Critical care : the official journal of the Critical Care Forum
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Randomized Controlled Trial Multicenter Study Clinical Trial
Prospectively validated predictions of shock and organ failure in individual septic surgical patients: the Systemic Mediator Associated Response Test.
Clinically useful predictions of end-organ function and failure in severe sepsis may be possible through analyzing the interactions among demographics, physiologic parameters, standard laboratory tests, and circulating markers of inflammation. The present study evaluated the ability of such a methodology, the Systemic Mediator Associated Response Test (SMART), to predict the clinical course of septic surgery patients from a database of medical and surgical patients with severe sepsis and/or septic shock. ⋯ SMART multivariate models accurately predict pathophysiology, shock, and organ failure in individual septic surgical patients. These prognostications may facilitate early treatment of end-organ dysfunction in surgical sepsis.
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Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support, in case the natural lungs are failing and are not able to maintain a sufficient oxygenation of the body's organ systems. ECMO technique was an adaptation of conventional cardiopulmonary bypass techniques and introduced into treatment of severe acute respiratory distress syndrome (ARDS) in the 1970s. The initial reports of the use of ECMO in ARDS patients were quite enthusiastic, however, in the following years it became clear that ECMO was only of benefit in newborns with acute respiratory failure. ⋯ In conventional treatment lung-protective ventilation strategies were introduced and ECMO was made safer by applying heparin-coated equipment, membranes and tubings. Many ECMO centres now use these advanced ECMO technology and report survival rates in excess of 50% in uncontrolled data collections. The question, however, of whether the improved ECMO can really challenge the advanced conventional treatment of adult ARDS is unanswered and will need evaluation by a future RCT.
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Clinical Trial Controlled Clinical Trial
Respiratory effects of dexmedetomidine in the surgical patient requiring intensive care.
STATEMENT OF The respiratory effects of dexmedetomidine were retrospectively examined in 33 postsurgical patients involved in a randomised, placebo-controlled trial after extubation in the intensive care unit (ICU). Morphine requirements were reduced by over 50% in patients receiving dexmedetomidine. ⋯ Interestingly the arterial partial oxygen tension (PaO2) : fractional inspired oxygen (FIO2) ratios were statistically significantly higher in the dexmedetomidine group. Dexmedetomidine provides important postsurgical analgesia and appears to have no clinically important adverse effects on respiration in the surgical patient who requires intensive care.
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Greater understanding of the pathophysiology of carbon dioxide kinetics during steady and nonsteady state should improve, we believe, clinical care during intensive care treatment. Capnography and the measurement of end-tidal partial pressure of carbon dioxide (PETCO2) will gradually be augmented by relatively new measurement methodology, including the volume of carbon dioxide exhaled per breath (VCO2,br) and average alveolar expired PCO2. Future directions include the study of oxygen kinetics.
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According to the Frank-Starling relationship, a patient is a 'responder' to volume expansion only if both ventricles are preload dependent. Mechanical ventilation induces cyclic changes in left ventricular (LV) stroke volume, which are mainly related to the expiratory decrease in LV preload due to the inspiratory decrease in right ventricular (RV) filling and ejection. In the present review, we detail the mechanisms by which mechanical ventilation should result in greater cyclic changes in LV stroke volume when both ventricles are 'preload dependent'. We also address recent clinical data demonstrating that respiratory changes in arterial pulse (or systolic) pressure and in Doppler aortic velocity (as surrogates of respiratory changes in LV stroke volume) can be used to detect biventricular preload dependence, and hence fluid responsiveness in critically ill patients.