treatment options.
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Incidence and prognosis of dysnatraemia in critically ill patients: analysis of a large prevalence study.
Eur. J. Clin. Invest.
PUBLISHED: 05-10-2013
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The objective of this study is to assess the impact of dysnatraemia on mortality among intensive care unit (ICU) patients in a large, international cohort.
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Determination of the learning curve for ultrasound-guided jugular central venous catheter placement.
Intensive Care Med
PUBLISHED: 05-03-2013
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Use of ultrasound (US) when introducing central venous catheters (CVC) may improve success rates, reduce the number of needle punctures, and decrease complication rates, but has been hampered by supposed difficulty in learning how to perform the technique. This study describes the learning curve for US-guided jugular CVC placement after a training program.
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The STOP the Bleeding Campaign.
Crit Care
PUBLISHED: 04-26-2013
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According to the World Health Organization, traumatic injuries worldwide are responsible for over 5 million deaths annually. Post-traumatic bleeding caused by traumatic injury-associated coagulopathy is the leading cause of potentially preventable death among trauma patients. Despite these facts, awareness of this problem is insufficient and treatment options are often unclear. The STOP the Bleeding Campaign therefore aims to increase awareness of the phenomenon of post-traumatic coagulopathy and its appropriate management by publishing European guidelines for the management of the bleeding trauma patient, by promoting and monitoring the implementation of these guidelines and by preparing promotional and educational material, organising activities and developing health quality management tools. The campaign aims to reduce the number of patients who die within 24 hours after arrival in the hospital due to exsanguination by a minimum of 20% within the next 5 years.
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Strongyloides disseminated infection successfully treated with parenteral ivermectin: case report with drug concentration measurements and review of the literature.
Int. J. Antimicrob. Agents
PUBLISHED: 04-24-2013
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We report the case of an immunosuppressed patient with Strongyloides disseminated infection who was successfully treated with the veterinary parenteral form of ivermectin. A kidney transplant recipient developed disseminated infection with Strongyloides stercoralis. Because oral treatment with ivermectin was not possible, subcutaneous ivermectin (75µg/kg/day, then 200µg/kg/day) was given for 9 days, with clinical improvement and disappearance of all larvae. Serum ivermectin concentrations were between 15.6ng/mL and 19.7ng/mL during the 9 days of therapy; however, drug accumulation (plasma levels >40ng/mL) 48h after discontinuation of therapy was associated with the development with encephalopathy. We also review all cases of human disseminated Strongyloides infection treated with parenteral ivermectin.
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How to select an antifungal agent in critically ill patients.
J Crit Care
PUBLISHED: 04-11-2013
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Fungal infections are common in critically ill patients and are associated with increased morbidity and mortality. Candida spp are the most commonly isolated fungal pathogens. The last 2 decades have seen an increased incidence of fungal infections in critical illness and the emergence of new pathogenic fungal species and also the development of more effective (better bioavailability) and safer (less toxicity, fewer drug interactions) drugs. The distinction between colonization and infection can be difficult, and problems diagnosing infection may delay initiation of antifungal treatment. A number of factors have been identified that can help to distinguish patients at high risk for fungal infection. The antifungal agents that are most frequently used in the intensive care unit are the first- and second-generation azoles and the echinocandins; amphotericin B derivatives (mainly the liposomal agents) are less widely used because of adverse effects. The choice of antifungal agent in critically ill patients will depend on the aim of therapy (prophylaxis, pre-emptive, empiric, definitive), as well as on local epidemiology and specific properties of the drug (antifungal spectrum, efficacy, toxicity, pharmacokinetic/pharmacodynamic properties, cost). In this article we will review all these aspects and propose an algorithm to guide selection of antifungal agents in critically ill patients.
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Invasive aspergillosis in patients with severe alcoholic hepatitis.
J. Hepatol.
PUBLISHED: 03-28-2013
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Severe alcoholic hepatitis (AH) has a poor short-term prognosis. Although infections are frequent complications of AH, the incidence of invasive aspergillosis (IA) and its impact on outcome remain unknown.
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Can changes in renal function predict variations in ?-lactam concentrations in septic patients?
