Critical care : the official journal of the Critical Care Forum
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Randomized Controlled Trial
Bronchoscopy versus an endotracheal tube mounted camera for the peri-interventional visualization of percutaneous dilatational tracheostomy - a prospective, randomized trial (VivaPDT).
Percutaneous dilatational tracheostomy (PDT) in critically ill patients often involves bronchoscopic optical guidance. However, this procedure is not without disadvantages. Therefore, we aimed to study a recently introduced endotracheal tube-mounted camera (VivaSightTM-SL tube [VST]; ETView, Misgav, Israel) for guiding PDT. ⋯ Visualization of PDT with the VST is not noninferior to guidance by bronchoscopy. Ventilation is superior with less hypercarbia with the VST. Because visualization is not a prerequisite for PDT, patients requiring stable ventilation with normocarbia may benefit from PDT with the VST.
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Without doubt, in medicine as in life, one size does not fit all. We do not administer the same drug or dose to every patient at all times, so why then would we live under the illusion that we should give the same nutrition at all times in the continuum of critical illness? We have long lived under the assumption that critical illness and trauma lead to a consistent early increase in metabolic/caloric need, the so-called "hypermetabolism" of critical illness. What if this is incorrect? Recent data indicate that early underfeeding of calories (trophic feeding) may have benefits and may require consideration in well-nourished patients. ⋯ Post resuscitation, increasing protein (1.5-2.0 g/kg/day) and calories are needed to attenuate LBM loss and promote recovery. Malnutrition screening is essential and parenteral nutrition can be safely added following resuscitation when enteral nutrition is failing based on pre-illness malnutrition and LBM status. Following the ICU stay, significant protein/calorie delivery for months or years is required to facilitate functional and LBM recovery, with high-protein oral supplements being essential to achieve adequate nutrition.
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With imprecise definitions, inexact measurement tools, and flawed study execution, our clinical science often lags behind bedside experience and simply documents what appear to be the apparent faults or validity of ongoing practices. These impressions are later confirmed, modified, or overturned by the results of the next trial. ⋯ In this paper we present a wide-ranging set of unproven 'out of the mainstream' ideas of our FCCM faculty, each with a defensible rationale and holding clear implications for altering bedside management. Each proposition was designed deliberately to be provocative so as to raise awareness, stimulate new thinking and initiate lively dialog.
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Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. ⋯ Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.