Critical care : the official journal of the Critical Care Forum
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A body of knowledge exists to suggest an association between nurse staffing and adverse patient outcomes. Hugonnet and colleagues add further evidence by linking nurse staffing to late-onset ventilator-associated pneumonia. Discussed are a number of concerns surrounding the analytic component of this study, including the construction of variables and the statistical models. The authors' estimation that hospitals maintaining a nurse-to-patient ratio above 2.2 could decrease the risk of health care associated infections is based on findings that are potentially biased and unrealistic.
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Review
Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability.
Pelvic trauma can lead to severe, uncontrollable haemorrhage and death related to prolonged shock and multiple organ failure. Massive retroperitoneal haematoma should be assumed to be present in cases of post-traumatic haemodynamic instability associated with pelvic fracture in the absence of extrapelvic haemorrhagic lesions. ⋯ Efficacy and safety of haemostatic procedures are also discussed, and particular attention is given to the efficacy of pelvic angiographic embolization and external pelvic fixation. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture that takes haemodynamic status and associated lesions into account.
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Comment Review
Vasopressin in vasodilatory shock: hemodynamic stabilization at the cost of the liver and the kidney?
Infusing arginine vasopressin (AVP) in advanced vasodilatory shock is usually accompanied by a decrease in cardiac index and systemic oxygen transport. Whether or not such a vasoconstriction impedes regional blood flow and thus visceral organ function, even when low AVP is used, is still a matter of debate. Krejci and colleagues now report, in this issue of Critical Care, that infusing 'low-dose' AVP during early, short-term, normotensive and normodynamic fecal peritonitis-induced porcine septicemia markedly reduced both renal and portal blood flow, and consequently total hepatic blood flow, whereas hepatic arterial flow was not affected. ⋯ From these findings the authors conclude that the use of AVP to treat hypotension should be cautioned against in patients with septic shock. Undoubtedly, given its powerful vasoconstrictor properties, which are not accompanied by positive inotropic qualities (in contrast with most of the equally potent standard care 'competitors', namely catecholamines), the safety of AVP is still a matter of concern. Nevertheless, the findings reported by Krejci and colleagues need to be discussed in the context of the model design, the timing and dosing of AVP as well as the complex interaction between visceral organ perfusion and function.
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Comparative Study
A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients.
There is little objective comparative information about the postoperative complications of tracheostomy in morbidly obese patients. The aim of this study was to determine the incidence and severity of complications associated with open tracheostomy in critically ill morbidly obese patients during hospitalization. ⋯ In the present series, morbid obesity is associated with increased frequency and life-threatening complications from conventional tracheostomy. Special techniques and operative policies must be applied to overcome loss of airway control.
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Randomized Controlled Trial
Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial.
Esophageal Doppler was confirmed as a useful non-invasive tool for management of fluid replacement in elective surgery. The aim of this study was to assess the effect of early optimization of intravascular volume using esophageal Doppler on blood lactate levels and organ dysfunction development in comparison with standard hemodynamic management in multiple-trauma patients. ⋯ Optimization of intravascular volume using esophageal Doppler in multiple-trauma patients is associated with a decrease of blood lactate levels, a lower incidence of infectious complications, and a reduced duration of ICU and hospital stays.