Critical care : the official journal of the Critical Care Forum
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To determine the clinical usefulness of immediate (stat) chest radiographs after endotracheal intubation when performed by experienced critical care personnel. ⋯ The incidence of endotracheal tube malposition after intubation was underestimated. However, when performed by experienced critical care personnel, acutely significant malpositions were rare (one out of 101 intubations). We conclude that, in the absence of specific pulmonary complications, endotracheal intubations performed by experienced operators may be followed by routine, rather than 'stat' chest radiographs.
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Recent meta-analyses have created uncertainties regarding the appropriate clinical role of colloid resuscitation fluids in critically ill patients and prompted changes in fluid management practice. Such changes may not be justified in view of methodological limitations inherent in the meta-analyses. Further research is nevertheless needed to resolve the questions raised concerning the relationship between choice of resuscitation fluid and patient outcome. ⋯ The results of the randomized animal studies, along with other preclinical data, could also be evaluated using accepted principles of 'critical appraisal' commonly applied to clinical trial results. This critical appraisal might, where appropriate, include meta-analysis of animal study findings. This alternative preclinical pathway to new product evaluation should be completed before the commencement of large-scale clinical trials.
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Ventilator-induced lung injury is a major outcome determinant of the acute respiratory distress syndrome (ARDS). Ventilatory strategies that limit ventilator-induced lung injury should improve outcome from ARDS. The ARDSnet trial showed improved survival in subjects ventilated with a lower tidal volume. ⋯ Finally, ventilator-induced lung injury occurs more commonly from repetitive collapse and re-expansion of injured lung units rather than from the overdistention of persistently aerated lung units. This was not addressed in the trial design. Thus, further study using targeted open-lung strategies are also needed.
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Continuous renal replacement therapy (CRRT) was first described in 1977 for the treatment of diuretic-unresponsive fluid overload in the intensive care unit (ICU). Since that time this treatment has undergone a remarkable technical and conceptual evolution. It is now available in most tertiary ICUs around the world and has almost completely replaced intermittent haemodialysis (IHD) in some countries. ⋯ The use of CRRT has also spurred renewed interest in the broader concept of blood purification, particularly in septic states. Experimental evidence suggests that this is a promising approach to the management of septic shock in critically ill patients. The evolution and use of CRRT is likely to continue and grow over the next decade.