Int. J. Antimicrob. Agents
PUBLISHED: 03-22-2013
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This study investigated whether variations in creatinine clearance (CLCr) are correlated with changes in ?-lactam concentrations or pharmacokinetics in septic patients. Data for 56 adult patients admitted to the ICU in whom routine therapeutic drug monitoring (TDM) of broad-spectrum ?-lactams (ceftazidime, cefepime, piperacillin or meropenem) was performed were reviewed. Patients were included if they had at least two TDM during their ICU stay for the same antibiotic and were not concomitantly treated with any extracorporeal replacement therapy. Serum drug concentrations were measured by HPLC-UV. Antibiotic pharmacokinetics were calculated using a one-compartment model and the percentage of time spent above four times the MIC (%T>4×MIC) for Pseudomonas aeruginosa and the antibiotic clearance (ATB-CL) were obtained. CLCr was measured on the same day as the TDM using 24-h urine collection. The %T>4×MIC and ATB-CL were significantly correlated with CLCr at the first (r=-0.41, P=0.002; r=0.56, P<0.001, respectively) and second (r=-0.61, P<0.001; r=0.63, P<0.001, respectively) TDM. However, changes in ATB-CL were only weakly correlated with changes in CLCr (r=0.34, P=0.01). The proportion of patients with insufficient ?-lactam concentrations at the first and second TDM were 39% and 30%, respectively, and increased proportionally to CLCr. Although CLCr was significantly correlated with concentrations and clearance of broad-spectrum ?-lactams, changes in CLCr did not reliably predict variations in drug pharmacokinetics/pharmacodynamics. Routine TDM should be considered to adapt ?-lactam doses in this setting.
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Effect of eritoran, an antagonist of MD2-TLR4, on mortality in patients with severe sepsis: the ACCESS randomized trial.
JAMA
PUBLISHED: 03-21-2013
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Eritoran is a synthetic lipid A antagonist that blocks lipopolysaccharide (LPS) from binding at the cell surface MD2-TLR4 receptor. LPS is a major component of the outer membrane of gram-negative bacteria and is a potent activator of the acute inflammatory response.
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Our favorite unproven ideas for future critical care.
Crit Care
PUBLISHED: 03-12-2013
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The future of critical care medicine will be shaped not only by the evidence-validated foundations of science, but also by innovations based on unproven and, in many cases, untested concepts and thoughtful visions of scientists and clinicians familiar with the complex problems actually faced in clinical practice. Clinical investigations and trials often lag behind collective experience and impressions, in a well-intentioned and necessary quest to determine the fallacy or validity of ongoing practice. Progress made in this way can be painfully slow, and imperfect theory may prove difficult to challenge. On occasion, an innovative paradigm shift fostered by a novel approach can reorient the forces of academic investigation toward generating an evidence base upon which such concepts and interpretations can find scientific justification. This discussion presents a selected set of ideas to improve the future practice of critical care - each having a defensible rationale, but unconfirmed validity.
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Critical care--where have we been and where are we going?
Crit Care
PUBLISHED: 03-12-2013
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The first ICUs were established in the late 1950s and the specialty of critical care medicine began to develop. Since those early days, huge improvements have been made in terms of technological advances and understanding of the pathophysiology and pathogenesis of the disease processes that affect critically ill patients. Progress in therapeutics has been less dramatic, but process of care has improved steadily with important changes, including less iatrogenicity, better communication with patients and families, and improved teamwork, which have helped improve outcomes for ICU patients. Critical care medicine is one of the fastest-growing hospital specialties and, looking back, it is clear just how far we have come in such a relatively short period of time. With the ICU set to occupy an increasingly important place in hospitals worldwide, we must learn from the past and wisely embrace new developments in technology, therapeutics, and process, to ensure that the goals of critical care medicine are met in the future.
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Diagnostic and prognostic markers in sepsis.
Expert Rev Anti Infect Ther
PUBLISHED: 03-06-2013
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Sepsis is a common and serious complication in intensive care unit patients. An important factor in optimizing survival rates in septic patients is the ability to start treatment early in the course of disease; there is, therefore, a need for accurate diagnostic tests. In recent years, there has been a move away from the rather vague and nonspecific signs that were previously used to diagnose sepsis towards the possible adjunctive role of biomarkers. Many biomarkers have been proposed and assessed clinically, but none alone is specific enough to definitively determine diagnosis. The future direction of research is most likely a greater focus on the use of panels or combinations of markers with clinical signs. Some biomarkers may also be useful for prognosis and guiding therapy. Here, the authors will review our changing approaches to sepsis diagnosis and discuss some of the markers that seem most relevant at the present time.
