Critical care : the official journal of the Critical Care Forum
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Comment
Bioelectrical impedance vector analysis in the critically ill: cool tool or just another 'toy'?
Assessment of volume and hydration status is far from easy and therefore technology such as bioelectrical impedance vector analysis (BIVA) may complement our examination techniques. This study highlights the fact that clinical assessment of volume balance and BIVA may correlate, but whether the routine use of BIVA will avoid significant volume overload in the critically ill remains unknown. Further studies are needed but at the moment appear a little way off.
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Hypotensive fluid resuscitation has a better effect before and during surgical intervention for multiple trauma patients with haemorrhagic shock. However, it is questionable whether hypotensive fluid resuscitation is suitable after surgical intervention for these patients, and whether resuscitation with different mean arterial pressure (MAP) targets after surgical intervention can obtain different results. The aim of this study was to investigate these questions and to explore the underlying mechanisms. ⋯ In our porcine model of resuscitation, targeting high MAP by fluid administration alone resulted in a huge increase in the infusion volume, severe tissue oedema, and organ dysfunction. Meanwhile, targeting low MAP resulted in persistent tissue hypoperfusion and metabolic stress. Hence, a resuscitation strategy of targeting appropriate MAP might be compatible with maintaining haemodynamic stability, tissue perfusion, and organ function.
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Hand hygiene is an effective, low-cost intervention that prevents the spread of multidrug-resistant bacteria. Despite mandatory education and reminders, compliance by physicians in our hospital remained stubbornly low. Our objective was to study whether surveillance by our unit coordinator (secretary) paired with regular feedback to chiefs of service would increase physician hand hygiene compliance in the ICU. ⋯ Physician hand hygiene compliance increased as a consequence of the surveillance conducted by a full-time ICU team member, leading to a highly significant increase in the number of observations. In turn, this allowed for specific comparative monthly feedback to individual chiefs of service. Over the next 2 years after the study ended, these gains were sustained, suggesting an enduring culture change in physician behavior.
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Comment
Arterial blood pressure targets in septic shock: is it time to move to an individualized approach?
Xu and colleagues evaluated the impact of increasing mean arterial blood pressure levels through norepinephrine administration on systemic hemodynamics, tissue perfusion, and sublingual microcirculation of septic shock patients with chronic hypertension. The authors concluded that, although increasing arterial blood pressure improved sublingual microcirculation parameters, no concomitant improvement in systemic tissue perfusion indicators was found. Here, we discuss why resuscitation targets may need to be individualized, taking into account the patient's baseline condition, and present directions for future research in this field.
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Tracheal reintubation is a common event in critical care. Elmer and colleagues provide the first comparison of complication rates of initial and subsequent reintubation(s) during the same hospitalization. Their work shows an increased risk of complications associated with reintubation, in particular hypoxemia and hypotension, reminding us to be cautious with patients having minimal reserve and potentially altered airway anatomy. See related research by Elmer et al., http://ccforum.com/content/19/1/12.