Chest
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Multicenter Study
Community-acquired bloodstream infection in critically ill adult patients: impact of shock and inappropriate antibiotic therapy on survival.
The objectives were to characterize the prognostic factors and evaluate the impact of inappropriate empiric antibiotic treatment and systemic response on the outcome of critically ill patients with community-acquired bloodstream infection (BSI). ⋯ Inappropriate antimicrobial treatment is the most important influence on outcome in patients admitted to the ICU for community-acquired BSI, particularly in presence of septic shock or high degrees of severity. Initial broad-spectrum therapy should be prescribed to septic patients in whom the source is unknown or in those requiring vasopressors.
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The role of corticosteroid therapy in the management of septic shock has been debated for half a century. Results from large, well-designed, randomized clinical trials demonstrate no benefit, and perhaps harm, associated with short duration, high-dose methylprednisolone or dexamethasone administered at the onset of septic shock. ⋯ A multicenter, placebo-controlled clinical trial demonstrated improved survival rates and faster cessation of vasopressors among patients with septic shock who have a poor response to corticotropin injection, consistent with relative adrenal insufficiency. However, concerns regarding a trend for higher mortality among corticotropin responders and the possibility that patients with true adrenal insufficiency may have been enrolled in this placebo-controlled trial, potentially skewing results, should be considered.
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Randomized Controlled Trial Clinical Trial
Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.
To determine whether there is any difference in diagnostic, therapeutic, and outcome efficacy between protocols utilizing daily (ie, routine) chest radiographs (CXRs) and those utilizing clinically indicated (ie, nonroutine) CXRs in mechanically ventilated patients. ⋯ For mechanically ventilated patients, a strategy calling for daily routine CXRs compared to CXRs obtained based on clinical indications alone was not associated with reduced ICU or hospital length of stay or with reduced mortality.
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The use of corticosteroids as adjunctive therapy for severe sepsis and septic shock has been a source of controversy for the past 35 years. Despite a wealth of preclinical data supporting both survival and physiologic benefit for early steroid use, the data in human sepsis have been much less convincing. ⋯ Recent trials have reported hemodynamic and survival benefits associated with the use of more physiologic steroid replacement therapy in patients with vasopressor-dependent septic shock. These results coupled with the observation of "relative adrenal insufficiency" in some patients with severe sepsis and septic shock may once again establish a defined role for corticosteroid therapy in the management of severe sepsis and septic shock.
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Effective management of hemorrhagic shock depends on titration of therapies against reliable resuscitation end points. Conventional clinical and laboratory indexes of shock are often slow to respond to progressive circulatory compromise. ⋯ Gastric tonometry, by detecting the presence of gastric intramucosal acidosis as a proxy of splanchnic hypoperfusion, may facilitate more timely and rational shock resuscitation. This article reviews the development and validation of gastric tonometry and summarizes the clinical studies that have used this modality to guide the management of shock in trauma patients.