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Blood transfusion in cardiac surgery is a risk factor for increased hospital length of stay in adult patients.
J Cardiothorac Surg
PUBLISHED: 03-04-2013
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BACKGROUND: Allogeneic red blood cell (RBC) transfusion has been proposed as a negative indicator of quality in cardiac surgery. Hospital length of stay (LOS) may be a surrogate of poor outcome in transfused patients. METHODS: Data from 502 patients included in Transfusion Requirements After Cardiac Surgery (TRACS) study were analyzed to assess the relationship between RBC transfusion and hospital LOS in patients undergoing cardiac surgery and enrolled in the TRACS study. RESULTS: According to the status of RBC transfusion, patients were categorized into the following three groups: 1) 199 patients (40%) who did not receive RBC, 2) 241 patients (48%) who received 3 RBC units or fewer (low transfusion requirement group), and 3) 62 patients (12%) who received more than 3 RBC units (high transfusion requirement group). In a multivariable Cox proportional hazards model, the following factors were predictive of a prolonged hospital length of stay: age higher than 65 years, EuroSCORE, valvular surgery, combined procedure, LVEF lower than 40% and RBC transfusion of > 3 units. CONCLUSION: RBC transfusion is an independent risk factor for increased LOS in patients undergoing cardiac surgery. This finding highlights the adequacy of a restrictive transfusion therapy in patients undergoing cardiac surgery.Trial registration: Clinicaltrials.gov identifier: NCT01021631.
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Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study.
Crit Care
PUBLISHED: 03-01-2013
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INTRODUCTION: Hyperglycemia, hypoglycemia, and increased glycemic variability have each been independently associated with increased risk of mortality in critically ill patients. The role of diabetic status on modulating the relation of these three domains of glycemic control with mortality remains uncertain. The purpose of this investigation was to determine how diabetic status affects the relation of hyperglycemia, hypoglycemia, and increased glycemic variability with the risk of mortality in critically ill patients. METHODS: This is a retrospective analysis of prospectively collected data involving 44,964 patients admitted to 23 intensive care units (ICUs) from nine countries, between February 2001 and May 2012. We analyzed mean blood glucose concentration (BG), coefficient of variation (CV), and minimal BG and created multivariable models to analyze their independent association with mortality. Patients were stratified according to the diagnosis of diabetes. RESULTS: Among patients without diabetes, mean BG bands between 80 and 140 mg/dl were independently associated with decreased risk of mortality, and mean BG bands >140 mg/dl, with increased risk of mortality. Among patients with diabetes, mean BG from 80 to 110 mg/dl was associated with increased risk of mortality and mean BG from 110 to 180 mg/dl with decreased risk of mortality. An effect of center was noted on the relation between mean BG and mortality. Hypoglycemia, defined as minimum BG <70 mg/dl, was independently associated with increased risk of mortality among patients with and without diabetes and increased glycemic variability, defined as CV >20%, was independently associated with increased risk of mortality only among patients without diabetes. Derangements of more than one domain of glycemic control had a cumulative association with mortality, especially for patients without diabetes. CONCLUSIONS: Although hyperglycemia, hypoglycemia, and increased glycemic variability is each independently associated with mortality in critically ill patients, diabetic status modulates these relations in clinically important ways. Our findings suggest that patients with diabetes may benefit from higher glucose target ranges than will those without diabetes. Additionally, hypoglycemia is independently associated with increased risk of mortality regardless of the patients diabetic status, and increased glycemic variability is independently associated with increased risk of mortality among patients without diabetes.
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High lactate levels are predictors of major complications after cardiac surgery.
J. Thorac. Cardiovasc. Surg.
PUBLISHED: 02-08-2013
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Although hyperlactatemia after cardiac surgery is common, the implications of raised levels remain controversial. The aim of this study was to evaluate whether high lactate levels after cardiac surgery are predictors of major complications including mortality.
