10 Feb 06
Posted in Critical Care, rhAPC, Sepsis at 21:34 by Laci
By J Carlet
Critical Care Medicine 34(2): 525-529
This is a point of view article commenting on the indications given several years ago to drotrecogin alpha (activated) for severe sepsis. This appears necessary following the recent publication of studies looking at subgroups within the initial PROWESS study, of the phase IV ENHANCE study, and of the results of two recent randomized clinical trials looking at the efficacy of this compound: the ADDRESS trial (with an editorial) and a pediatric study (not yet published), both recently stopped for futility.
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Posted in Brain injury, Critical Care at 21:13 by Laci
By NS Naval, RD Stevens, MA Mirski, A Bhardwaj
Critical Care Medicine. 34(2):511-524
Background
The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management.
Objective
To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation.
Data Source
Search of MEDLINE and Cochrane databases and manual review of article bibliographies.
Data Synthesis and Conclusions
Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.
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Posted in Critical Care, Infection, Sepsis at 21:08 by Laci
By JL Vincent, Y Sakr, CL Sprung, VM Ranieri, K Reinhart, H Gerlach et al
Critical Care Medicine 2006;34:344-353
Objective
To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units.
Design
Cohort, multiple-center, observational study.
Setting
One hundred and ninety-eight intensive care units in 24 European countries.
Patients
All new adult admissions to a participating intensive care unit between May 1 and 15, 2002.
Interventions
None.
Measurements and Main Results
Demographic data, comorbid diseases, and clinical and laboratory data were collected prospectively. Patients were followed up until death, until hospital discharge, or for 60 days. Of 3,147 adult patients, with a median age of 64 yrs, 1,177 (37.4%) had sepsis; 777 (24.7%) of these patients had sepsis on admission. In patients with sepsis, the lung was the most common site of infection (68%), followed by the abdomen (22%). Cultures were positive in 60% of the patients with sepsis. The most common organisms were Staphylococcus aureus (30%, including 14% methicillin-resistant), Pseudomonas species (14%), and Escherichia coli (13%). Pseudomonas species was the only microorganism independently associated with increased mortality rates. Patients with sepsis had more severe organ dysfunction, longer intensive care unit and hospital lengths of stay, and higher mortality rate than patients without sepsis. In patients with sepsis, age, positive fluid balance, septic shock, cancer, and medical admission were the important prognostic variables for intensive care unit mortality. There was considerable variation between countries, with a strong correlation between the frequency of sepsis and the intensive care unit mortality rates in each of these countries.
Conclusions
This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsis and the intensive care unit mortality in the various countries. In addition to age, a positive fluid balance was among the strongest prognostic factors for death. Patients with intensive care unit acquired sepsis have a worse outcome despite similar severity scores on intensive care unit admission.
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Posted in Critical Care, Mechanical ventilation at 21:03 by Laci
By R Kalhan, M Mikkelsen, P Dedhiya, J Christie, C Gaughan, Christine et al
Critical Care Medicine. 34(2):300-306
Objective
To determine the frequency of use of low-tidal-volume ventilation in appropriate patients with acute lung injury (ALI) and the factors associated with the choice of tidal volume.
Design
Prospective observational cohort study of patients identified with ALI or acute respiratory distress syndrome from September 2000 to November 2002.
Setting
Medical and surgical intensive care unit (ICU) at an academic tertiary-care hospital.
Measurements and Main Results
Measurements included the proportion for whom the ventilation tidal volume (TV) was <=7.5 mL/kg predicted body weight (PBW) on days 2, 4, and 7 of ALI and the proportion for whom the ventilation TV was <=6.5 and <=8.5 mL/kg/PBW (sensitivity analysis). Demographic and clinical characteristics of patients undergoing ventilation with low and high TV were compared. Of 88 total patients studied, 39% had ventilation with TV <=7.5 mL/kg/PBW on day 2 of ALI, 49% on day 4, and 56% on day 7. In contrast, 49% of patients had ventilation with TV >8.5 mL/kg/PBW on day 2 of ALI, 30% on day 4, and 24% on day 7. The use of low TV was significantly associated with clinical parameters indicative of worse disease severity, including low values for Pao2 (p = .01), Pao2/Fio2 (p = .08), and static compliance of the respiratory system (p = .006).
Conclusions
Ventilation with a low TV was used in a minority of patients with ALI, despite results published in 1998 and 2000 supporting this approach. This may be related to clinicians’ underrecognition of less severe cases of ALI, their reserving of low-TV ventilation for more severe cases, or both.
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