Critical care : the official journal of the Critical Care Forum
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In the continuing dispute about the superiority of either intermittent or continuous renal replacement therapy for the critically ill, hybrid methods such as sustained low-efficiency dialysis (SLED) combining the advantages of both modalities--that is, excellent hemodynamic stability and low costs--receive growing attention. The study by Schwenger and colleagues is the first randomized trial indicating that there may be no significant difference in survival at 90 days between patients treated with SLED as compared with those treated with continuous veno-venous hemofiltration.
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Antimicrobial stewardship involves a multifaceted approach aimed at combating the emergence of antibiotic resistance, improving patient outcomes, and controlling healthcare costs by optimizing antimicrobial use. Therefore, stewardship is of great importance and relevance in the ICU. The rapid pace of escalating antibiotic resistance and the widespread use of antibiotics in critical care require that stewardship programs be routinely employed in the ICU setting.
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Editorial Comment
Peri-operative hemodynamic therapy: only large clinical trials can resolve our uncertainty.
In this issue of Critical Care, Cecconi and colleagues report the findings of a small trial of goal-directed hemodynamic therapy (GDT) in patients undergoing major orthopedic surgery under regional anesthesia. This is an interesting trial and the first of which we are aware to test the efficacy of GDT in this patient group. ⋯ However, in this trial, as in all small trials of GDT, the potential for bias leaves some uncertainty regarding how widely the findings should be implemented. Such limitations may be impossible to completely eliminate from trials of complex interventions, but large multicenter trials may allow us to substantially decrease bias and improve the generalizability of the findings.
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Editorial Comment
The desperate need for good-quality clinical trials to evaluate the optimal source and dose of fibrinogen in managing bleeding.
Recent interest in transfusion management of trauma patients has heightened expectation in the role of blood component therapy in improving patient outcome. Optimal transfusion support in supplementation with fibrinogen has not been defined by high-quality evidence. ⋯ Studies of cost-effectiveness have not been considered in research. An international move to supplement fibrinogen more 'aggressively' without direct clinical evaluation beforehand represents a failed opportunity to improve our very limited understanding of optimal transfusion practice.