Critical care : the official journal of the Critical Care Forum
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In a previous issue of Critical Care, Schilder and colleagues report the results of their multicenter trial (Citrate Anticoagulation Versus Systemic Heparinization; CASH) comparing regional anticoagulation with citrate to heparin anticoagulation. They found that citrate was safer, more efficacious and cheaper than heparin. In contrast to the largest previous trial, however, a survival benefit was not found, which was the primary endpoint of the CASH trial. ⋯ Selection bias was high: only 6% of the renal replacement therapy patients were included (versus 56% in the previous trial) and exclusion was 56% for increased risk of bleeding, 2.5 times as frequent as in the previous trial. Thus, the trial with survival benefit apparently included more patients with risk of bleeding and also more severely ill patients and these are the groups that potentially benefit the most from citrate. Nevertheless, the CASH trial is the third large randomized trial showing superiority of citrate over heparin, supporting the recommendation of citrate as first choice anticoagulant.
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Randomized Controlled Trial
Predicting six-month mortality of patients with traumatic brain injury: usefulness of common intensive care severity scores.
The aim of this study was to evaluate the usefulness of the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score II) and SOFA (Sequential Organ Failure Assessment) scores compared to simpler models based on age and Glasgow Coma Scale (GCS) in predicting long-term outcome of patients with moderate-to-severe traumatic brain injury (TBI) treated in the intensive care unit (ICU). ⋯ A simple prognostic model, based only on age and GCS, displayed a fairly good prognostic performance in predicting six-month mortality of ICU-treated patients with TBI. The use of the more complex scoring systems APACHE II, SAPS II and SOFA added little to the prognostic performance.
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Meta Analysis
Effect of statin therapy on mortality from infection and sepsis: a meta-analysis of randomized and observational studies.
Observational data have suggested that statin therapy may reduce mortality in patients with infection and sepsis; however, results from randomized studies are contradictory and do not support the use of statins in this context. Here, we performed a meta-analysis to investigate the effects of statin therapy on mortality from infection and sepsis. ⋯ Limited evidence suggests that statins may not be associated with a significant reduction in mortality from infection and sepsis. Although meta-analysis from observational studies showed that the use of statins was associated with a survival advantage, these outcomes were limited by high heterogeneity and possible bias in the data. Therefore, we should be cautious about the use of statins in infection and sepsis.
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Multicenter Study Observational Study
Thromboelastometry and organ failure in trauma patients: a prospective cohort study.
Data on the incidence of a hypercoagulable state in trauma, as measured by thromboelastometry (ROTEM), is limited and the prognostic value of hypercoagulability after trauma on outcome is unclear. We aimed to determine the incidence of hypercoagulability after trauma, and to assess whether early hypercoagulability has prognostic value on the occurrence of multiple organ failure (MOF) and mortality. ⋯ The incidence of a hypercoagulable state after trauma is 10% up to 24 hours after admission, which is broadly comparable to the rate of hypocoagulability. Further work in larger studies should define the clinical consequences of identifying hypercoagulability and a possible role for very early, targeted use of anticoagulants.
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Multicenter Study
The lower limit of intensity to control uremia during continuous renal replacement therapy.
The recommended lower limit of intensity during continuous renal replacement therapy (CRRT) is 20 or 25 mL/kg/h. However, limited information is available to support this threshold. We aimed to evaluate the impact of different intensities of CRRT on the clearance of creatinine and urea in critically ill patients with severe acute kidney injury (AKI). ⋯ The lower limit of delivered intensity to control uremia during CRRT was approximately between 10 and 15 mL/kg/h in our cohort. A prescribed intensity of approximately 15 mL/kg/h might be adequate to control uremia for patients with severe AKI in the ICU. However, considering the limitations due to the retrospective nature of this study, prospective studies are required to confirm our findings.