Critical care : the official journal of the Critical Care Forum
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Communication failures are a significant contributor to medical errors that harm patients. Critical care delivery is a complex system of inter-professional work that is distributed across time, space, and multiple disciplines. Because health-care education and delivery remain siloed by profession, we lack a shared framework within which we discuss and subsequently optimize patient care. ⋯ We suggest that the 'phases-of-illness paradigm' will facilitate communication about critically ill patients and create a shared mental model for interdisciplinary patient care. In so doing, this paradigm may reduce communication errors, complications, and costs while improving resource utilization and trainee education. Additional research applications are feasible.
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Molecular biology has not yet fully reached its ambitious goals in clinical bacteriology. Notwithstanding the tremendous technical challenges, the detection of nucleic acids directly from the blood of septic patients has not been shown cost-effective or even clinically relevant. Yet the potential for rapid molecular detection of circulating DNA (DNAemia) coupled to an educated antimicrobial drug adaptation has been repetitively advocated as a predicted breakthrough. Why do we still remain in such uncertainty?
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Cytomegalovirus (CMV) is a ubiquitous virus present in approximately two-thirds of the healthy population. This virus rarely causes an active disease in healthy individuals, but it is among the most common opportunistic infections in immunocompromised patients such as solid organ transplant recipients, patients receiving chemotherapy for cancer or patients with human immunodeficiency virus. Critically ill patients who are immunocompetent before intensive care unit admission may also become more prone to develop active CMV infection if they have prolonged hospitalizations, high disease severity, and severe sepsis. ⋯ The present issue of Critical Care brings a new study by Heininger and colleagues in which the authors found that patients with severe sepsis who developed active CMV infection had significantly longer intensive care unit and hospital stays, prolonged mechanical ventilation, but no changes in mortality compared to patients without CMV infection. We discuss the possible reasons for their findings (for example, selection bias and low (20%) statistical power to detect mortality endpoints), and also perform an update of our previous meta-analysis with the addition of Heininger and colleagues' study to verify whether the higher mortality rate with CMV holds. Our updated meta-analysis with approximately 1,000 patients shows that active CMV infection continues to be associated with a significant 81% higher mortality rate than that in critically ill patients without active CMV infection.
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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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Editorial Comment
Positioning of patients with acute respiratory distress syndrome: combining prone and upright makes sense.
Positional strategies have been proposed for mechanically ventilated patients with acute respiratory distress syndrome. Despite different physiological mechanisms involved, oxygenation improvement has been demonstrated with both prone and upright positions. ⋯ The combined positioning enhanced the response rate in terms of oxygenation. Other benefits, such as a reduction in ventilator-associated pneumonia and better enteral feeding tolerance, can potentially be expected.