Critical care : the official journal of the Critical Care Forum
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Clinical Trial
Efficacy of and tolerance to mild induced hypothermia after out-of-hospital cardiac arrest using an endovascular cooling system.
We evaluated the efficacy of and tolerance to mild therapeutic hypothermia achieved using an endovascular cooling system, and its ability to reach and maintain a target temperature of 33 degrees C after cardiac arrest. ⋯ The intravascular cooling system is effective, safe and allows a target temperature to be reached fairly rapidly and steadily over a period of 36 hours.
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Clinical data considering vasopressin as an equivalent option to epinephrine in cardiopulmonary resuscitation (CPR) are limited. The aim of this prehospital study was to assess whether the use of vasopressin during CPR contributes to higher end-tidal carbon dioxide and mean arterial blood pressure (MAP) levels and thus improves the survival rate and neurological outcome. ⋯ End-tidal carbon dioxide and MAP are strong prognostic factors for the outcome of out-of-hospital cardiac arrest. Resuscitated patients treated with vasopressin alone or followed by epinephrine have higher average and final end-tidal carbon dioxide values as well as a higher MAP on admission to the hospital than patients treated with epinephrine only. This combination vasopressor therapy improves restoration of spontaneous circulation, short-term survival, and neurological outcome. In the subgroup of patients with initial asystole, it improves the hospital discharge rate.
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Comparative Study
Discordance between microvascular permeability and leukocyte dynamics in septic inducible nitric oxide synthase deficient mice.
Microvascular dysfunction causing intravascular leakage of fluid and protein contributes to hypotension and shock in sepsis. We tested the hypothesis that abrogation of inducible nitric oxide synthase (iNOS) activation would decrease leukocyte rolling, leukocyte adhesion, and microvascular leakage in sepsis. We compared wild-type mice made septic by cecal ligation and puncture with mice deficient in iNOS. ⋯ Leukocyte adhesion and vascular leakage were discordant in this setting. The finding that septic iNOS-deficient mice exhibited less microvascular leakage than wild-type septic mice despite equivalent increases in leukocyte adhesion suggests an important role for nitric oxide in modulating vascular permeability during sepsis.
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Increasing evidence suggests that high case volume is associated with improved outcomes in the intensive care unit (ICU). Potential explanations for the volume-outcome relationship include selective referral, clinical experience and organizational factors common to high-volume ICUs. Distinguishing between these explanations has important health policy implications, because outcomes at low-volume ICUs could be improved either by exporting best practices found at high-volume centers or by regionalizing adult critical care - two very different care strategies. Future research efforts should be directed at better characterizing the process of care in high-volume ICUs and exploring the feasibility of creating a regionalized system of care.