Critical care : the official journal of the Critical Care Forum
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Multicenter Study Comparative Study
Morbidity and cost burden of methicillin-resistant Staphylococcus aureus in early onset ventilator-associated pneumonia.
To gain a better understanding of the clinical and economic outcomes associated with methicillin-resistant Staphylococcus aureus (MRSA) infection in patients with early onset ventilator-associated pneumonia (VAP), we retrospectively analyzed a multihospital US database to identify patients with VAP over a 24 month period (2002-2003). ⋯ S. aureus remains a common cause of VAP. VAP due to MRSA was associated with increased overall LOS, ICU LOS, and attributable ICU LOS compared with MSSA-related VAP. Although not statistically significant because of small sample size and large variation, the attributable excess costs of MRSA amounted to approximately US8000 dollars per case after controlling for case mix and severity.
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Randomized Controlled Trial Comparative Study
Sedation in the intensive care unit with remifentanil/propofol versus midazolam/fentanyl: a randomised, open-label, pharmacoeconomic trial.
Remifentanil is an opioid with a unique pharmacokinetic profile. Its organ-independent elimination and short context-sensitive half time of 3 to 4 minutes lead to a highly predictable offset of action. We tested the hypothesis that with an analgesia-based sedation regimen with remifentanil and propofol, patients after cardiac surgery reach predefined criteria for discharge from the intensive care unit (ICU) sooner, resulting in shorter duration of time spent in the ICU, compared to a conventional regimen consisting of midazolam and fentanyl. In addition, the two regimens were compared regarding their costs. ⋯ Compared with midazolam/fentanyl, a remifentanil-based regimen for analgesia and sedation supplemented with propofol significantly reduced the time on mechanical ventilation and allowed earlier discharge from the ICU, at equal overall costs.
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Review
Predicting volume responsiveness in spontaneously breathing patients: still a challenging problem.
The prediction of which patients respond to fluid infusion and which patients do not is an important issue in the intensive care setting. Assessment of this response by monitoring changes in some hemodynamic characteristics in relation to spontaneous breathing efforts would be very helpful for the management of the critically ill. This unfortunately remains a difficult clinical problem, as discussed in the previous issue of the journal. Technical factors and physiological factors limit the usefulness of current techniques.
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Comparative Study
SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: a cohort study.
To compare the discriminative ability of the SOFA and MOD scoring systems with respect to hospital mortality and unfavorable neurologic outcome in patients with severe traumatic brain injury admitted to intensive care. ⋯ In patients with brain injury, the SOFA scoring system has superior discriminative ability and stronger association with outcome compared to the MOD scoring system with respect to hospital mortality and unfavorable neurologic outcome.
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Neurologic disability is a feared outcome of resuscitation from cardiac arrest. The study by Rech and colleagues in the previous issue of Critical Care describes the use of neuron-specific enolase to inform an early prognosis in patients who survived in-hospital cardiac arrest. In their study 'none of the patients had a DNR order and there was no limitation of life support.' As a result, 10% of patients remained in a vegetative state at 6 months, a higher percentage than in other recent studies. ⋯ High neuron-specific enolase levels have been reported in patients that awoke and seem to occur in studies with a higher percentage of patients in a vegetative state at follow-up (more uniform support). If a comprehensive set of clinical, electrophysiological, biochemical and imaging measures could be obtained in a uniform manner in a cohort of patients without limitations in care, a more objective set of comprehensive prognostic indicators could be obtained. A focused international consortium is called for.