Critical care : the official journal of the Critical Care Forum
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Ventilator-associated pneumonia (VAP) is a major healthcare-associated complication with considerable attributable morbidity, mortality and cost. Inherent design flaws in the standard high-volume low-pressure cuffed tracheal tubes form a major part of the pathogenic mechanism causing VAP. The formation of folds in the inflated cuff leads to microaspiration of pooled oropharyngeal secretions into the trachea, and biofilm formation on the inner surface of the tracheal tube helps to maintain bacterial colonization of the lower airways. ⋯ Furthermore, coating tracheal tubes with antibacterial agents reduces biofilm formation and the incidence of VAP. In this Viewpoint article we explore the published data supporting the new tracheal tubes and their potential contribution to VAP prevention strategies. We also propose that it may now be against good medical practice to continue to use a 'standard cuffed tube' given what is already known, and the weight of evidence supporting the use of newer tube designs.
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Sepsis continues to pose a clear challenge as one of the most difficult and costly problems to treat and prevent. Sepsis is caused by systemic or localized infections that damage the integrity of microcirculation in multiple organs. The challenge of sepsis and its long-term sequelae was addressed by the National Institutes of Health National Heart Lung and Blood Institute Division of Blood Diseases and Resources. Defining sepsis as severe endothelial dysfunction syndrome that causes multiorgan failure in response to intravascular or extravascular microbial agents, the National Heart Lung and Blood Institute panel proposed the concept of genome wars as a platform for new diagnostic, therapeutic, and preventive approaches to sepsis.
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Low tidal volume (VT 6 ml/predicted body weight) pressure limited (plateau pressure <30 cmH2O) protective ventilation as proposed by the ARDS Network was associated with an improvement in mortality and is considered the gold standard for acute respiratory distress syndrome (ARDS) ventilation strategies. Limiting plateau pressure minimizes ventilator-induced lung injury by reducing the trans-pulmonary pressure, which is the real alveolar distending pressure. ⋯ Moreover, low tidal volume to keep plateau pressure <30 cmH2O could be associated with large differences compared to measured total lung capacity. Quantitative bedside techniques that are able to measure lung volumes together with trans-pulmonary pressure could expand our chances to tailor mechanical ventilation in ARDS patients.
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Lactic acid was first discovered in human blood in 1843. Since then it has been used as a prognosticator of outcome in critical illness. Regardless of its etiology, lactate's presence and trend over time have been shown to be independently associated with mortality. Two dynamic lactate measures, the time-weighted average lactate and the absolute change in lactate over the first 24 hours in the ICU, were recently shown to be better than static lactate measurements in predicting hospital and ICU deaths.
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Donnino and colleagues provide new insights into the field of oxidative stress and mitochondrial dysfunction during septic shock. These authors suggest a coenzyme Q10 (CoQ10) deficiency in patients with septic shock. Larger prospective observational trials measuring CoQ10 in patients with septic shock are required to confirm the possibility of CoQ10 depletion. This study is a new step toward a study testing CoQ10 as a potential therapeutic agent for patients with septic shock.