Critical care : the official journal of the Critical Care Forum
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Asymmetrical dimethyl arginine (ADMA) is an endogenous non-selective inhibitor of nitric oxide synthase that may influence the severity of organ failure and the occurrence of shock secondary to an infectious insult. Levels may be genetically determined by a promoter polymorphism in a regulatory gene encoding dimethylarginine dimethylaminohydrolase II (DDAH II), which functions by metabolising ADMA to citrulline. The aim of this study was to examine the association between ADMA levels and the severity of organ failure and shock in severe sepsis and also to assess the influence of a promoter polymorphism in DDAH II on ADMA levels. ⋯ Severity of organ failure, inflammation and presence of early shock in severe sepsis are associated with increased ADMA levels. ADMA concentrations may be influenced by a polymorphism in the DDAH II gene.
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Clinical Trial
Successful pulmonary administration of activated recombinant factor VII in diffuse alveolar hemorrhage.
Diffuse alveolar hemorrhage (DAH) is a serious pulmonary complication seen in patients with autoimmune disorders and patients treated with chemotherapy or after hematopoietic stem cell transplantation. The clinical management of DAH is complex and the condition has a high mortality rate. Tissue factor is expressed in the lung alveoli during inflammation and therefore pulmonary administration of human recombinant activated factor VIIa (rFVIIa) could be a rational treatment option. ⋯ Symptomatic therapy of DAH after intrapulmonary administration of one or more doses of rFVIIa was found to have a good to excellent hemostatic effect in six consecutive patients with DAH. The intrapulmonary administration of rFVIIa seemed to have a high benefit-to-risk ratio. Larger series should confirm the safety of this approach.
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Comparative Study
Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study.
Anemia among the critically ill has been described in patients with short to medium length of stay (LOS) in the intensive care unit (ICU), but it has not been described in long-stay ICU patients. This study was performed to characterize anemia, transfusion, and phlebotomy practices in patients with prolonged ICU LOS. ⋯ Anemia, phlebotomy, and transfusions, despite low hemoglobin triggers, are common in ICU patients long after admission. Small decreases in phlebotomy volume are associated with significantly reduced transfusion requirements in patients with prolonged ICU LOS.
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Further work on the use of albumin in the intensive care unit is discussed. The interesting pilot study by Dubois and colleagues examines the potential benefits for albumin supplementation in the hypoalbuminaemic critically ill patient. Maintaining the fluid theme, we discuss recent work on factors influencing post-intensive care unit blood transfusion as well as another study on erythropoietin. Finally, a large multicentred trial comparing continuous venovenous haemofiltration with intermittent haemodialysis is outlined, the results of which pose more questions than answers.
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Predicting fluid responsiveness has become a topic of major interest. Measurements of intravascular pressures and volumes often fail to predict the response to fluids, even though very low values are usually associated with a positive response to fluids. ⋯ PLR induces an abrupt increase in preload due to autotransfusion of blood contained in capacitance veins of the legs, which leads to an increase in cardiac output in preload-dependent patients. This commentary discusses some of the technical issues related to this test.