Critical care : the official journal of the Critical Care Forum
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Endothelial damage accounts greatly for the high mortality in septic shock. Higher expression of mediators (IL-6, IL-8, soluble intercellular adhesion molecule 1 [sICAM-1], soluble endothelial-linked adhesion molecule 1 [sELAM-1]) have been described for non-survivors in comparison with survivors. We investigated the predictive value of the mediators IL-6, IL-8, sELAM-1 and sICAM-1 and their time course in intensive care unit patients who developed septic shock with respect to outcome. ⋯ sELAM-1 showed a markedly opposing course after 48 hours of septic shock. This adhesion molecule may be a useful early predictor of disease severity in the course of septic shock after early initial treatment of the patients, and might suggest considering endothelial-restoring therapy.
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The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. ⋯ A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED.
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The definition of risk in surgical patients is a complex and controversial area. Generally risk is poorly understood and depends on past individual and professional perception, and societal norms. ⋯ The usefulness of risk assessment and the definition of risk is however in doubt because there are very few studies that have materially altered patient outcome based on information gained by risk assessment. This paper discusses these issues, highlights areas where more research could usefully be performed, and by defining limits for high surgical risk, suggests a practical approach to the assessment of risk using risk assessment tools.
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How good is the care patients receive during interhospital transfer? The results of a study in this journal make for some disturbing reading. Adverse events occur in about one-third of cases. ⋯ So how do we make things better? All transfer equipment needs to be standardized and be "fit-for-purpose". Each hospital needs to take responsibility for the quality of care received in transfer, and this should include guidelines, training and equipment.
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Comparative Study
A quantitative analysis of the acidosis of cardiac arrest: a prospective observational study.
Metabolic acidosis is common in patients with cardiac arrest and is conventionally considered to be essentially due to hyperlactatemia. However, hyperlactatemia alone fails to explain the cause of metabolic acidosis. Recently, the Stewart-Figge methodology has been found to be useful in explaining and quantifying acid-base changes in various clinical situations. This novel quantitative methodology might also provide useful insight into the factors responsible for the acidosis of cardiac arrest. We proposed that hyperlactatemia is not the sole cause of cardiac arrest acidosis and that other factors participate significantly in its development. ⋯ The cause of metabolic acidosis in patients with out-of-hospital cardiac arrest is complex and is not due to hyperlactatemia alone. Furthermore, compensating changes occur spontaneously, attenuating its severity.