Critical care medicine
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Critical care medicine · Mar 2009
Randomized Controlled Trial Multicenter StudyImpact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial.
The impact of continuous venovenous hemofiltration on sepsis-induced multiple organ failure severity is controversial. We sought to assess the effect of early application of hemofiltration on the degree of organ dysfunction and plasma cytokine levels in patients with severe sepsis or septic shock. ⋯ These data suggest that early application of standard continuous venovenous hemofiltration is deleterious in severe sepsis and septic shock. This study does not rule out an effect of high-volume hemofiltration (>35 mL/kg/hr) on the course of sepsis.
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Critical care medicine · Mar 2009
Randomized Controlled Trial Comparative StudyPiperacillin penetration into tissue of critically ill patients with sepsis--bolus versus continuous administration?
To describe a pharmacokinetic model of piperacillin concentrations in plasma and subcutaneous tissue when administered by bolus dosing and continuous infusion in critically ill patients with sepsis on days 1 and 2 of antibiotic therapy and to compare results against previous results for piperacillin from a cohort of patients with septic shock. ⋯ Patients with sepsis do not seem to have the same level of impairment of tissue distribution as described for patients with septic shock. A 25% lower dose of piperacillin administered by continuous infusion seems to maintain higher trough concentrations compared with standard bolus dosing. It is likely that the clinical advantages of continuous infusion are most likely to be evident when treating pathogens with high minimum inhibitory concentration, although without therapeutic drug monitoring and subsequent dose adjustment, infusions may never achieve target concentrations of organisms with very high minimum inhibitory concentrations in a small number of patients.
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Critical care medicine · Mar 2009
Randomized Controlled TrialPulsatile perfusion with intra-aortic balloon pumping ameliorates whole body response to cardiopulmonary bypass in the elderly.
The growing life expectancy has led the elderly to be increasingly referred to coronary artery bypass grafting. Preexisting comorbidities may benefit from theoretical advantages of pulsatile perfusion during cardiopulmonary bypass (CPB). ⋯ IABP-induced pulsatile flow significantly improves whole body perfusion in the elderly undergoing CPB.
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Critical care medicine · Mar 2009
Deciding in the dark: advance directives and continuation of treatment in chronic critical illness.
Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation. ⋯ Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.
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Critical care medicine · Mar 2009
Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis.
To evaluate the hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis on processes of medical care and patient outcomes. ⋯ The implementation of a hospital-wide standardized order set for the management of bacteremic severe sepsis was associated with greater fluid administration, improved antibiotic therapy, decreased incidence of organ failure, and improved survival.