Critical care : the official journal of the Critical Care Forum
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Editorial Comment
A rapidly progressing lymphocyte exhaustion after severe sepsis.
Septic syndromes induce immune alterations that have long been considered solely an overwhelming pro-inflammatory response. Increasing evidence now suggests that, after the first pro-inflammatory hours, sepsis is accompanied by the occurrence of a systemic immune failure. Here, novel perspectives regarding sepsis-induced lymphocyte alterations will be discussed in the context of a recently published study investigating overtime evolution of co-inhibitory lymphocyte receptor expressions in patients with severe sepsis.
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The C-MAC video laryngoscope substantially reduced poor glottic views and increased intubation success in ICU patients with at least one predictor for difficult intubation. However, all video-assisted and optical intubation devices have different view angles, thus producing different images with particular distortion, and even experts in 'old-fashioned' airway management need a substantial level of training with a certain device before using it safely and successfully in critical situations and patients. Video laryngoscopes, regardless of a particular brand or device, cannot be used intuitively - they require expert skills and routines to be turned into a life-saving airway management tool.
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In the continuing dispute about the superiority of either intermittent or continuous renal replacement therapy for the critically ill, hybrid methods such as sustained low-efficiency dialysis (SLED) combining the advantages of both modalities--that is, excellent hemodynamic stability and low costs--receive growing attention. The study by Schwenger and colleagues is the first randomized trial indicating that there may be no significant difference in survival at 90 days between patients treated with SLED as compared with those treated with continuous veno-venous hemofiltration.
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Diagnosis and classification of acute kidney injury was addressed systematically only 8 years ago when the classification called RIFLE (acronym of Risk, Injury, Failure, Loss of function and End stage Kidney disease describing progressive severity of renal damage) was created. Since then, several studies have tried to apply, validate, criticize and modify this initial scheme: as a matter of fact, RIFLE is today one of the most appreciated and utilized medical classification systems worldwide. After an initial period of epidemiological research, it is acceptable to apply it now at the bedside, following both urine output and creatinine criteria, with the purpose of routinely monitoring renal function of critically ill patients.
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One of the therapeutic essentials in severe sepsis and septic shock is an adequate fluid replacement to restore and maintain circulating plasma volume, improve organ perfusion and nutritive microcirculatory flow. The type of solution to be used as a fluid replacement remains under discussion. The aim of the study was to evaluate the effects of clinically used fluid replacement solutions on renal function and inflammatory response. ⋯ Despite similar maintenance of macrocirculation 6% hydroxyethylstarch 130/0.42 and Ringer's acetate significantly preserve renal function and attenuate tubular damage better than 10% hydroxyethylstarch 200/0.5 in saline.