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Management of bleeding and coagulopathy following major trauma: an updated European guideline.
Crit Care
PUBLISHED: 02-02-2013
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INTRODUCTION: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient. When these recommendations are implemented patient outcomes may be improved. METHODS: The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document represents an updated version of the guideline published by the group in 2007 and updated in 2010. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS: Key changes encompassed in this version of the guideline include new recommendations on the appropriate use of vasopressors and inotropic agents, and reflect an awareness of the growing number of patients in the population at large treated with antiplatelet agents and/or oral anticoagulants. The current guideline also includes recommendations and a discussion of thromboprophylactic strategies for all patients following traumatic injury. The most significant addition is a new section that discusses the need for every institution to develop, implement and adhere to an evidence-based clinical protocol to manage traumatically injured patients. The remaining recommendations have been re-evaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS: A comprehensive, multidisciplinary approach to trauma care and mechanisms with which to ensure that established protocols are consistently implemented will ensure a uniform and high standard of care across Europe and beyond.
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Can population pharmacokinetic modelling guide vancomycin dosing during continuous renal replacement therapy in critically ill patients?
Int. J. Antimicrob. Agents
PUBLISHED: 01-29-2013
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Treatment of resistant bacteria such as meticillin-resistant Staphylococcus aureus (MRSA) relies on achieving adequate antibiotic concentrations at the site of infection. Strategies to attain such targets in septic critically ill patients receiving renal replacement therapy (RRT) are uncommon but could be useful for increasing the likelihood of therapeutic dosing. The aim of this study was to conduct a population pharmacokinetic (PK) analysis in septic patients undergoing continuous RRT and to determine which parameters were associated with inadequate vancomycin concentrations. In total, 81 patients with 199 blood samples were included in the study. All patients received vancomycin dosing according to the local protocol, which included a weight-based loading dose followed by continuous infusion. The vancomycin concentration-time points were adequately described with a one-compartment model with zero order input. The median population PK estimate for vancomycin clearance (CL) was 2.9 L/h [interquartile range (IQR) 2.4-3.4 L/h] and for volume of distribution (Vd) was 0.8 L/kg (IQR 0.6-1.1 L/kg). The goodness-of-fit plots for the model were adequate. When covariates were tested, none were found to adequately explain changing vancomycin CL or Vd in the population PK model. In particular, the lack of correlation between CL and RRT settings was likely due to the multiple confounders known to influence antibiotic prescription in this setting. These data provide a cautionary tale of the challenges of describing pharmacokinetics in critically ill patients receiving RRT and highlights the need for a detailed, prospective, multicentre study to better inform dosing practice.
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Myocardial dysfunction during H1N1 influenza infection.
J Crit Care
PUBLISHED: 01-28-2013
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The purpose of the study is to evaluate the incidence and hemodynamic consequences of right ventricular (RV) and left ventricular (LV) dysfunction in critically ill patients with H1N1 infection.
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Assessment of left ventricular function by pulse wave analysis in critically ill patients.
Intensive Care Med
PUBLISHED: 01-28-2013
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Left ventricular (LV) performance is often quantified by echocardiography in critically ill patients. Pulse wave analysis (PWA) systems can also monitor cardiac function but in a continuous fashion. We compared echocardiographic and PWA-derived indices of LV function.
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Relationship between red cell storage duration and outcomes in adults receiving red cell transfusions: a systematic review.
Crit Care
PUBLISHED: 01-22-2013
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INTRODUCTION: The duration of red blood cell (RBC) storage before transfusion may alter RBC function and supernatant and, therefore, influence the incidence of complications or even mortality. METHODS: A MEDLINE search from 1983 to December 2012 was performed to identify studies reporting age of transfused RBCs and mortality or morbidity in adult patients. RESULTS: Fifty-five studies were identified; most were single-center (93%) and retrospective (64%), with only a few, small randomized studies (eight studies, 14.5%). The numbers of subjects included ranged from eight to 364,037. Morbidity outcomes included hospital and intensive care unit (ICU) length of stay (LOS), infections, multiple organ failure, microcirculatory alterations, cancer recurrence, thrombosis, bleeding, vasospasm after subarachnoid hemorrhage, and cognitive dysfunction. Overall, half of the studies showed no deleterious effects of aged compared to fresh blood on any endpoint. Eleven of twenty-two (50%) studies reported no increased mortality, three of nine (33%) showed no increased LOS with older RBCs and eight of twelve (66%) studies showed no increased risks of organ failure. Ten of eighteen (55%) studies showed increased infections with transfusion of older RBCs. The considerable heterogeneity among studies and numerous methodological flaws precluded a formal meta-analysis. CONCLUSIONS: In this systematic review, we could find no definitive argument to support the superiority of fresh over older RBCs for transfusion.
