Critical care : the official journal of the Critical Care Forum
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Sepsis and septic shock continue to contribute to our workload and stimulate our research activities although many fundamental questions remain. Studies reported on here focus on inotrope use and a novel way of predicting inotrope response. ⋯ Finally we discuss a paper on the outcome of the obese patient on a general ICU. Like sepsis a continuing challenge.
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Multicenter Study Comparative Study
Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study.
Albumin administration in the critically ill has been the subject of some controversy. We investigated the use of albumin solutions in European intensive care units (ICUs) and its relationship to outcome. ⋯ Albumin administration was associated with decreased survival in this population of acutely ill patients. Further prospective randomized controlled trials are needed to examine the effects of albumin administration in sub-groups of acutely ill patients.
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Independent lung ventilation (ILV) can be classified into anatomical and physiological lung separation. It requires either endobronchial blockade or double-lumen endotracheal tube intubation. Endobronchial blockade or selective double-lumen tube ventilation may necessitate temporary one lung ventilation. ⋯ There are some clear indications for ILV as a primary intervention and as a rescue ventilator strategy in both anatomical and physiological lung separation. Potential pitfalls are related to establishing and maintaining lung isolation. Nevertheless, ILV can be used in the intensive care setting safely with a good understanding of its limitations and potential complications.
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Blood transfusion has been used to treat the injured since the US Civil War. Now, it saves the lives of tens of thousands of injured patients each year. However, not everyone who receives blood benefits, and some recipients are injured by the transfusion itself. ⋯ Issues of current clinical concern in highly developed trauma systems include how to manage massive transfusion events, how to limit blood use and so minimize exposure to transfusion risks, how to integrate new hemorrhage control modalities, and how to deal with blood shortages. Less developed trauma systems are primarily concerned with speeding transport to specialized facilities and assembling trauma center resources. This article reviews the factors that effect blood use in urgent trauma care.
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Regional tissue distress caused by microcirculatory dysfunction and mitochondrial depression underlies the condition in sepsis and shock where, despite correction of systemic oxygen delivery variables, regional hypoxia and oxygen extraction deficit persist. We have termed this condition microcirculatory and mitochondrial distress syndrome (MMDS). Orthogonal polarization spectral imaging allowed the first clinical observation of the microcirculation in human internal organs, and has identified the pivotal role of microcirculatory abnormalities in defining the severity of sepsis, a condition not revealed by systemic hemodynamic or oxygen-derived variables. ⋯ Resuscitation following MMDS must include focused recruitment of hypoxic-shunted microcirculatory units and/or resuscitation of the mitochondria. A combination of agents is required for successful rescue of the microcirculation. Single compounds such as activated protein C, which acts on multiple pathways, can be expected to be beneficial in rescuing the microcirculation in sepsis.