Critical care : the official journal of the Critical Care Forum
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The early detection and treatment of sepsis are the most important factors in improving the outcome of patients with this condition. However, many patients admitted to hospital experience a long delay in the diagnosis of sepsis. ⋯ The early diagnosis of sepsis may be challenging as many of the signs and symptoms are non-specific. Clinical studies suggest that early diagnosis of sepsis requires a high index of suspicion and comprehensive clinical evaluation together with laboratory tests, including a complete blood count with differential, lactate and procalcitonin levels.
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Iron as an element is a double-edged sword, essential for living but also potentially toxic through the generation of oxidative stress. The recent study by Chen and colleagues in Critical Care reminds us of this elegantly. ⋯ This work underscores that hepcidin acts not only systematically (as a hormone) but also locally for iron metabolism regulation. This opens areas of research for sepsis treatment but also for iron deficiency or anaemia treatment, since the local and systemic iron regulation appear to be independent.
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Zampieri and colleagues used sophisticated statistical methods to create a picture of acid-base pattern and inflammation relationship in a clinical context. The observed independent relationship between acidosis and albumin concentration and inflammatory pattern opens up a new area for research. It has become clear that, in addition to the characterization of mediators, receptors, and cellular phenotypes, the inflammatory response has to be interpreted in light of acid-base status, albumin concentration, and probably also carbon dioxide level.
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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.