Critical care : the official journal of the Critical Care Forum
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Do-not-resuscitate (DNR) orders are commonly implemented in the critical care setting as a prelude to end-of-life care. This is often based on presumed prognosis for favorable outcome and interpretation of patient, family, and even physician wishes. While DNR orders explicitly apply only to an individual patient, the hospital culture and milieu in which DNR orders are implemented could potentially have an overall impact on aggressiveness of care across patients. As illustrated by the example of intracerebral hemorrhage, this may unexpectedly influence outcome even in patients without DNR orders in place.
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Editorial Comment
Number needed to treat = six: therapeutic hypothermia following cardiac arrest--an effective and cheap approach to save lives.
In 2005, the European Resuscitation Council (ERC) guidelines stated: Unconscious adult patients with spontaneous circulation after out-of-hospital ventricular fibrillation cardiac arrest should be cooled to 32 to 34 degrees C for 12 to 24 hours. Patients with cardiac arrest from a non-shockable rhythm, in-hospital patients and children may also benefit from hypothermia. There is no argument to wait. We have to treat the next unconscious cardiac arrest patient with hypothermia.
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In acute lung injury (ALI), elevation of procollagen type III (PC III) occurs early and has an adverse impact on outcome. We examined whether different high-inflation strategies of mechanical ventilation (MV) in oleic acid (OA) ALI alter regional expression of PC III. ⋯ PC III expression is higher in nondependent regions and in ventilatory strategies that caused overdistension. This response was partially attenuated by prone positioning.
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One potential mechanism of ventilator-induced lung injury (VILI) is due to shear stresses associated with alveolar instability (recruitment/derecruitment). It has been postulated that the optimal combination of tidal volume (Vt) and positive end-expiratory pressure (PEEP) stabilizes alveoli, thus diminishing recruitment/derecruitment and reducing VILI. In this study we directly visualized the effect of Vt and PEEP on alveolar mechanics and correlated alveolar stability with lung injury. ⋯ A ventilatory strategy employing high Vt and low PEEP causes alveolar instability, and to our knowledge this is the first study to confirm this finding by direct visualization. These studies demonstrate that low Vt and high PEEP work synergistically to stabilize alveoli, although increased PEEP is more effective at stabilizing alveoli than reduced Vt. In this animal model of ARDS, alveolar instability results in lung injury (VILI) with minimal changes in plasma and bronchoalveolar lavage cytokines and proteases. This suggests that the mechanism of lung injury in the high Vt/low PEEP group was mechanical, not inflammatory in nature.
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Comparative Study
Inhibition of the RAGE products increases survival in experimental models of severe sepsis and systemic infection.
The receptor for advanced glycation end products (RAGE), a multi-ligand member of the immunoglobulin superfamily, contributes to acute and chronic disease processes, including sepsis. ⋯ Further studies are warranted to determine the clinical utility of anti-RAGE antibody as a novel treatment for sepsis.