Critical care : the official journal of the Critical Care Forum
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An evaluation of critical care outreach services was published in the previous issue of Critical Care that fails to demonstrate any important outcome benefit associated with these services. It is now time to ask some difficult questions about the future of outreach, including whether the lack of evidence should lead to disinvestment in such services.
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Withdrawal and limitation of life support in the intensive care unit is common, although how this decision is reached can be varied and arbitrary. Inevitably, the patient is unable to participate in this discussion because their capacity is limited by the nature of the illness and the effects of its treatment. Physicians often discuss these decisions with relatives in an attempt to respect the patient's wishes despite evidence suggesting that the relatives may not correctly reflect the patient's desires. ⋯ In October 2007 in England and Wales, advance decisions will become legally binding as part of the 2005 Mental Capacity Act. This has been the case in the USA for many years. The purpose of the present review is to examine the published literature regarding the effect of advance decisions in relation to the provision of adult critical care.
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Endothelium dysfunction is one of the hallmarks of sepsis. Looney and Mattay, in the previous issue of Critical Care, highlight the role of activated protein C (APC) as a protective endothelial drug in septic situations. Nevertheless, the results of in vivo studies are less explicit and it remains uncertain whether these properties are relevant in human septic shock. ⋯ Nevertheless, if rAPC is efficient when infused in the early phase of septic challenge, we thus need to treat our patients earlier. At the least, genetically engineered variants have been designed with greater anti-apoptotic activity and reduced anticoagulant activity relative to wild-type APC. Further studies are needed to demonstrate the usefulness of these variants in septic shock therapy.
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The respiratory variation in pulse pressure (PP) has been established as a dynamic variable of cardiac preload which indicates fluid responsiveness in mechanically ventilated patients. The impact of acute changes in cardiac performance on respiratory fluctuations in PP has not been evaluated until now. We used cardiac resynchronization therapy as a model to assess the acute effects of changes in left ventricular performance on respiratory PP variability without the need of pharmacological intervention. ⋯ Changes in cardiac performance have a significant impact on respiratory hemodynamic fluctuations in ventilated patients. This influence should be taken into consideration when interpreting PP variation.
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Comparative Study Clinical Trial
Liquid versus gel handrub formulation: a prospective intervention study.
Hand hygiene is one of the cornerstones of the prevention of health care-associated infection, but health care worker (HCW) compliance with good practices remains low. Alcohol-based handrub is the new standard for hand hygiene action worldwide and usually requires a system change for its successful introduction in routine care. Product acceptability by HCWs is a crucial step in this process. ⋯ Facilitated access to an alcohol-based gel formulation leads to improved compliance with hand hygiene and better skin condition in HCWs.