19 Dec 08
Posted in Fluid management at 0:00 by Laci
By F Schortgen, E Girou, N Deye, L Brochard for the CRYCO Study Group
Intensive Care Med 2008:34;2157-2168
Crystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypooncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician’s choice.
Participants and setting
International prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded.
Measurements and results
Influence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians’ preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24–4.97)] and hyperoncotic albumin [OR: 5.99 (2.75–13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42–5.47)].
Conclusions
This study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist.
See the Editorial by PM Honorel, O Joannes-Boyau and W Boer: Hyperoncotic colloids in shock and risk of renal injury: enough evidence for a banning order?
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18 Dec 08
Posted in Early goal directed therapy, ScvO2, Sepsis at 14:22 by Laci
By C F de Oliveira1, D S de Oliveira1, A F C Gottschald, J D G Moura1, G A Costa1, A C Ventura et al
Intensive Care Med 2008:34;1065-1075
The ACCM/PALS guidelines address early correction of paediatric septic shock using conventional measures. In the evolution of these recommendations, indirect measures of the balance between systemic oxygen delivery and demands using central venous or superior vena cava oxygen saturation (ScvO2>=70%) in a goal-directed approach have been added. However, while these additional goal-directed endpoints are based on evidence-based adult studies, the extrapolation to the paediatric patient remains unvalidated.
Objective
The purpose of this study was to compare treatment according to ACCM/PALS guidelines, performed with and without ScvO2 goal-directed therapy, on the morbidity and mortality rate of children with severe sepsis and septic shock.
Design, participants and interventions
Children and adolescents with severe sepsis or fluid-refractory septic shock were randomly assigned to ACCM/PALS with or without ScvO2 goal-directed resuscitation.
Measurements
Twenty-eight-day mortality was the primary endpoint.
Results Of the 102 enrolled patients, 51 received ACCM/PALS with ScvO2 goal-directed therapy and 51 received ACCM/PALS without ScvO2 goal-directed therapy. ScvO2 goal-directed therapy resulted in less mortality (28-day mortality 11.8% vs. 39.2%, p=0.002), and fewer new organ dysfunctions (p=0.03). ScvO2 goal-directed therapy resulted in more crystalloid (28 (20–40) vs. 5 (0–20)ml/kg, p<0.0001), blood transfusion (45.1% vs. 15.7%, p=0.002) and inotropic (29.4% vs. 7.8%, p=0.01) support in the first 6h.
Conclusions
This study supports the current ACCM/PALS guidelines. Goal-directed therapy using the endpoint of a ScvO2>=70% has a significant and additive impact on the outcome of children and adolescents with septic shock.
See the Editorial by M J Peters and J Brierley: Back to basics in septic shock
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14 Dec 08
Posted in Procedure videos at 0:00 by Laci
By J Hsiao and V Pacheco-Fowler
NEJM 2008;358:e25
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Cricothyroidotomy is an emergent procedure performed on patients experiencing severe respiratory distress in whom orotracheal or nasotracheal intubation has failed. The procedure involves making an incision in the cricothyroid membrane, which lies between the thyroid and |
cricoid cartilages, followed by inserting a tracheostomy tube, which allows ventilation. This video describes how to perform a cricothyroidotomy in an adult. The major indication for cricothyroidotomy is the inability to establish an airway by orotracheal or nasotracheal intubation. Failure to secure an orotracheal or nasotracheal airway may be due to factors such as difficult patient anatomy; excessive blood in the mouth or . . . .
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12 Dec 08
Posted in Monitoring, PA catheter at 0:00 by Laci
By GA Ospina-Tascon, RL Cordioli, JL Vincent
Intensive Care Med 2008; 34:800-820
Lack of evidence that some monitoring systems can improve outcomes has raised doubts about their use in the intensive care unit (ICU). The objective of this study was to determine which monitoring techniques have been shown to improve outcomes in ICU patients.
Design
Comprehensive literature review.
Methods
We conducted a highly sensitive search, up to June 2006, in the Cochrane Central Register of Controlled Trials (CENTRAL) and MedLine, for prospective, randomized controlled trials (RCTs) conducted in adult patients in the ICU and the operating room (major surgical procedures) and focusing on the impact of monitoring on outcome.
Measurements and results
Of 4,175 potential articles, 67 evaluated the impact of monitoring in acutely ill adult patients. There were 40 studies related to hemodynamic monitoring, 17 to respiratory monitoring, and10 to neurological monitoring. Seven studies were classified in two different categories. Positive non-mortality outcomes were observed in 17 of 40 hemodynamic studies, 11 of 17 respiratory, and in all 10 neurological studies. Mortality was evaluated in 31 hemodynamic studies, but a beneficial impact was demonstrated in only 10. For respiratory monitoring, 7 studies evaluated mortality, but only 3 of them showed an improved outcome. We found no neurological monitoring studies that assessed mortality.
Conclusion
There is no broad evidence that any form of monitoring improves outcomes in the ICU and most commonly used devices have not been evaluated by RCT. This review puts into perspective the recent negative studies on the use of the pulmonary artery catheter in the acutely ill.
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