Critical care : the official journal of the Critical Care Forum
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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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Editorial Comment
A lipid mediator controls neutrophil recruitment in acute lung injury - should we really be surprised?
New therapeutic approaches are sorely needed for acute lung injury. Neutrophil recruitment is a pathological hallmark of this syndrome, and is mainly regulated by CXC chemokine receptor 2 and its ligand CXC ligand 1. Rossaint and colleagues have described a new mechanism for regulation of this axis by 12/15-lipoxygenase products. This work opens the door for new therapeutic approaches and highlights the crucial interplay between lipid mediators and chemokines, a time-honored but often-ignored concept.
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Intra-abdominal hypertension is frequent in surgical and medical critically ill patients. Intra-abdominal hypertension has a serious impact on the function of respiratory as well as peripheral organs. ⋯ The optimal setting of mechanical ventilation and its impact on respiratory function and hemodynamics in ARDS associated with intra-abdominal hypertension are far from being assessed. We suggest that the optimal ventilator management of patients with ARDS and intra-abdominal hypertension would include the following: (a) intra-abdominal, esophageal pressure, and hemodynamic monitoring; (b) ventilation setting with protective tidal volume, recruitment maneuver, and level of positive end-expiratory pressure set according to the 'best' compliance of the respiratory system or the lung; (c) deep sedation with or without neuromuscular paralysis in severe ARDS; and (d) open abdomen in selected patients with severe abdominal compartment syndrome.
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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
Interleukin-27: a potential new sepsis biomarker exposed through genome-wide transcriptional profiling.
Sepsis is a complex clinical condition that is driven predominantly by deviations from the orderly stereotypic immunological response to infection. Much effort has been undertaken in the search for biomarkers that can assist in discriminating critically ill patients with sterile inflammation from those with sepsis. Such biomarkers may aid the clinician in therapeutic decision making upon admission of a patient. Interleukin-27 may be such a discriminative biomarker, as suggested in the previous issue of Critical Care by a study of critically ill children.