Critical care : the official journal of the Critical Care Forum
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Fresh blood has many potential advantages over older blood, but there is no evidence that these properties translate into clinical benefit for intensive care patients. The observational multicenter study by Karam and colleagues provides some evidence suggesting that blood stored for less than 14 days is better than older blood in terms of new organ failure and reduction in length of stay in pediatric intensive care units. ⋯ As a consequence, it is ethical and certainly pertinent to conduct a randomized clinical trial in order to test the hypothesis that fresh blood might reduce mortality. The rationale is strong and the potential benefit of fresh blood is substantial.
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The impact of anemia on functional outcome and mortality in patients suffering from non-traumatic intracerebral hemorrhage (ICH) has not been investigated. Here, we assessed the relationship between hemoglobin (HB) levels and clinical outcome after ICH. ⋯ We report an association between low HB and poor outcome in patients with non-traumatic, supratentorial ICH. While a causal relationship could not be proven, previous experimental studies and studies in brain injured patients provide evidence for detrimental effects of anemia on brain metabolism. However, the potential risk of anemia must be balanced against the risk of harm from red blood cell infusion.
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Goal-directed therapy (GDT) can be a vague term, meaning different things to different people and, depending on the clinical environment, sometimes even different things to the same person. It can refer to perioperative fluid management, clinicians driving oxygen delivery to supramaximal values, early treatment of sepsis in the emergency department, and even to restriction of perioperative crystalloids with the goal of maintaining preadmission body weight. Understandably, strong opinions about GDT vary; some clinicians consider it essential for perioperative care, others completely ineffective in critically ill patients. This commentary aims to further position the excellent review by Lees and colleagues in the context of the critical care and perioperative setting.
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In a randomised trial comparing early enteral feeding by gastric and post-pyloric routes, White and colleagues have shown that gastric feeding is possible and efficient in the vast majority of critically ill patients. But the authors' conclusion that gastric is equivalent to post-pyloric is true in only the least severe patients. Given the extra workload and costs, post-pyloric is now clearly indicated in case of gastric feeding failure.
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Comment
Bending the cost curve in the United States: the role of comparative effectiveness research.
Owing to an increasing focus on the rising cost of medical care in the United States, bending the cost curve has become the central tenet of healthcare reform. The exact definition of this phrase, however, remains elusive. In order to affect change in the cost and quality of healthcare, the importance of comparative effectiveness research must be recognized.