Critical care : the official journal of the Critical Care Forum
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The early administration of tranexamic acid (TXA) to bleeding trauma patients reduces all-cause mortality without increasing the risk of vascular occlusive events. Indeed, the risk of arterial thrombosis appears to be reduced with TXA. ⋯ These include inhibition of the inflammatory effects of plasmin, effects on platelets and effects on factors V and VIII. If proven, these antithrombotic effects would have major implications for the systemic use of TXA in surgical patients, where TXA has been clearly shown to reduce bleeding.
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Editorial Comment
Crystalloids versus colloids during acute normovolemic anemia: the quest continues...
The optimal kind of fluid for fluid resuscitation during acute, severe hemorrhage is still discussed controversially. Of particular interest in this context is the choice of colloids versus crystalloids and their effect on the critical hemoglobin level. In a previous issue of Critical Care, Pape and colleagues describe the effect of four different volume replacement options on the critical hemoglobin concentration, and show marked differences for the different treatments. Even though some important pathophysiological issues remain unsolved, the current manuscript adds interesting evidence to an ongoing quest.
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Editorial Comment
Etomidate for intubation of patients who have sepsis or septic shock - where do we go from here?
Etomidate is an intravenous induction agent that is associated with hemodynamic stability during intubation. The agent is therefore attractive for use in critically ill patients who have a high risk of hemodynamic instability during this procedure. However, etomidate causes adrenal suppression, which itself has been associated with increased mortality in critically ill patients. The ongoing debate surrounding use of etomidate is thus centered on the immediate favorable hemodynamic profile versus the long-term risks of adrenal insufficiency, particularly in patients who have severe sepsis or septic shock.
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Currently, the major issue in glycemic control in neurocritical care patients is that tight glycemic control (target range of 80 to 110 mg/dL) using intensive insulin therapy is associated with higher rates of hypoglycemia without an improvement in survival rate. The review by Kramer and colleagues in this issue of Critical Care confirms these data but provides solid evidence about the relationship between hyperglycemia and worsened neurological outcome after acute brain injury. ⋯ In addition, we recommend adequate nutrition before and during insulin infusion, avoidance of insulin as a bolus, and the use of continuous insulin infusion, beginning with low doses with titration to individual sensitivity. Careful and accurate glycemic monitoring is especially important when insulin is infused.