Critical care : the official journal of the Critical Care Forum
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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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Randomized Controlled Trial Comparative Study
Ventilator-associated pneumonia using a heated humidifier or a heat and moisture exchanger: a randomized controlled trial [ISRCTN88724583].
Some guidelines to prevent ventilator-associated pneumonia (VAP) do not establish a recommendation for the preferential use of either heat and moisture exchangers (HMEs) or heated humidifiers (HHs), while other guidelines clearly advocate the use of HMEs. The aim of this study was to determine the incidence of VAP associated with HHs or HMEs. ⋯ The patients mechanically ventilated during more than 5 days developed a lower incidence of VAP with a heated humidifier than heat and moisture exchanger.
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Comparative Study
Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: results of an experimental study in adult sheep.
Extracorporeal lung assist, an extreme resource in patients with acute respiratory failure (ARF), is expanding its indications since knowledge about ventilator-induced lung injury has increased and protective ventilation has become the standard in ARF. ⋯ We obtained a significant reduction of PaCO2 using low blood flow rates, if compared with other techniques. Percutaneous venous access, simplicity of circuit, minimal anticoagulation requirements, blood flow rate, and haemodynamic impact of this device are more similar to renal replacement therapy than to common extracorporeal respiratory assistance, making it feasible not only in just a few dedicated centres but in a large number of intensive care units as well.
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Comment Review
Measuring the anticoagulant effect of low molecular weight heparins in the critically ill.
Antithrombotic prophylaxis in critically ill patients frequently fails. Venous thromboembolism is associated with adverse clinical outcomes, including a prolonged intensive care unit stay and death. ⋯ In the previous issue of the journal, Rommers and colleagues examined whether subcutaneous edema reduces absorption of a low molecular weight heparin; although small, and thus underpowered, the authors failed to find any relationship between the level of low molecular weight heparin and the presence of edema. These findings provide reassurance that subcutaneously administered medications may be used in critically ill patients with edema.
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Progress in the treatment of acute respiratory distress syndrome(ARDS) has been slow, perhaps in part due to the heterogeneity in the biology underlying this syndrome. Open lung biopsy is a feasible approach to define various subcategories of underlying histology. ⋯ More research is needed on assessing efficacy of potential therapies within histologically defined subgroups. In the future, various biomarkers may be available to non-invasively classify ARDS patients from the standpoint of responsiveness to various therapies, such as glucocorticoids.