Critical care : the official journal of the Critical Care Forum
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Why is the practice of intensive care so heterogenous? Uncertainty as to 'best practice', conservatism, and complacency may all contribute to our divergent management strategies. The need for further generalisable research, anonymised audit, external peer review and open access databases is discussed.
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Editorial Comment
Selenium supplementation in critically ill patients: can too much of a good thing be a bad thing?
A recent study by Forceville and colleagues evaluated the effect of high-dose selenium administration as a treatment for septic shock. The study was negative and conflicts with existing clinical data regarding selenium administration in critically ill patients. Perhaps the key to understanding the differences between these discrepant observations lies in considering the dose and timing of selenium administration.
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Editorial Comment
Corticosteroids to prevent postextubation upper airway obstruction: the evidence mounts.
Intubation of the airway can lead to laryngotracheal injury, resulting in extubation failure from upper airway obstruction (UAO). A number of factors can help to identify patients who are at greatest risk for postextubation UAO. Three randomized controlled trials demonstrate that prophylactic corticosteroids decrease the risk for postextubation UAO and probably the need for re-intubation.
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Editorial Comment
Surfactant for acute respiratory failure in children: where should it fit in our treatment algorithm?
In a recent meta-analysis, surfactant administration in paediatric acute respiratory failure was associated with improved oxygenation, reduced mortality, increased ventilator-free days and reduced duration of ventilation. Surfactant is expensive, however, and its use involves installation of large volumes into the lungs, resulting in transient hypoxia and hypotension in some patients. Many questions also remain unanswered, such the as optimum dosage and the timing of administration of surfactant. The merits of surfactant administration should therefore still be decided on an individual case-by-case basis.
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Editorial Comment
Perioperative goal directed haemodynamic therapy--do it, bin it, or finally investigate it properly?
The literature concerning the use of goal directed haemodynamic therapy (GDHT) in high risk surgical patients has been importantly increased by the study of Lopes and colleagues. Using a minimally invasive assessment of fluid status and pulse pressure variation monitoring during mechanical ventilation, improvements were seen in post-operative complications, duration of mechanical ventilation, and length of hospital and intensive care unit (ICU) stay. Many small studies have shown improved outcome using various GDHT techniques but widespread implementation has not occurred. Those caring for perioperative patients need to accept the published evidence base or undertake a larger, multi-centre study.