Critical care : the official journal of the Critical Care Forum
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Evaluation of a new biomarker from bronchoalveolar fluid, the Clara cell protein 10, adds data to the search for a diagnostic marker for ventilator-associated pneumonia (VAP). For more than 15 years, investigators tried to identify such a marker for predicting or diagnosing VAP. ⋯ For optimal management of critically ill, ventilated patients with clinical suspicion of VAP, clinicians need accurate microbiological information to decide to treat in case of confirmed infection and to guide the initial choice of antibiotic therapy with identification of the responsible pathogen(s). Thus, today, the potential advantages of biomarkers are to improve the rapidity and performance of current diagnostic procedures and to reduce antibiotic exposure and selective pressure.
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The rapid response system concept is one of the first patient-centered and organizational-wide systems aimed at preventing deaths and serious adverse events. It has been strongly argued that we need a benchmark that reflects the care of a deteriorating patient across the organization using a 'score to door time'; that is, the time from the first vital sign abnormality to admission to the ICU. The study by Oglesby and colleagues highlights serious issues, especially delays, which could adversely impact on patient care, and the study proposes that we concentrate more on measuring patient care from a broad perspective.
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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.
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Mechanical ventilation (MV) could prime the lung toward an inflammatory response if exposed to another insult such as bacterial invasion. The underlying mechanisms are not so far clear. Toll-like receptors (TLRs) allow the host to recognize selectively bacterial pathogens and in turn to trigger an immune response. We therefore hypothesized that MV modulates TLR2 expression and in turn modifies responsiveness to agonists such as bacterial lipopeptide (BLP). ⋯ Mild-stretch MV increases lung expression of TLR2 and sensitizes the lung to bacterial TLR2 ligands. This may account for the propensity of mechanically ventilated patients to develop acute lung injury in the context of airway bacterial colonization/infection.
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Prevalent in critically ill patients, delirium remains poorly understood and difficult to treat. In a cross-sectional study conducted in 12 countries, delirium was identified in close to one third of patients and was independently associated with increased mortality. While such epidemiological accounts represent an important cornerstone for research, scientific efforts are needed to elucidate the causes of delirium and the mechanisms underlying its association with poor outcomes.