Critical care : the official journal of the Critical Care Forum
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Randomized Controlled Trial Comparative Study
The impact of an hematocrit of 20% during normothermic cardiopulmonary bypass for elective low risk coronary artery bypass graft surgery on oxygen delivery and clinical outcome--a randomized controlled study [ISRCTN35655335].
Cardiopulmonary bypass (CPB) induces hemodilutional anemia, which frequently requires the transfusion of blood products. The objective of this study was to evaluate oxygen delivery and consumption and clinical outcome in low risk patients who were allocated to an hematocrit (Hct) of 20% versus 25% during normothermic CPB for elective coronary artery bypass graft (CABG) surgery. ⋯ These data indicate that an Hct of 20% during normothermic CPB maintained calculated whole body oxygen delivery above a critical level after elective CABG surgery in low risk patients. The question of whether a transfusion trigger in excess of 20% Hct during normothermic CPB is still supported requires a larger prospective and randomized trial.
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Review
Evidence-based review of the use of the pulmonary artery catheter: impact data and complications.
The pulmonary artery catheter (PAC) was introduced in 1971 for the assessment of heart function at the bedside. Since then it has generated much enthusiasm and controversy regarding the benefits and potential harms caused by this invasive form of hemodynamic monitoring. This review discusses all clinical studies conducted during the past 30 years, in intensive care unit settings or post mortem, on the impact of the PAC on outcomes and complications resulting from the procedure. Although most of the historical observational studies and randomized clinical trials also looked at PAC-related complications among their end-points, we opted to review the data under two main topics: the impact of PAC on clinical outcomes and cost-effectiveness, and the major complications related to the use of the PAC.
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Delirium is a serious and prevalent problem in intensive care units (ICU). The purpose of this study was to develop a research algorithm to enhance detection of delirium in critically ill ICU patients using chart review to complement a validated clinical delirium instrument. ⋯ Eight of 10 patients in this cohort study developed delirium in the ICU. Although use of a validated delirium instrument with frequent direct observations is recommended for clinical care, this approach may not always be feasible, especially in a research setting. The algorithm proposed here comprises a more comprehensive method for delirium detection in a research setting taking into account the fluctuation that occurs with delirium, a key component to accurately determining delirium status. Improving delirium detection is of paramount importance first to advance delirium research and, subsequently to enhance clinical care and patient safety.
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Randomized Controlled Trial
Reduction of nosocomial pneumonia after major burns by trace element supplementation: aggregation of two randomised trials.
Nosocomial pneumonia is a major source of morbidity and mortality after severe burns. Burned patients suffer trace element deficiencies and depressed antioxidant and immune defences. This study aimed at determining the effect of trace element supplementation on nosocomial or intensive care unit (ICU)-acquired pneumonia. ⋯ Enhancing trace element status and antioxidant defences by selenium, zinc, and copper supplementation was associated with a decrease of nosocomial pneumonia in critically ill, severely burned patients.
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Obtaining or maintaining vascular access for continuous hemofiltration can sometimes be problematic, especially in the child or adult in multiple organ failure with edema and/or coagulopathy. Problems commonly encountered include obstruction of the femoral vein by the catheter, insertion difficulties, safety concerns when cannulating the subclavian vein in coagulopathy, and catheter and circuit occlusion due to disseminated intravascular coagulation. For access in infants we describe a technique utilizing two single-lumen thin-walled vascular sheaths. ⋯ At any age an alternative route to the subclavian vein, from above the clavicle, is potentially 'compressible' in the event of hemorrhage during the procedure. We remind the reader of the utility of ultrasound guidance for cannulation of the internal jugular and subclavian veins. And lastly we review the options for venous return via the umbilical vein in infants, and via the antecubital vein in larger children and adults.