Critical care medicine
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Critical care medicine · May 2002
ReviewSoluble thrombomodulin, plasma-derived unactivated protein C, and recombinant human activated protein C in sepsis.
To review the physiologic and biochemical mechanisms and the rationale for the use of soluble thrombomodulin, plasma-derived protein C, and recombinant human activated protein C in sepsis. ⋯ The multipotent pharmacodynamic effects (antithrombotic, profibrinolytic, and anti-inflammatory) of activated protein C may explain why recombinantly derived human activated protein C is the first experimental agent to demonstrate a significant survival benefit in patients with severe sepsis.
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Critical care medicine · May 2002
Comparative StudyEffects of epinephrine and vasopressin in a piglet model of prolonged ventricular fibrillation and cardiopulmonary resuscitation.
We recently demonstrated that vasopressin alone resulted in a poorer outcome in a pediatric porcine model of asphyxial cardiac arrest when compared with epinephrine alone or with epinephrine plus vasopressin in combination. Accordingly, this study was designed to differentiate whether the inferior effects of vasopressin in pediatrics were caused by the type of cardiac arrest. ⋯ In this pediatric porcine model of ventricular fibrillation, the combination of epinephrine with vasopressin during cardiopulmonary resuscitation resulted in significantly higher levels of left ventricular myocardial blood flow than either vasopressin alone or epinephrine alone. Both vasopressin alone and the combination of epinephrine with vasopressin, but not epinephrine alone, improved total cerebral blood flow during cardiopulmonary resuscitation. In stark contrast to asphyxial cardiac arrest, vasopressin alone or in combination with epinephrine appears to be of benefit after ventricular fibrillation in the pediatric porcine model.
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Critical care medicine · May 2002
Comparative StudySuccessful determination of lower inflection point and maximal compliance in a population of patients with acute respiratory distress syndrome.
To compare the ease and efficacy of two commonly used methods for choosing optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome: a static pressure-volume curve to determine the lower inflection point (P(flex)) and the "best PEEP" (PEEP(best)) as determined by the maximal compliance curve. ⋯ Our data show that optimal PEEP, as determined by a pressure-volume curve and a maximal compliance curve, are sometimes unobtainable by practical means but, when obtained, often correspond. A maximal compliance is more often identified, has less interobserver variability, and poses less risk to the patient. We conclude that determining optimal PEEP by maximal static compliance may be easier to measure and more frequently obtained at the bedside than by using a static pressure-volume curve.
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Critical care medicine · May 2002
Transcutaneous carbon dioxide monitoring during high-frequency oscillatory ventilation in infants and children.
Continuous monitoring of ventilation during mechanical ventilation may improve patient management by facilitating proactive rather than reactive ventilator adjustments and may decrease the need for repeated arterial blood gas analysis. Because of their more critical pulmonary status, patients requiring high-frequency oscillatory ventilation may especially benefit from continuous monitoring. ⋯ TC(CO2) monitoring provides an accurate and clinically acceptable estimate of PaCO2 over a wide range of CO2 values in pediatric patients during high-frequency oscillatory ventilation.
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Critical care medicine · May 2002
Lessons from everyday lives: a moral justification for acute care research.
Progress in emergency and critical care requires that clinical research be performed on patients who are incapable of granting consent for research participation. Analyses of the ethics of such research have left some questions incompletely answered. ⋯ By relying on a framework for assessing research risks, and by drawing on the example of pediatric research, this justification is founded in how institutional review boards, and society in general, analyze risk. Our justification for emergency research also suggests additional protections for emergency research participants, including a stringent threshold for research risk, that still permit important research to proceed.