Critical care : the official journal of the Critical Care Forum
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The assessment of volume responsiveness and the decision to administer a fluid bolus is a common dilemma facing physicians caring for critically ill patients. Static markers of cardiac preload are poor predictors of volume responsiveness, and dynamic markers are often limited by the presence of spontaneous respirations or cardiac arrhythmias. Passive leg raising (PLR) represents an endogenous volume challenge that can be used to predict fluid responsiveness. ⋯ Non-invasive SV measurement and PLR can predict fluid responsiveness in a broad population of medical ICU patients. Less than 50% of ICU patients given fluid boluses were volume responsive.
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Volumetric parameters acquired by transpulmonary thermodilution had been repeatedly proven superior to filling pressures for estimation of cardiac preload. Up to now, the proposed normal ranges were never studied in detail. We investigated the relationship of the global end-diastolic volume (GEDV) acquired by transpulmonary thermodilution with age and gender in awake and spontaneously breathing patients. ⋯ The volumetric parameter GEDV shows a large inter-individual variance and is dependent on age and gender. These dependencies persist after indexing GEDV to body surface area calculated with predicted body weight. Targeting resuscitation using fixed ranges of preload volumes acquired by transpulmonary thermodilution without concern to an individual patient's age and gender seems not to be appropriate.
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The current debate about the side effects of induction agents, e.g. possible adrenal suppression through etomidate, emphasizes the relevance of choosing the correct induction agent in septic patients. However, cardiovascular depression is still the most prominent adverse effect of these agents, and might be especially hazardous in septic patients presenting with a biventricular cardiac dysfunction--or so-called septic cardiomyopathy. Therefore, we tested the dose-response direct cardiac effects of clinically available induction agents in an isolated septic rat heart model. ⋯ Overall, this study demonstrates that these tested drugs indeed have differential direct cardiac effects in the isolated septic heart. Propofol showed the most pronounced adverse direct cardiac effects. In contrast, S(+)ketamine showed cardiovascular stability over a wide range of concentrations, and might therefore be a beneficial alternative to etomidate.
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Every day, critical care physicians around the world face the same challenge of the optimal timing of antimicrobial administration: when to start and when to stop antibiotics. Duration of antibiotic therapy for sepsis is mostly based on expert opinion, but its reduction is arguably the most promising approach to decrease emergence and selection of antibiotic resistance. The study by Hochreiter and colleagues presents another piece of evidence suggesting that procalcitonin may indeed be a valuable diagnostic parameter to guide antibiotic treatment duration, despite the ongoing controversy about the diagnostic accuracy of pro-calcitonin.
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Renal replacement therapy (RRT) is a fully established treatment for critically ill patients with acute kidney injury (AKI) but there are no scientifically established criteria when to initiate it. Our objectives were to describe the epidemiology of critically ill patients with AKI receiving RRT and to evaluate the relationship between biochemical, physiological and comorbid factors at time of RRT and ICU mortality. ⋯ Oligoanuria, acidosis and concomitant dysfunction of other organs at time of RRT were associated with poor survival. In contrast, serum creatinine and urea levels only had a weak correlation with outcome after RRT.