Critical care medicine
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Critical care medicine · Apr 2003
Randomized Controlled Trial Clinical TrialStress doses of hydrocortisone reduce severe systemic inflammatory response syndrome and improve early outcome in a risk group of patients after cardiac surgery.
Severe systemic inflammation with a vasodilatory syndrome occurs in about one third of all patients after cardiac surgery with cardiopulmonary bypass. Hydrocortisone has been used successfully to reverse vasodilation in septic patients. We evaluated if stress doses of hydrocortisone attenuate severe systemic inflammatory response syndrome in a predefined risk group of patients after cardiac surgery with cardiopulmonary bypass. ⋯ Although we acknowledge the limitations of a nonblinded interventional trial, stress doses of hydrocortisone seem to attenuate systemic inflammation in a predefined risk group of patients after cardiac surgery with cardiopulmonary bypass and improve early outcome.
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To describe hypothalamic-pituitary-adrenal (HPA) activation and the role of glucocorticoids in immune modulation during critical illness, and to review clinical trials of pharmacologic and "replacement"' doses of glucocorticoids in early and late acute respiratory distress syndrome (ARDS) and sepsis. ⋯ Current evidence indicates that short-duration, high-dose glucocorticoid therapy is not effective for early ARDS or severe sepsis. One small randomized, controlled trial suggests that moderate doses of glucocorticoids may be beneficial for patients with late ARDS; a much larger randomized controlled trial is ongoing. Some patients with pressor-dependent severe sepsis appear to have relative adrenal insufficiency and benefit from replacement glucocorticoid/mineralocorticoid therapy. The accuracy of the diagnostic criteria for, and the prevalence of, relative adrenal insufficiency in patients with acute lung injury/ARDS is unknown. It is also unclear whether such a response, if present, predisposes patients to ongoing lung inflammation and the development of late fibroproliferative ARDS, or if it is predictive of a beneficial response to steroids. Studies of HPA axis activation and the role of relative adrenal insufficiency on the outcome of patients with acute lung injury are needed.
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Critical care medicine · Apr 2003
ReviewEpidemiology and outcome of acute respiratory failure in intensive care unit patients.
To summarize the prevalence of various forms of acute respiratory failure in acutely ill patients and review the major factors involved in the outcome of these patients. ⋯ The prevalence of acute respiratory failure varies according to the definition used and the population studied. Nonsurvivors of acute respiratory distress syndrome die predominantly of respiratory failure in <20% of cases. The relatively high mortality rates of acute lung injury/acute respiratory distress syndrome are primarily related to the underlying disease, the severity of the acute illness, and the degree of organ dysfunction.
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Critical care medicine · Apr 2003
ReviewLung recruitment maneuvers in acute respiratory distress syndrome and facilitating resolution.
To summarize the possible ways that acute respiratory distress syndrome (ARDS) lungs can be recruited and to present the experimental and clinical results of these maneuvers, along with the possible effects on patient outcome. ⋯ High airway pressures can open collapsed ARDS lungs and partially open edematous ARDS lungs. High PEEP levels and low tidal volume ventilation decrease bronchoalveolar and plasma inflammatory mediators and improve survival compared with low PEEP/high tidal volume ventilation. In the near future, thoracic computed tomography associated with high-performance monitoring of regional ventilation (electrical impedance tomography) may be used at the bedside to determine the optimal mechanical ventilation of ARDS patients.
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Critical care medicine · Apr 2003
Multicenter StudyCarriage of methicillin-resistant Staphylococcus aureus, ceftazidime-resistant Gram-negative bacilli, and vancomycin-resistant enterococci before and after intensive care unit admission.
To measure patients' risk for acquiring antibiotic-resistant microorganisms associated with intensive care unit admission. ⋯ These data suggest that hospitalization in the intensive care unit introduces significant risk to patients in terms of transmission of MRSA and/or CR-GNB. This risk seems to be influenced strongly by the proportion of patients with colonization at intensive care unit admission and is associated with severity of illness, length of stay, and exposures to antibiotics and medical devices.