Critical care : the official journal of the Critical Care Forum
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Hypoglycemia is consistently associated with an increased risk of death in hospital patients in general, patients treated in intensive care units, and type II diabetes patients recruited to large randomized controlled trials. In 1965, Sir Austin Bradford Hill elucidated nine characteristics that help establish a causal relationship between exposure to a potentially harmful substance or event (in this context, hypoglycemia) and disease onset or death; hypoglycemia exhibits some of those characteristics but others remain to be explored. While we await data that address the outstanding issues, common sense dictates that clinicians avoid causing hypoglycemia whenever possible.
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The rapid institution of therapeutic hypothermia after cardiac arrest has become an accepted practice. In the previous issue of Critical Care, Haugk and colleagues present a retrospective analysis of 13 years of experience with therapeutic hypothermia at their center that suggests an association between rate of cooling and less favorable neurological outcomes. The association most likely reflects easier cooling in patients more severely brain injured by their initial cardiac arrest, and should not lead clinicians to abandon or slow their efforts to achieve post-resuscitative cooling.
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Perioperative haemodynamic optimisation of high-risk surgical patients has long been documented to improve both short-term and long-term outcomes, as well as to reduce the rate of postoperative complications. Based on the evidence, cardiac output monitoring and fluid resuscitation, combined with the use of inotropes, would seem to be the gold standard of care for these difficult surgical cases. However, clinicians do not universally apply these techniques and principles in their everyday practice. By exploring the reasons why this is so, perhaps we could move forward in the standardisation of care and the application of evidence-based practice.
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Editorial Comment
Why high suPAR is not super--diagnostic, prognostic and potential pathogenic properties of a novel biomarker in the ICU.
The soluble urokinase plasminogen activator receptor (suPAR) has been suggested as a biomarker that reflects immune cell activation. In critically ill patients, several independent investigations have reported elevated suPAR in conditions of systemic inflammatory response syndrome (SIRS), bacteriemia, sepsis, and septic shock, in which high circulating suPAR levels indicated an unfavorable prognosis. ⋯ High systemic levels indicated an adverse prognosis. This study expands our knowledge of the diagnostic power of suPAR, confirms its prognostic value, and raises the demand for future studies investigating the pathogenic involvement of suPAR.
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Comment
Prognostic value of pulmonary dead space in patients with the acute respiratory distress syndrome.
A study published in the previous issue of Critical Care demonstrates that measurement of the pulmonary dead-space fraction is superior to hypoxemia as an indicator of a favorable physiologic response to prone positioning in patients with severe acute respiratory distress syndrome. These results add to the growing evidence supporting the clinical and research value of measuring pulmonary dead space in patients with acute respiratory distress syndrome and using this pulmonary physiologic end-point as one indicator of a favorable response to therapy.