Critical care : the official journal of the Critical Care Forum
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The choice of inotropic agent, particularly in catecholamine-resistant septic shock, remains an area of debate. Here we discuss a recent trial examining the use of vasopressin in a carefully controlled trial setting. Yet more data on the use of drotrecogin alfa (activated) in septic shock are described, as are novel but as yet experimental approaches to the treatment of sepsis. Finally, it is important not to forget to read the latest surviving sepsis guidelines.
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Comment
Ocular sonography in patients with raised intracranial pressure: the papilloedema revisited.
Invasive devices are recommended for the early detection of raised intracranial pressure (ICP) after severe traumatic brain injury. Owing to contraindication or local issues, however, invasive ICP monitoring is not always possible. Moreover, a significant proportion of moderate traumatic brain injury patients (managed without invasive ICP) will develop raised ICP. ⋯ Soldatos and colleagues report the usefulness of ocular sonography in the diagnosis of raised ICP. Focusing on cerebrospinal fluid accumulation around the retrobulbar optic nerve, they show interesting results for the optic nerve sheath diameter in the diagnosis of raised ICP. If confirmed by further studies, and despite important limitations related to sonography, this technique could serve as a screening test in patients at risk for raised ICP, when invasive monitoring is not possible or is not clearly recommended.
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Identification of good surrogate end-points can greatly facilitate the design of clinical trials. Using data from PROWESS and ENHANCE, Shorr and colleagues explore the potential value of several plasma biomarkers for treatment trials of activated protein C for severe sepsis. ⋯ Only protein C had acceptable performance characteristics as a type 2 biomarker, or surrogate end-point. The utility of protein C as a surrogate end-point for studies of severe sepsis must be validated in future prospective studies.
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Although sodium disturbances are common in hospitalised patients, few studies have specifically investigated the epidemiology of sodium disturbances in the intensive care unit (ICU). The objectives of this study were to describe the incidence of ICU-acquired hyponatraemia and hypernatraemia and assess their effects on outcome in the ICU. ⋯ ICU-acquired hyponatraemia and hypernatraemia are common in critically ill patients and are associated with increased risk of hospital mortality.
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Animal studies of acute lung injury (ALI) suggest nebulised heparin may limit damage from fibrin deposition in the alveolar space and microcirculation. No human studies have been undertaken to date. We assessed the feasibility, safety and potential anticoagulant effects of administration of nebulised heparin to patients with ALI. ⋯ Administration of nebulised heparin to mechanically ventilated patients with ALI is feasible. Nebulised heparin was not associated with any serious adverse events, and at higher doses it increased APTT levels. Larger trials are required to further investigate the safety and efficacy of nebulised heparin. In these trials due consideration must be given to systemic anticoagulant effects.