Critical care medicine
-
Critical care medicine · Oct 2012
Randomized Controlled Trial Multicenter StudyAngiotensin-converting enzyme inhibition or mineralocorticoid receptor blockade do not affect prevalence of atrial fibrillation in patients undergoing cardiac surgery.
This study tested the hypothesis that interruption of the renin-angiotensin system with either an angiotensin-converting enzyme inhibitor or a mineralocorticoid receptor antagonist will decrease the prevalence of atrial fibrillation after cardiac surgery. ⋯ Neither angiotensin-converting enzyme inhibition nor mineralocorticoid receptor blockade decreased the primary outcome of postoperative atrial fibrillation. Treatment with an angiotensin-converting enzyme inhibitor or mineralocorticoid receptor antagonist was associated with decreased acute renal failure. Spironolactone use was also associated with a shorter duration of mechanical ventilation after surgery.
-
Critical care medicine · Oct 2012
Diurnal sedative changes during intensive care: impact on liberation from mechanical ventilation and delirium.
To determine whether benzodiazepine and propofol doses are increased at night and whether daytime and nighttime sedative doses are associated with delirium, coma, and delayed liberation from mechanical ventilation. ⋯ Nearly half of mechanically ventilated intensive care unit patients received greater doses of sedation at night, a practice associated with failed spontaneous breathing trials, coma, and delirium. Over the first 5 days in our study, patients spent 75% of their time in coma or delirium, outcomes that may be reduced by efforts to decrease sedative exposure during both daytime and nighttime hours in the intensive care unit.
-
Critical care medicine · Oct 2012
Multicenter StudyFluid balance in critically ill children with acute lung injury.
In the Fluid and Catheter Treatment Trial (NCT00281268), adults with acute lung injury randomized to a conservative vs. liberal fluid management protocol had increased days alive and free of mechanical ventilator support (ventilator-free days). Recruiting sufficient children with acute lung injury into a pediatric trial is challenging. A Bayesian statistical approach relies on the adult trial for the a priori effect estimate, requiring fewer patients. Preparing for a Bayesian pediatric trial mirroring the Fluid and Catheter Treatment Trial, we aimed to: 1) identify an inverse association between fluid balance and ventilator-free days; and 2) determine if fluid balance over time is more similar to adults in the Fluid and Catheter Treatment Trial liberal or conservative arms. ⋯ Increasing fluid balance on day 3 in children with acute lung injury at these centers is independently associated with fewer ventilator-free days. Our findings and the similarity of fluid balance patterns in our cohort to adults in the Fluid and Catheter Treatment Trial liberal arm demonstrate the need to determine whether a conservative fluid management strategy improves clinical outcomes in children with acute lung injury and support a Bayesian trial mirroring the Fluid and Catheter Treatment Trial.
-
Critical care medicine · Oct 2012
ReviewTracheostomy practice in adults with acute respiratory failure.
Tracheostomy remains one of the most commonly performed surgical procedures in adults with acute respiratory failure and identifies a patient cohort which is among the most resource-intensive to provide care. The objective of this concise definitive review is the synthesis of current knowledge regarding tracheostomy practice in this context. ⋯ In patients who otherwise lack indication for surgical airway, clinicians should defer tracheostomy placement for at least 2 wks following the onset of acute respiratory failure to insure need for ongoing ventilatory support. Subpopulations of patients (e.g., those with acute neurological injury or stroke) may benefit from earlier tracheostomy. Percutaneous dilational tracheostomy should be considered the preferred technique for this intervention in the appropriately selected individual. Future investigations should include efforts to optimize post-tracheostomy management and to quantify tracheostomy effects on patient-centric outcomes.
-
Critical care medicine · Oct 2012
Initial resuscitation guided by the Surviving Sepsis Campaign recommendations and early echocardiographic assessment of hemodynamics in intensive care unit septic patients: a pilot study.
To compare therapeutic interventions during initial resuscitation derived from echocardiographic assessment of hemodynamics and from the Surviving Sepsis Campaign guidelines in intensive care unit septic patients. ⋯ A weak agreement was found in the prescription of fluid loading and inotropic support derived from early transesophageal echocardiography assessment of hemodynamics and Surviving Sepsis Campaign guidelines in patients presenting with septic shock.