Critical care : the official journal of the Critical Care Forum
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Reade et al. studied 20 agitated intubated patients in a pilot open-label trial comparing the efficacy of dexmedetomidine versus haloperidol in facilitating extubation. While the study design had limitations, which are outlined by the authors themselves in the paper published in this issue of Critical Care, the study demonstrated an impressive reduction in time to extubation and length of stay. Dexmedetomidine is a promising sedative agent that acts via alpha2-receptors and has been shown to decrease prevalence and duration of delirium in mechanically ventilated patients. ⋯ Agitated delirious patients are at risk of immediate adverse events as well as prolonged respiratory support. All delirious patients are at risk of poor cognitive outcomes. Further research is needed into the pharmacological management of delirium, including the use of dexmedetomidine in the management of agitation and the clinical efficacy of haloperidol.
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Angiotensin II (Ang II) is a potential vasopressor treatment for hypotensive hyperdynamic sepsis. However, unlike other vasopressors, its systemic, regional blood flow and renal functional effects in hypotensive hyperdynamic sepsis have not been investigated. ⋯ In early experimental hypotensive hyperdynamic sepsis, intravenous angiotensin II infusion decreased renal blood while inducing a marked increase in urine output and normalizing creatinine clearance.
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In a group of postoperative patients, Taniguchi and coworkers compared the effect of a computerized system for weaning against 'manual care'. The computerized system involved automatic adjustments to the level of pressure support to achieve a target respiratory rate. Manual care involved adjustments to the level of pressure support to keep the ratio of respiratory frequency to tidal volume below 80. ⋯ The level of pressure support, however, was lower with manual care than with computerized ventilation. The study adds support to the notion that ventilator duration is shortened when weaning is contemplated at the earliest possible time. The findings also emphasize the importance of the Hippocratic dictum that patient outcome is improved when care is individualized rather than delivered according to a protocol.
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A recent observational study in a large cohort of critically ill patients confirms the association between hyperlactatemia and mortality. The mechanisms regulating the rates of lactate production and clearance in critical illness remain poorly understood. ⋯ Possible mechanisms include regional hypoperfusion, an inflammation-induced upregulation of the glycolitic flux, alterations in lactate-clearing mechanisms, and increases in the work of breathing. Understanding how these complex processes interact to produce elevations in lactate continues to be an important area of research.
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Severe status asthmaticus (SA) in children may require intubation and mechanical ventilation with a subsequent increased risk of death. In the patient with SA and refractory hypercapnoeic respiratory failure, use of extracorporeal life support (ECLS) has been anecdotally reported for carbon dioxide removal and respiratory support. We aimed to review the experience of a single paediatric centre with the use of ECLS in children with severe refractory SA, and to compare this with international experience from the Extracorporeal Life Support Organization (ELSO) registry. ⋯ Single centre and ELSO registry experience provide results of a cohort of children with refractory SA managed with ECLS support. Further study is necessary to determine if use of ECLS in this setting produces better outcomes than careful mechanical ventilation and medical therapy alone.