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ICU nephrology: the implications of cardiovascular alterations in the acutely ill.
Kidney Int.
PUBLISHED: 11-23-2011
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Cardiovascular alterations are common in critically ill patients and can have important implications for multiple organ systems, including the kidney. Restoring and maintaining adequate hemodynamic status in such patients is crucial to ensure sufficient oxygen availability to tissues and organs so that they can function optimally. In this text, we will return to the basic physiology of cardiac output and its components so that we can better understand the effects of cardiovascular alterations in critically ill patients, and how best to treat them.
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An uncalibrated pulse contour method to measure cardiac output during aortic counterpulsation.
Anesth. Analg.
PUBLISHED: 10-14-2011
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Less-invasive monitoring systems, such as pulse contour methods, are increasingly being used to estimate cardiac output (CO). However, alterations in the arterial waveform caused by intraaortic balloon pump counterpulsation may affect the ability of pulse contour algorithms to determine CO. We investigated the reliability of an uncalibrated pulse contour method, the MostCare system, in patients with cardiac failure receiving intraaortic balloon pump counterpulsation by comparing its measurements of CO with those determined by an intermittent thermodilution method.
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Continuous epileptiform discharges in patients treated with cefepime or meropenem.
Arch. Neurol.
PUBLISHED: 10-12-2011
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To test the hypothesis that treatment with cefepime hydrochloride leads to higher incidence of periodic epileptiform discharges compared with treatment with other ?-lactams.
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Massive bleeding in polytrauma: how can we make progress?
Crit Care
PUBLISHED: 10-11-2011
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Trauma is a major cause of death worldwide, with some 30% of deaths associated with hemorrhage. Rapid control of bleeding in such patients is thus an essential aspect of trauma care. Recombinant human factor VIIa is sometimes used off-label in massively bleeding patients and has been demonstrated in two randomized trials to significantly reduce the need for blood transfusions. Whether this translates into improved outcomes has not been determined, most notably because mortality appears to be much lower than in the past as a result of improved general care of trauma patients. In this setting it may be increasingly difficult to demonstrate that any intervention can influence survival since the number of patients needed for sufficient power is so high and the duration needed for recruitment of the patients too long. In the present commentary, we reflect on how we can move forward in the management of severely bleeding trauma patients in the current environment.
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Cardiovascular and microvascular responses to mild hypothermia in an ovine model.
Resuscitation
PUBLISHED: 09-15-2011
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Hypothermia is used for brain protection after resuscitation from cardiac arrest and other forms of brain injury, but its impact on systemic and tissue perfusion has not been well defined. The aim of this study was to evaluate the cardiovascular and microvascular responses to mild therapeutic hypothermia (MTH) in an ovine model.
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The accuracy of noninvasive hemoglobin measurement by multiwavelength pulse oximetry after cardiac surgery.
Anesth. Analg.
PUBLISHED: 09-14-2011
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In March 2008, a new multiwavelength pulse oximeter, the Radical 7 (Rad7; Masimo Corp., Irvine, CA), was developed that offers noninvasive measurement of hemoglobin concentration. Accuracy has been established in healthy adults and some surgical patients, but not in cardiac surgery intensive care patients, a group at high risk of postoperative bleeding events and anemia in whom early diagnosis could improve management.
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Acute kidney injury, acute lung injury and septic shock: how does mortality compare?
