Critical care medicine
-
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
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
Multicenter StudyLongitudinal changes in procalcitonin in a heterogeneous group of critically ill patients.
The utility of procalcitonin for the diagnosis of infection in the critical care setting has been extensively investigated with conflicting results. Herein, we report procalcitonin values relative to baseline patient characteristics, presence of shock, intensive care unit time course, infectious status, and Gram stain of infecting organism. ⋯ Procalcitonin dynamics were similar between surgical and medical cohorts. Shock had an association with higher procalcitonin values independent of the presence of infection. Trends in differences in procalcitonin values were seen in patients who had incident vs. prevalent infections.
-
Critical care medicine · Oct 2012
Clinical TrialInhalation versus endovenous sedation in subarachnoid hemorrhage patients: effects on regional cerebral blood flow.
Isoflurane is a volatile anesthetic that has a vasodilating effect on cerebral vessels producing a cerebral blood flow increase. Furthermore, it has been shown in animal studies that isoflurane, when used as a preconditioning agent, has neuroprotective properties, inducing tolerance to ischemia. However, it is not routinely used in neurointensive care because of the potential increase in intracranial pressure caused by the rise in cerebral blood flow. Nevertheless, subarachnoid hemorrhage patients who are at risk for vasospasm may benefit from an increase in cerebral blood flow. We measured regional cerebral blood flow during intravenous sedation with propofol and during sedation with isoflurane in patients with severe subarachnoid hemorrhage not having intracranial hypertension. ⋯ Isoflurane increases regional cerebral blood flow in comparison to propofol. Intracranial pressure did not change significantly in the population not affected by intracranial hypertension.
-
Critical care medicine · Oct 2012
Transfusion-related acute lung injury in cardiac surgery patients is characterized by pulmonary inflammation and coagulopathy: a prospective nested case-control study.
Transfusion-related acute lung injury is the leading cause of transfusion-related morbidity and mortality. Clinical data on the pathogenesis of transfusion-related acute lung injury are sparse. The objective of the present study was to determine inflammation and coagulation pathways involved in the onset of transfusion-related acute lung injury. ⋯ Prior to onset of transfusion-related acute lung injury, there is systemic inflammation and neutrophil sequestration. Transfusion-related acute lung injury is characterized by both systemic and pulmonary inflammation and activation of neutrophils, as well as enhanced coagulation and suppressed fibrinolysis.