Critical care clinics
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Critical care clinics · Apr 2008
ReviewSepsis and septic shock: selection of empiric antimicrobial therapy.
This article is a brief overview of empiric antibiotic selection for sepsis and septic shock. The article includes a differential diagnosis of the mimics of sepsis and stresses a strategy for avoiding problems associated with antibiotic resistance. Although early appropriate empiric therapy is the cornerstone of sepsis and septic shock therapy, nonantibiotic interventions are critical as well. ⋯ Empiric monotherapy for sepsis and septic shock is preferred. Multiple-drug therapy is more expensive, has an increased potential for drug-drug interactions, has a higher likelihood of side effects, and does not decrease the resistance potential of the antibiotics being used. For these reasons, early empiric monotherapy is optimal and de-escalation is not necessary if initial mono therapy was wisely selected.
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The emergence of gram-negative bacteria resistant to most available antibiotics has led to the readministration of polymyxins B and E (colistin) as "salvage" therapy in critically ill patients. Recent studies demonstrated acceptable effectiveness and considerably less toxicity than reported in older studies of polymyxins. These old antibiotics may be administered for the treatment of intensive care unit-acquired infections of various types, including ventilator-associated pneumonia, urinary tract infections, bacteremia, and meningitis caused by multidrug resistant gram-negative pathogens, such as Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Enterobacter species. Randomized controlled trials are urgently needed to further clarify various issues regarding the effectiveness and safety of polymyxins, however.
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Critical care clinics · Jan 2008
ReviewThe alteration of autonomic function in multiple organ dysfunction syndrome.
Autonomic dysfunction is associated with the severity of illness and mortality in patients with multiple organ dysfunction syndrome (MODS) and may contribute significantly to the pathogenesis of this syndrome. Several treatment approaches may possibly restore autonomic function in MODS and thus cause the survival benefit.
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Critical care clinics · Jan 2008
ReviewThe pathophysiology of long-term neuromuscular and cognitive outcomes following critical illness.
Despite the recent and marked improvement in short-term mortality after critical illness, significant morbidities persist for many patients following hospital discharge. This article discusses the risk factors for muscle, nerve, and brain dysfunction after critical illness and preliminary basic science data to support possible pathophysiologic mechanisms mediating this disability. Additionally, it presents a roadmap outlining future directions in this area of research.
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Seizures represent stereotypic electroencephalographic (EEG) and behavioral paroxysms as a consequence of electrical neurologic derangement. Seizures are usually described as focal or generalized motor convulsions; however, nonconvulsive seizures that occur in the absence of motor activity may escape clinical detection. ⋯ For optimal treatment, early diagnosis of the seizure type and its cause is important to ensure appropriate therapy. Convulsive status epilepticus requires emergent treatment before irreversible brain injury and severe metabolic disturbances occur.