Critical care : the official journal of the Critical Care Forum
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Several recent meta-analyses have shown that the use of SDD can reduce the occurrence of nosocomial pneumonia among ventilated patients in the intensive care unit (ICU) setting. However, the use of SDD has also been demonstrated to increase subsequent patient colonization and infection with antibiotic-resistant bacteria, particularly Gram-positive cocci. ⋯ This is already an accepted practice in most patients during the perioperative period (eg prophylactic parenteral antibiotics for 24 h). Prolonged decontamination of the aerodigestive tract with topical antimicrobials does not appear to influence outcome, and should not be routinely employed.
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Review Comparative Study
The appropriate role of colloids in managing fluid imbalance: a critical review of recent meta-analytic findings.
Three meta-analyses have recently been reported on the relationship between choice of resuscitation fluid and risk of mortality in critically ill patients. The relative risk of death (1.16-1.19) in two of the meta-analyses was slightly higher in colloid than crystalloid recipients; however, this observation was not statistically significant. In the third meta-analysis, 6% (95% confidence interval [CI], 3-9%) pooled excess mortality was documented in patients receiving albumin for hypovolaemia, burns or hypoalbuminaemia. ⋯ The meta-analyses do not support the conclusion that choice of resuscitation fluid is a major determinant of mortality in critically ill patients, nor do they support changes to current fluid management practice. Changes such as exclusive reliance on crystalloids would necessitate a reassessment of the goals and methods of fluid therapy. Since the effect on mortality may be minimal or non-existent, choice of resuscitation fluid should rest on whether the particular fluid permits the intensive care unit to provide better patient care.
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The modern intensive care unit (ICU) has evolved into an area where mortality and morbidity can be reduced by identification of unexpected hemodynamic and ventilatory decompensations before long-term problems result. Because intensive care physicians are caring for an increasingly heterogeneous population of patients, the indications for aggressive monitoring and close titration of care have expanded. Agitated patients are proving difficult to deal with in nonmonitored environments because of the unpredictable consequences of the agitated state on organ systems. The severe agitation state that is associated with ethanol withdrawal and delirium tremens (DT) is examined as a model for evaluating the efficacy of the ICU environment to ensure consistent stabilization of potentially life-threatening agitation and delirium.
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Comparative Study Clinical Trial Controlled Clinical Trial
Helium-oxygen mixture does not improve gas exchange in mechanically ventilated children with bronchiolitis.
STATEMENT OF Varying concentrations of helium-oxygen (heliox) mixtures were evaluated in mechanically ventilated children with bronchiolitis. We hypothesized that, with an increase in the helium:oxygen ratio, and therefore a decrease in gas density, ventilation and oxygenation would improve in children with bronchiolitis. Ten patients, aged 1-9 months, were mechanically ventilated in synchronized intermittent mandatory ventilation (SIMV) mode with the following gas mixtures delivered at 15-min intervals: 50%/50% nitrogen/oxygen, 50%/50% heliox, 60%/40% heliox, 70%/30% heliox, and return to 50%/50% nitrogen/oxygen. The use of different heliox mixtures compared with 50%/50% nitrogen/oxygen in mechanically ventilated children with bronchiolitis did not result in a significant or noticeable decrease in ventilation or oxygenation.
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Key questions remain unresolved regarding the advantages and limitations of colloids for fluid resuscitation despite extensive investigation. Elucidation of these questions has been slowed, in part, by uncertainty as to the optimal endpoints that should be monitored in assessing patient response to administered fluid. Colloids and crystalloids do not appear to differ notably in their effects on preload recruitable stroke volume or oxygen delivery. ⋯ Colloids can be considered in patients with severe or acute shock or hypovolaemia resulting from sudden plasma loss. Colloids may be combined with crystalloids to obviate administration of large crystalloid volumes. Further clinical trials are needed to define the optimal role for colloids in critically ill patients.