Critical care : the official journal of the Critical Care Forum
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Controlled Clinical Trial Pragmatic Clinical Trial
The way in which a physiotherapy service is structured can improve patient outcome from a surgical intensive care: a controlled clinical trial.
The physiological basis of physiotherapeutic interventions used in intensive care has been established. We must determine the optimal service approach that will result in improved patient outcome. The aim of this article is to report on the estimated effect of providing a physiotherapy service consisting of an exclusively allocated physiotherapist providing evidence-based/protocol care, compared with usual care on patient outcomes. ⋯ A physiotherapy service approach that includes an exclusively allocated physiotherapist providing evidence-based/protocol care that addresses pulmonary dysfunction and promotes early mobility improves patient outcome. This could be a more cost-effective service approach to care than is usual care. This information can now be considered by administrators in the management of scarce physiotherapy resources and by researchers in the planning of a multicenter randomized controlled trial.
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Ultrasound measurements of brachial artery reactivity in response to stagnant ischemia provide estimates of microvascular function and conduit artery endothelial function. We hypothesized that brachial artery reactivity would independently predict severe sepsis and severe sepsis mortality. ⋯ Brachial artery hyperemic blood velocity is a noninvasive index of microvascular function that independently predicts mortality in severe sepsis. In contrast, brachial artery flow-mediated dilation, reflecting conduit artery endothelial function, was not associated with mortality in our severe sepsis cohort. Brachial artery hyperemic velocity may be a useful measurement to identify patients who could benefit from novel therapies designed to reverse microvascular dysfunction in severe sepsis and to assess the physiologic efficacy of these treatments.
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Editorial Comment
Non-invasive mechanical ventilation in hematology patients: let's agree on several things first.
Acute respiratory failure is a dreaded and life-threatening event that represents the main reason for ICU admission. Respiratory events occur in up to 50% of hematology patients, including one-half of those admitted to the ICU. Mortality from acute respiratory failure in hematology patients depends on the patient's general status, acute respiratory failure etiology, need for mechanical ventilation and associated organ dysfunction. ⋯ There is growing concern about the safety of non-invasive mechanical ventilation to treat hypoxemic acute respiratory failure overall, but also in hematology patients. Prophylactic non-invasive mechanical ventilation in patients with acute respiratory failure but not respiratory distress seems to be effective in hematology patients with a reduced rate of intubation. However, curative non-invasive mechanical ventilation should be restricted to those patients with isolated respiratory failure, with fast improvement of respiratory distress under non-invasive mechanical ventilation, and with rapid switch to intubation to avoid deleterious delays in optimal invasive mechanical ventilation.
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Standardization of data collection in severely injured trauma patients in order to find the best performance and practice has been an issue for more than 20 years. The incidence of trauma has decreased and outcomes have improved over the past decades. Trauma still remains an important public health problem, however, and is listed by the World Health Organization as a leading cause of death and disability. ⋯ In-depth analysis is currently only partially possible. The future of standardizing data collection in trauma looks bright. However, bridging and cross-linking is necessary to a great extent in the future.
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Observational Study
Steroidogenesis in the adrenal dysfunction of critical illness: impact of etomidate.
This study was aimed at characterizing basal and adrenocorticotropic hormone (ACTH)-induced steroidogenesis in sepsis and nonsepsis patients with a suspicion of critical illness-related corticosteroid insufficiency (CIRCI), taking the use of etomidate-inhibiting 11β-hydroxylase into account. ⋯ A single dose of etomidate may attenuate stimulated more than basal cortisol synthesis. However, it may only partly contribute, particularly in the stressed sepsis patient, to the adrenal dysfunction of CIRCI, in addition to substrate deficiency.