Critical care : the official journal of the Critical Care Forum
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Brain injury (BI) induces a state of immunodepression leading to pneumonia. We investigated the invariant natural killer T (iNKT) cell compartment. ⋯ We observed severe alterations of the iNKT cell compartment, including the presence of inhibitory serum factors. We demonstrate for the first time that the decreased capacity to present antigens is not a generalized phenomenon because whereas the expression of HLA-DR molecules is decreased, the capacity for presenting glycolipids through CD1d expression is higher in patients.
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Meta Analysis
Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis.
Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury. ⋯ The present meta-analysis suggests that targeting GDT to perioperative systemic oxygen delivery, by means of fluids and inotropes, can be the best way to improve renal perfusion and oxygenation in high-risk patients undergoing major abdominal and orthopedic surgery.
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The last decade, there have been many initiatives worldwide to increase the number of organ donors. However, it is not clear which initiatives are most effective. The aim of this study is to provide an overview of interventions aimed at healthcare professionals in order to increase the number of organ donors. ⋯ Although there is paucity of data, collaborative care pathways, training of healthcare professionals and additional support for relatives of potential donors seem to be promising interventions to increase the number of organ donors.
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Until relatively recently, critical illness was considered as a separate entity and the intensive care unit (ICU), often a little cut-off from other areas of the hospital, was in many cases used as a last resort for patients so severely ill that it was no longer possible to care for them on the general ward. However, we are increasingly realizing that critical illness should be seen as just one part of the patient's disease trajectory and how the patient is managed before and after ICU admission has an important role to play in optimizing outcomes. Identifying critical illness early, before it reaches a stage where it is life-threatening, is a challenge and requires a combination of improved and more frequent or continuous monitoring of at-risk patients, staff training to recognize when a patient is deteriorating, a system to "call for help," and an effective response to that call. ⋯ Early intensivist input may also be important for patients undergoing interventions that are likely to result in ICU admission, e.g., transplantation or cardiac surgery. The patient's continuum after ICU discharge must also be taken into account during their ICU stay, with attempts made to limit the longer-term physical and psychological consequences of critical illness as much as possible. Minimal sedation, good communication, and early mobilization are three factors that can help patients survive their ICU stay with minimal sequelae.
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The founding tenet of evidence-based medicine is to combine best evidence with clinical expertise. As David Sackett opined 'Without clinical expertise, practice risks becoming tyrannised by evidence'. Rigid protocols and mandates, based on an inconclusive and low-level evidence base, cannot suit the physiological, biochemical and biological heterogeneity displayed by the individual septic patient. ⋯ Therapy thus needs to be tailored to meet the individual patient's needs. The same principle should be applied to clinical trials; the continued disappointments of multiple investigational strategies trialled over three decades, despite (often) a sound biological rationale, suggest a repeated methodological failure that does not account for the marked heterogeneity within the septic patient's biological phenotype and thus marked variation in their host response. The increasing availability of rapid point-of-care diagnostics and theranostics should facilitate better patient selection and titrated optimization of the therapeutic intervention.