Contrib Nephrol
PUBLISHED: 09-09-2011
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Acute kidney injury (AKI), acute lung injury (ALI) and sepsis are all commonly encountered in critically ill patients. Although considered as separate conditions, largely for therapeutic purposes, a common inflammatory response is often implicated in their pathophysiologies and they are frequently present simultaneously. Mortality rates in critically ill patients suffering from renal failure, respiratory failure or severe sepsis are quite similar at about 40%, and all increase substantially when these conditions coexist. Most intensive care unit patients will die from multiple rather than individual organ failure, and further research is needed to evaluate the patterns of organ failure in surviving and nonsurviving critically ill patients, as well as the importance and mechanisms of organ-organ crosstalk in such patients.
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Clinical review: Update on hemodynamic monitoring--a consensus of 16.
Crit Care
PUBLISHED: 08-18-2011
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Hemodynamic monitoring plays a fundamental role in the management of acutely ill patients. With increased concerns about the use of invasive techniques, notably the pulmonary artery catheter, to measure cardiac output, recent years have seen an influx of new, less-invasive means of measuring hemodynamic variables, leaving the clinician somewhat bewildered as to which technique, if any, is best and which he/she should use. In this consensus paper, we try to provide some clarification, offering an objective review of the available monitoring systems, including their specific advantages and limitations, and highlighting some key principles underlying hemodynamic monitoring in critically ill patients.
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Current management of sepsis in critically ill adult patients.
Expert Rev Anti Infect Ther
PUBLISHED: 08-04-2011
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Severe sepsis is a common occurrence in critically ill patients and a major cause of morbidity and mortality in this population. Management relies on the early identification and treatment of the underlying causative infection, adequate and rapid hemodynamic resuscitation, support of associated organ failure and modulation of the immune response with drotrecogin alfa (activated) when it is not contraindicated, and corticosteroids in severe septic shock. We will review current approaches to each of these categories.
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Characteristics, practice patterns, and outcomes in patients with acute hypertension: European registry for Studying the Treatment of Acute hyperTension (Euro-STAT).
Crit Care
PUBLISHED: 07-29-2011
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Although effective strategies are available for the management of chronic hypertension, less is known about treating patients with acute, severe elevations in blood pressure. Using data from the European registry for Studying the Treatment of Acute hyperTension (Euro-STAT), we sought to evaluate real-life management practices and outcomes in patients who received intravenous antihypertensive therapy to treat an episode of acute hypertension.
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Red blood cell transfusion in the critically ill patient.
Ann Intensive Care
PUBLISHED: 07-29-2011
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Red blood cell (RBC) transfusion is a common intervention in intensive care unit (ICU) patients. Anemia is frequent in this population and is associated with poor outcomes, especially in patients with ischemic heart disease. Although blood transfusions are generally given to improve tissue oxygenation, they do not systematically increase oxygen consumption and effects on oxygen delivery are not always very impressive. Blood transfusion may be lifesaving in some circumstances, but many studies have reported increased morbidity and mortality in transfused patients. This review focuses on some important aspects of RBC transfusion in the ICU, including physiologic considerations, a brief description of serious infectious and noninfectious hazards of transfusion, and the effects of RBC storage lesions. Emphasis is placed on the importance of personalizing blood transfusion according to physiological endpoints rather than arbitrary thresholds.
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Lactate and base deficit are predictors of mortality in critically ill patients with cancer.
Clinics (Sao Paulo)
PUBLISHED: 07-04-2011
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Cancer patients frequently require admission to intensive care unit. However, there are a few data regarding predictive factors for mortality in this group of patients. The aim of this study was to evaluate whether arterial lactate or standard base deficit on admission and after 24 hours can predict mortality for patients with cancer.
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Increased blood glucose variability during therapeutic hypothermia and outcome after cardiac arrest.
Crit. Care Med.
PUBLISHED: 06-28-2011
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Hypothermia impairs blood glucose homeostasis and insulin sensitivity. However, the impact of therapeutic hypothermia on blood glucose levels and insulin requirements is unknown. We analyzed blood glucose variability during therapeutic hypothermia in patients with coma after cardiac arrest and examined its impact on outcome.
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Microcirculatory alterations: potential mechanisms and implications for therapy.
