Critical care : the official journal of the Critical Care Forum
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The diagnosis and treatment of dyspnea in the emergency department and in the prehospital setting is a challenge faced by the emergency physician and other prehospital care providers. While the use of lung ultrasound as a diagnostic tool in dyspneic patients has been well researched, there has been limited evaluation of its use in the prehospital setting. In the previous issue of Critical Care, Prosen and colleagues study the accuracy of lung ultrasound compared with both N-terminal pro-brain natriuretic peptide and the clinical examination for differentiating between acute decompensated congestive heart failure and chronic obstructive pulmonary disease exacerbations for patients in the prehospital setting. Their article adds to the growing body of evidence demonstrating the diagnostic efficacy of lung ultrasound in differentiating between these two disease processes in the acutely dyspneic patient.
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Comment
Appropriate antibiotic dosing in severe sepsis and acute renal failure: factors to consider.
Severe sepsis and septic shock cause considerable morbidity and mortality. Early appropriate empiric broad-spectrum antibiotics and advanced resuscitation therapy are the cornerstones of treatment for these conditions. In prescribing an antibiotic regimen in septic patients with acute renal failure treated with continuous renal replacement therapy, several factors should be considered: pharmacokinetics, weight, residual renal function, hepatic function, mode of renal replacement therapy (membrane and surface area, sieving coefficient, effluent and dialysate rate, and blood flow rate), severity of illness, microorganism, minimum inhibitory concentration, and others. Studies that determine the serum antibiotic concentrations are very useful in establishing the correct dosage in critical patients.
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Editorial Comment
Whole blood thromboelastometry: another Knight at the Roundtable?
Thromboelastography and thromboelastometry represent viscoelastic diagnostic methodologies with promising application to diseases of altered coagulation. Their use in trauma-induced coagulopathy as a means of assessing the real-time status of the patient's functional coagulation profile in addition to its impact on effective and appropriate use of blood product support has been gaining acceptance among trauma surgeons, anesthesiologists, and transfusion medicine specialists. However, the ability of viscoelastic testing to augment or supplant conventional coagulation testing for the diagnosis and management of trauma-induced coagulopathy remains controversial. Many of these issues pertain to the differences in methodology, instrumentation, logic, accessibility, ease of use, operator variability, and the method's relationship to patient care, blood product use, cost, and conventional testing algorithms.
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Despite a widespread belief in the value of aggressive prehospital airway management, the therapeutic benefits of early tracheal intubation (TI) remain unclear. In fact, most attempts to elucidate the benefits of prehospital TI on outcome from traumatic brain injury and cardiopulmonary arrest have documented an increase in mortality associated with the procedure. While some degree of selection bias is likely present in these studies, the inherent adverse physiological effects of intubation and a high incidence of desaturation and subsequent hyperventilation may indicate a harmful effect of the procedure. ⋯ To this end, the Utstein prehospital airway conference proposed a set of variables that would move us in that direction. However, the present article by Lossius and colleagues documents how far we still have to travel before such standardization can be achieved. Only through these efforts can we elucidate the true benefits - or harm - of advanced airway management during critical resuscitation.
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Computed tomography of the lung has shown that ventilation shifts from dependent to nondependent lung regions. In this study, we investigated whether, at the bedside, electrical impedance tomography (EIT) at the cranial and caudal thoracic levels can be used to visualize changes in ventilation distribution during a decremental positive end-expiratory pressure (PEEP) trial and the relation of these changes to global compliance in mechanically ventilated patients. ⋯ At the bedside, EIT measured at two thoracic levels showed different behavior between the caudal and cranial lung levels during a decremental PEEP trial. These results indicate that there is probably no single optimal PEEP level for all lung regions.