Critical care : the official journal of the Critical Care Forum
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Hypothermia as a protectant of neurologic function in the treatment of cardiac arrest patients, although not a new concept, is now supported by two recent randomized, prospective clinical trials. The basic science research in support of the effects of hypothermia at the cellular and animal levels is extensive. The process of cooling for cerebral protection holds potential promise for human resuscitation efforts in multiple realms. It appears that, at least, those patients who suffer a witnessed cardiac arrest with ventricular fibrillation and early restoration of spontaneous circulation, such as those who were included in the European and Australian trials (discussed here), should be considered for hypothermic therapy.
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The majority of intensive care practitioners, until comparatively recently, was content to discharge surviving patients to the care of referring primary specialty colleagues who would undertake subsequent inpatient and outpatient care. With the exception of mortality statistics from clinical studies, the practitioners were thus denied the opportunity of understanding the full impact of critical illness on a patient and their family. The concept of the intensive care follow-up clinic has developed more recently, and is run commonly on multidisciplinary lines. ⋯ The purpose of the present review is to highlight some of the important issues that impact on recovery from critical illness towards an acceptable quality of postdischarge life. We have concentrated on the adult literature, and specifically on studies that inform us about the more general effects of critical illness. Head and spinal injury are thus largely ignored, as the effects of the primary injury overwhelm the effects of 'general' critical illness.
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Stress hyperglycemia and diabetes mellitus with myocardial infarction are associated with increased risk for in-hospital mortality, congestive heart failure, or cardiogenic shock. Hyperglycemia triggers free radical generation and suppresses endothelial nitric oxide generation, and thus initiates and perpetuates inflammation. ⋯ It is proposed that the balance between insulin and plasma glucose levels is critical to recovery and/or complications that occur following acute myocardial infarction and in the critically ill. Adequate attention should be given to maintaining euglycemia (plasma glucose
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Prone positioning in respiratory failure has been shown to be a useful adjunct in the treatment of severe hypoxia. However, the prone position can result in dislodgment or malfunction of tubes and cannulae. Certain patients receiving extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) may also benefit from positional therapy. The impact of cannula-related complications in these patients is potentially disastrous. The safety and efficacy of prone positioning of these patients has not been previously reported. ⋯ Patients with venous cannulae for ECMO or CRRT can be safely placed in the prone position. Flow rates are maintained in this position. Potential cannula complications of ECMO and CRRT are not a contraindication to prone positioning in severely ill patients.
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Case Reports
Case report: Survival after deliberate strychnine self-poisoning, with toxicokinetic data.
Strychnine poisoning is uncommon, and in most severe cases, the patient dies before reaching hospital. The management of strychnine poisoning is well documented, although there are few data on the kinetics of elimination of strychnine after overdose. ⋯ Strychnine poisoning presents with classical features, and with early diagnosis and supportive management, the patient can survive. The initial serum concentration of 4.73 mg/l is the highest reported concentration in a patient who has survived. Previous reports of the elimination half-life have suggested it is between 10 and 16 hours, which conforms to the elimination data in our case.