Critical care : the official journal of the Critical Care Forum
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Ventilator-associated pneumonia (VAP) is a new (nosocomial) lower respiratory tract infection diagnosed in mechanically ventilated patients 48 or more hours after intubation. There is no gold standard for establishing the diagnosis and its pathogenesis is iatrogenic and multifactorial. ⋯ VAP is associated with increased mortality and morbidity, prolonged duration of ventilation and hospital stay, and escalated costs of hospitalisation. VAP 'bundles' are championed as the antidote.
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Comparative Study
Inhibition of complement C5a prevents breakdown of the blood-brain barrier and pituitary dysfunction in experimental sepsis.
Septic encephalopathy secondary to a breakdown of the blood-brain barrier (BBB) is a known complication of sepsis. However, its pathophysiology remains unclear. The present study investigated the effect of complement C5a blockade in preventing BBB damage and pituitary dysfunction during experimental sepsis. ⋯ Collectively, the neutralisation of C5a greatly ameliorated pathophysiological changes associated with septic encephalopathy, implying a further rationale for the concept of pharmacological C5a inhibition in sepsis.
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Sepsis, a systemic inflammatory response to infective etiologies, has a high mortality rate that is linked both to excess cytokine activity and apoptosis of critical immune cells. Dexmedetomidine has recently been shown to improve outcome in a septic cohort of patients when compared to patients randomized to a benzodiazepine-based sedative regimen. We sought to compare the effects of dexmedetomidine and midazolam, at equi-sedative doses, on inflammation and apoptosis in an animal model of severe sepsis. ⋯ Sedation with midazolam and dexmedetomidine both improve outcome in polymicrobial severely septic rats. Possible benefits conveyed by one sedative regimen over another may become evident over a more prolonged time-course as both IL-6 and apoptosis were reduced by dexmedetomidine but not midazolam. Further studies are required to evaluate this hypothesis.
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A growing consensus seems to be emerging that neurocognitive outcomes are poor for patients who have been critically ill with acute respiratory distress syndrome and multiple organ failure. However, intensive care unit delirium, post-traumatic stress disorder, and other outcomes must be considered as potentially confounding factors. Once the uncertainty around the causes of postmorbid cognitive functioning is acknowledged, there are practical implications for appropriate rehabilitative interventions and there are ethical implications for the kinds of appropriate disclosure to patients.
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Dynamic predictors are clearly superior to static pressures in predicting whether a patient will respond to a fluid bolus. Hand-carried ultrasound (HCUS) can measure changes in blood flow velocity in the brachial artery that parallel arterial pulse pressure variation. The potential for HCUS to guide fluid therapy non-invasively must overcome problems of sensitivity and applicability.