Critical care medicine
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Critical care medicine · Jan 2012
Passive leg-raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance.
We tested whether the poor ability of pulse pressure variation to predict fluid responsiveness in cases of acute respiratory distress syndrome was related to low lung compliance. We also tested whether the changes in cardiac index induced by passive leg-raising and by an end-expiratory occlusion test were better than pulse pressure variation at predicting fluid responsiveness in acute respiratory distress syndrome patients. ⋯ The ability of pulse pressure variation to predict fluid responsiveness was inversely related to compliance of the respiratory system. If compliance of the respiratory system was ≤ 30 mL/cm H2O, then pulse pressure variation became less accurate for predicting fluid responsiveness. However, the passive leg-raising and end-expiratory occlusion tests remained valuable in such cases.
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Critical care medicine · Jan 2012
Changes in cardiovascular effects of dopamine in response to graded hypothermia in vivo.
Inotropic drugs are frequently administered in hypothermic patients to support an assumed inadequate circulation, but their pharmacologic properties at reduced temperatures are largely unknown. Thus we estimated dopamine pharmacokinetics as well as left ventricular function and global hemodynamics after dopamine infusions at various core temperatures in a pig model of surface cooling and rewarming. ⋯ Pharmacodynamic effects and pharmacokinetics of dopamine are maintained during the rewarming phase at moderate hypothermia. However, at 25 °C dopamine pharmacokinetics were seriously altered and dopamine failed to increase cardiac index since stroke index was reduced with incrementing dosages. Properties of the low-flow, high-viscosity circulatory state, combined with altered pharmacokinetics of dopamine, may explain lack of beneficial--and potentially harmful--effects from dopamine administration at 25 °C.
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Critical care medicine · Jan 2012
Multisociety Task Force for Critical Care Research: key issues and recommendations.
Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. ⋯ This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists, clinicians, and educators. It provides a unique framework for future research in critical care medicine.
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Critical care medicine · Jan 2012
Prevention of ventilator-associated pneumonia or ventilator-associated complications: a worthy, yet challenging, goal.
Ventilator-associated pneumonia is a difficult diagnosis to establish in the critically ill patient because of the presence of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with this infection. However, the escalating antimicrobial resistance of the bacterial pathogens associated with ventilator-associated pneumonia, as well as with other nosocomial infections, has created an imperative to reduce their occurrence and the unnecessary use of antibiotics. ⋯ Given current restrictions in hospital resources, absence of available new antimicrobial agents, and potential lack of reimbursement for patients with development of ventilator-associated pneumonia, hospitals need to develop and successfully implement programs aimed at reducing ventilator-associated pneumonia. The use of evidence-based bundles targeting ventilator-associated pneumonia seems to be a reasonable first step in addressing this important clinical problem.
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Critical care medicine · Jan 2012
Case ReportsCoronary stent thrombosis in patients undergoing multidigit replantation.
The development of drug-eluting stents has decreased the rate of in-stent restenosis. However, there have been reports of late stent thrombosis in patients with drug-eluting stents, especially when dual antiplatelet therapy is interrupted. The high mortality rate associated with cardiac stent thrombosis has led to recent recommendations regarding duration of antiplatelet therapy as well as timing of elective surgery in patients with both drug-eluting stents and bare metal stents. However, in patients requiring emergency operations, delaying surgery is not an option. ⋯ Several factors including large transfusion requirements and the complex pharmacogenetics of clopidogrel may have played a role. These cases bring to light the increasing number of patients with indwelling drug-eluting stents in whom the need for massive surgical or trauma type management will become more frequent.