Ann Intensive Care
PUBLISHED: 05-27-2011
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Multiple experimental and human trials have shown that microcirculatory alterations are frequent in sepsis. In this review, we discuss the characteristics of these alterations, the various mechanisms potentially involved, and the implications for therapy. Sepsis-induced microvascular alterations are characterized by a decrease in capillary density with an increased number of stopped-flow and intermittent-flow capillaries, in close vicinity to well-perfused capillaries. Accordingly, the surface available for exchange is decreased but also is highly heterogeneous. Multiple mechanisms may contribute to these alterations, including endothelial dysfunction, impaired inter-cell communication, altered glycocalyx, adhesion and rolling of white blood cells and platelets, and altered red blood cell deformability. Given the heterogeneous nature of these alterations and the mechanisms potentially involved, classical hemodynamic interventions, such as fluids, red blood cell transfusions, vasopressors, and inotropic agents, have only a limited impact, and the microcirculatory changes often persist after resuscitation. Nevertheless, fluids seem to improve the microcirculation in the early phase of sepsis and dobutamine also can improve the microcirculation, although the magnitude of this effect varies considerably among patients. Finally, maintaining a sufficient perfusion pressure seems to positively influence the microcirculation; however, which mean arterial pressure levels should be targeted remains controversial. Some trials using vasodilating agents, especially nitroglycerin, showed promising initial results but they were challenged in other trials, so it is difficult to recommend the use of these agents in current practice. Other agents can markedly improve the microcirculation, including activated protein C and antithrombin, vitamin C, or steroids. In conclusion, microcirculatory alterations may play an important role in the development of sepsis-related organ dysfunction. At this stage, therapies to target microcirculation specifically are still being investigated.
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Recombinant activated factor VII safety in trauma patients: results from the CONTROL trial.
J Trauma
PUBLISHED: 05-26-2011
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Safety data on recombinant activated factor VII (rFVIIa, NovoSeven; Novo Nordisk A/S, Bagsværd, Denmark) in actively hemorrhaging trauma patients are limited. We present detailed safety data from a large multicenter, randomized, placebo-controlled phase III study (the CONTROL trial).
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Increased mortality associated with methicillin-resistant Staphylococcus aureus (MRSA) infection in the intensive care unit: results from the EPIC II study.
Int. J. Antimicrob. Agents
PUBLISHED: 05-12-2011
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Controversy continues regarding whether the presence of meticillin resistance increases mortality risk in Staphylococcus aureus infections. In this study, we assessed the role of meticillin resistance in survival of patients with S. aureus infection included in the EPIC II point-prevalence study of infection in critically ill patients performed on 8 May 2007. Demographic, physiological, bacteriological and therapeutic data were collected for 13796 adult patients in 1265 participating Intensive Care Units (ICUs) from 75 countries on the study day. ICU and hospital outcomes were recorded. Characteristics of patients with meticillin-sensitive S. aureus (MSSA) and meticillin-resistant S. aureus (MRSA) infections were compared. Co-morbidities, age, Simplified Acute Physiology Score (SAPS) II, site of infection, geographical region and MRSA/MSSA were entered into a multivariate model, and adjusted odds ratios (ORs) [95% confidence interval (CI)] for ICU and hospital mortality rates were calculated. On the study day, 7087 (51%) of the 13796 patients were classified as infected. There were 494 patients with MRSA infections and 505 patients with MSSA infections. There were no significant differences between the two groups in use of mechanical ventilation or haemofiltration/haemodialysis. Cancer and chronic renal failure were more prevalent in MRSA than in MSSA patients. ICU mortality rates were 29.1% and 20.5%, respectively (P<0.01) and corresponding hospital mortality rates were 36.4% and 27.0% (P<0.01). Multivariate analysis of hospital mortality for MRSA infection showed an adjusted OR of 1.46 (95% CI 1.03-2.06) (P=0.03). In ICU patients, MRSA infection is therefore independently associated with an almost 50% higher likelihood of hospital death compared with MSSA infection.
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Effects of changes in arterial pressure on organ perfusion during septic shock.
Crit Care
PUBLISHED: 04-28-2011
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Septic shock is characterized by altered tissue perfusion associated with persistent arterial hypotension. Vasopressor therapy is generally required to restore organ perfusion but the optimal mean arterial pressure (MAP) that should be targeted is uncertain. The aim of this study was to assess the effects of increasing MAP using norepinephrine (NE) on hemodynamic and metabolic variables and on microvascular reactivity in patients with septic shock.
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