查看更多>>摘要：ABSTRACT: Intensive glycemic control has become standard practice. Existing data, however, suggest this practice may have adverse consequences for traumatic brain injury. The recent paper by Meier and colleagues suggests that intensive glycemic control may be deleterious. The present article explores existing literature surrounding this controversy, and outlines the literature that raises concern. Finally, I suggest an alternative course of action that may enable control of glucose in an optimal range.
查看更多>>摘要：ABSTRACT: Medical databases serve a critical function in healthcare, including the areas of patient care, administration, research and education. The quality and breadth of information collected into existing databases varies tremendously, between databases, between institutions and between national boundaries. The field of critical care medicine could be advanced substantially by the development of comprehensive and accurate databases.
查看更多>>摘要：ABSTRACT: Sepsis with myocardial dysfunction is seen commonly. Beta-blockers have been used successfully to treat chronic heart failure based on the premise that chronically elevated adrenergic drive is detrimental to the myocardium. However, recent reports on the acute use of beta-blockers in situations with potential hemodynamic compromise have shown the risks associated with this approach. In critical situations, the main effect of adrenergic activation is to support cardiovascular function. Caution should be exercised in designing studies to assess beta-blockers in septic patients.
查看更多>>摘要：ABSTRACT: In the field of continuous renal replacement therapy (CRRT), session length, downtime and dose require detailed research, which will provide information important in relation to prescription, anticoagulation and circuit material choice (membrane type and size, vascular access site and size). In particular, it appears that many of the data currently existing in the literature and accepted regarding CRRT prescription and delivery in critically ill adult patients are not strictly applicable to the paediatric setting. Furthermore, many of the available paediatric studies are small, retrospective or underpowered. In paediatric CRRT, epidemiological investigations and prospective trials to investigate practical aspects of extracorporeal therapies are welcome and urgently needed.
查看更多>>摘要：ABSTRACT: Activation of the coagulation cascade resulting in alveolar fibrin deposition is recognized as a hallmark of acute lung injury (ALI). Anticoagulant treatment with recombinant human activated protein C (rhAPC) appears promising, because - like in sepsis - there is a deficiency of protein C in ALI, which is correlated with poor outcome in both syndromes. Recently in Critical Care, Waerhaug and colleagues confirmed the beneficial effects of rhAPC on pulmonary function in ovine endotoxin-induced ALI. Notably, the authors reported no differences in hemorrhage in histologic analyses between rhAPC-treated and untreated animals. However, a recently reported randomized, placebo-controlled, multicenter trial in ALI patients without severe sepsis failed to identify any differences in the number of ventilator-free days or 60 day-mortality between the rhAPC and placebo group. In addition to (or perhaps because of) the complex pathogenesis, the discrepancy between clinical and experimental results in ALI is another common feature with sepsis. The future challenge will be to transfer our theoretical knowledge adequately into daily clinical practice. Anticoagulant therapy might be a useful tool in the treatment of ALI; however the proper operating instruction remains to be defined.
查看更多>>摘要：ABSTRACT: Gastrointestinal dysfunction is an intuitively important, yet descriptively elusive component of the multiple organ dysfunction syndrome. Reintam and colleagues have attempted to quantify this dimension using a combination of intolerance of enteral feeding, and the development of intra-abdominal hypertension. While they show that both parameters are associated with an increased risk of death (and therefore that, in combination, the risk of death is even greater), they fall short in developing a novel descriptor of gastrointestinal dysfunction. Nonetheless, and even with its shortcomings, their effort is a welcome contribution to the surprisingly complex process of describing the morbidity of critical illness.
查看更多>>摘要：ABSTRACT: The current gold standard for the diagnosis of elevated intracranial pressure (ICP) remains invasive monitoring. Given that invasive monitoring is not always available or clinically feasible, there is growing interest in non-invasive methods of assessing ICP using diagnostic modalities such as ultrasound or magnetic resonance imaging (MRI). Increased ICP is transmitted through the cerebrospinal fluid surrounding the optic nerve, causing distention of the optic nerve sheath diameter (ONSD). In this issue of Critical Care, Geeraerts and colleagues describe a non-invasive method of diagnosing elevated ICP using MRI to measure the ONSD. They report a positive correlation between measurements of the ONSD on MRI and invasive ICP measurements. If the findings of this study can be replicated in larger populations, this technique may be a useful non-invasive screening test for elevated ICP in select populations.
查看更多>>摘要：ABSTRACT: The Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock recommend that the initial hemodynamic resuscitation be done according to the protocol used by Rivers and colleagues in their well-known early goal-directed therapy (EGDT) study. However, it may well be that their patients were much sicker on admission than many other septic patients. Compared with other populations of septic patients, the patients of Rivers and colleagues had a higher incidence of severe comorbidities, a more severe hemodynamic status on admission (excessively low central venous oxygen saturation [ScvO2], low central venous pressure [CVP], and high lactate), and higher mortality rates. Therefore, it may well be that these patients arrived to the hospital in late untreated hypovolemic sepsis, which may have been due, in part at least, to low socioeconomic status and reduced access to health care. The EGDT protocol uses target values for CVP and ScvO2 to guide hemodynamic management. However, filling pressures do not reliably predict the response to fluid administration, while the ScvO2 of septic patients is characteristically high due to decreased oxygen extraction. For all these reasons, it seems that the hemodynamic component of the Surviving Sepsis Campaign guidelines cannot be applied to all septic patients, particularly those who develop sepsis during their hospital stay.
查看更多>>摘要：ABSTRACT: You are asked to be involved in organizing a trauma service for a major urban center. You are asked to make a decision on whether the services general approach to trauma in the city (which does have a well-established trauma center) will be scoop and run (minimal resuscitation at the scene with a goal to getting the patient to a trauma center as quickly as possible) or on-the-scene resuscitation with transfer following some degree of stabilization.
查看更多>>摘要：ABSTRACT: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life-threatening disorders that have substantial adverse effects on outcomes in critically ill patients. ALI/ARDS develops in response to pulmonary or extrapulmonary injury and is characterized by increased leakage from the pulmonary microvasculature and excessive infiltration of polymorphonuclear cells into the lung. Currently, no therapeutic strategies are available to control these fundamental pathophysiological processes in human ALI/ARDS. In a variety of animal models and experimental settings, the purine nucleoside adenosine has been demonstrated to regulate both endothelial barrier integrity and polymorphonuclear cell trafficking in the lung. Adenosine exerts its effects through four G-protein-coupled receptors (A1, A2A, A2B, and A3) that are expressed on leukocytes and nonhematopoietic cells, including endothelial and epithelial cells. Each type of adenosine receptor (AR) is characterized by a unique pharmacological and physiological profile. The development of selective AR agonists and antagonists, as well as the generation of gene-deficient mice, has contributed to a growing understanding of the cellular and molecular processes that are critically involved in the development of ALI/ARDS. Adenosine-dependent pathways are involved in both protective and proinflammatory effects, highlighting the need for a detailed characterization of the distinct pathways. This review summarizes current experimental observations on the role of adenosine signaling in the development of acute lung injury and illustrates that adenosine and ARs are promising targets that may be exploited in the development of innovative therapeutic strategies.
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