Intensive care medicine
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Intensive care medicine · May 2003
Randomized Controlled Trial Multicenter Study Clinical TrialEarly enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial.
To compare the mortality of critically ill patients given either enteral feeding with an immune-enhancing formula or parenteral nutrition (PN). We report the results of a planned interim analysis on patients with severe sepsis which was undertaken earlier than planned once a meta-analysis suggested excess mortality in patients with severe sepsis given enteral immunonutrition. ⋯ Our results show that enteral immunonutrition, compared to PN, may be associated with excess mortality in patients with severe sepsis.
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Intensive care medicine · May 2003
Randomized Controlled Trial Comparative Study Clinical TrialInfluence of two different volume replacement regimens on renal function in elderly patients undergoing cardiac surgery: comparison of a new starch preparation with gelatin.
There is continuing concern on the influence of hydroxethyl starch (HES) on renal function. ⋯ Sensitive markers of kidney dysfunction increased in our elderly patients indicating moderate alterations in kidney integrity during cardiac surgery. The two volume replacement regimens did not differ with regard to kidney integrity in elderly patients undergoing cardiac surgery.
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Intensive care medicine · May 2003
ReviewThe impact of critical care pharmacists on enhancing patient outcomes.
The highly specialized knowledge and skills needed to care for critically ill patients requires a multidisciplinary team approach. Pharmacists are integral members of this team. They make valuable contributions to improve clinical, economic, and humanistic outcomes of patients. ⋯ Pharmacist interventions include correcting/clarifying orders, providing drug information, suggesting alternative therapies, identifying drug interactions, and therapeutic drug monitoring. Pharmacist involvement in improving clinical outcomes of critically ill patients is associated with optimal fluid management and substantial reductions in the rates of adverse drug events, medication administration errors, and ventilator-associated pneumonia. Furthermore, economic evaluations of clinical pharmacy services in the ICU consistently reveal the potential for considerable cost savings.
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Intensive care medicine · May 2003
ReviewAll great truths are iconoclastic: selective decontamination of the digestive tract moves from heresy to level 1 truth.
The objective was to compare evidence of the effectiveness, costs and safety of the traditional parenteral antibiotic-only approach against that gathered from 53 randomised trials involving more than 8,500 patients and six meta-analyses on selective decontamination of the digestive tract (SDD) to control infection on the intensive care unit (ICU). PHILOSOPHY: Traditionalists believe that all infections are due to breaches of hygiene except those established in the first 2 days, and that all micro-organisms can cause death. In contrast, newer insights show that transmission via the hands of carers are responsible only for infections occurring after one week, and that only a limited range of 15 potential pathogens contribute to mortality. INTERVENTIONS TO PREVENT ICU INFECTION: The traditional approach is based on hand disinfection aiming at the prevention of transmission of all micro-organisms, to control all infections that occur after 2 days on the ICU. The second feature is the restrictive use of systemic antibiotics, only in cases of microbiologically proven infection. In contrast, SDD aims to control the three types of infection: primary, secondary endogenous and exogenous due to 15 potential pathogens. The classical SDD tetralogy comprises four components: (i) a parenteral antibiotic, cefotaxime, administered for three days to prevent primary endogenous infections typically occurring "early"; (ii) the oropharyngeal and enteral antimicrobials, polymyxin E, tobramycin and amphotericin B administered in throat and gut throughout the treatment on the ICU to prevent secondary endogenous infections tending to develop "late"; (iii) a high standard of hygiene to control transmission of potential pathogens; and (iv) surveillance samples of throat and rectum to monitor the efficacy of the treatment. ⋯ The traditionalists still rely on level 5 evidence, i.e. expert opinion, with a grade E recommendation, whilst the proponents of SDD are able to cite level 1 evidence allowing a grade A recommendation in their attempts to control infection on the ICU. The main reason for SDD not being widely used is the primacy of opinion over evidence.
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Intensive care medicine · May 2003
A universal method for determining intensive care unit bed requirements.
Most methods used to estimate ICU bed needs rely either on simple formulas that do not consider the actual needs of the population or on simulations that are too specific to be applicable to all hospitals. We sought to develop a universally applicable nonparametric method. ⋯ Our model is reliable for determining the number of beds needed in any type of ICU and can be used by all ICU managers. The software is available.