Critical care : the official journal of the Critical Care Forum
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Blood pressure saggy? Cardiac output low? Oliguria? Increasing acidosis? Peripheries a bit cool? Poor cardiac history? No problem. Just start some dobutamine and watch the numbers improve. ⋯ Or is it? Catecholamines are long-established drugs that have never undergone formal testing of long-term outcomes and safety. Their use requires re-evaluation in the light of a wide range of deleterious actions and retrospective studies suggesting harm.
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Intracranial vascular complications are an important complication of acute bacterial meningitis. Ischemic stroke in meningitis is reported as a result of vasculitis, vasospasm, endocarditis or intraarterial thrombosis. The aim of the study was to identify the value of measuring cerebral blood flow velocity (CBFv) on transracranial doppler (TCD) in the identification of patients at risk for meningitis-associated stroke. ⋯ In summary, TCD was found to be a valuable bedside test to detect arterial alterations in patients with bacterial meningitis. These patients have an increased risk of stroke.
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In the previous issue of Critical Care, Takala and colleagues presented the results of a multicenter study to investigate whether the early presence of less invasive hemodynamic monitoring improves outcome in patients admitted with hemodynamic instability to the intensive care unit. The authors' results suggest that it makes no difference. We discuss these findings and compare them to the literature on early goal-directed therapy in which monitors are used early but with a protocol.
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The sepsis resuscitation bundle is the result of an effort on behalf of the Surviving Sepsis Campaign and the Institute for Healthcare Improvement to translate individual guideline recommendations into standardized, achievable goals for physicians caring for the critically ill patient. Implementation of this bundle is associated with decreased mortality. ⋯ Elevations in serum lactate are associated with increased mortality, and may result from either increased lactate production or impaired lactate clearance. Lactate clearance may be an important addition to the monitoring and management bundles of patients with severe sepsis and septic shock, However, specific mechanisms of lactate clearance, the relation of lactate clearance to traditional hemodynamic parameters, and the importance of lactate clearance as a therapeutic target or monitoring tool remain unclear.
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Editorial Comment
The desperate need for good-quality clinical trials to evaluate the optimal source and dose of fibrinogen in managing bleeding.
Recent interest in transfusion management of trauma patients has heightened expectation in the role of blood component therapy in improving patient outcome. Optimal transfusion support in supplementation with fibrinogen has not been defined by high-quality evidence. ⋯ Studies of cost-effectiveness have not been considered in research. An international move to supplement fibrinogen more 'aggressively' without direct clinical evaluation beforehand represents a failed opportunity to improve our very limited understanding of optimal transfusion practice.