Critical care : the official journal of the Critical Care Forum
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Comment Comparative Study
Optimal management of the high risk surgical patient: beta stimulation or beta blockade?
Several groups of investigators have shown that peri-operative goal directed therapy (GDT) may reduce mortality in high-risk surgical patients. GDT usually requires the use of beta-adrenergic agents, however, and these may also carry the risk of cardiac ischemia, especially in patients with ischemic diseases. ⋯ It is likely that beta-blockade should be proposed in patients with moderate risk of death, whereas GDT using fluids and inotropic agents should be applied in patients with high risk of peri-operative death. Monitoring central venous oxygen saturation may be useful to individualize therapy, but further studies are required to validate this option.
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Comment Comparative Study
Prediction of ventilation weaning outcome: children are not little adults.
Prediction of ventilation weaning outcome in children is important, as unsuccessful extubation increases both morbidity and mortality. Adult weaning criteria are poor predictors of weaning outcome in children for several possible reasons: the length of mechanical ventilation is generally much shorter, and the weaning failure rate is lower in children (thus larger patient numbers are required); integrated weaning indices, such as the rapid shallow breathing index, do not account for normal developmental changes in respiratory function; and the heterogeneity of mechanically ventilated children is greater than in adults. The challenge remains to find universal weaning outcome predictors in children.
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Severe sepsis is more and more frequent, especially because of an increased rate of immunocompromised patients. Despite the improvement in the overall prognosis of HIV/AIDS patients and the improvement of global ICU care, the prognosis of HIV/ADS patients hospitalized in ICU with severe sepsis remained poor. ⋯ However, medical literature suggests that ICU prognosis of immunocompromised (especially cancer) patients should be largely improved by early ICU admission and by an early institution of supportive techniques. This strategy should be used in HIV/AIDS patients with severe sepsis.
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Cardiac troponins are highly sensitive and specific indicators of myocardial injury. Although the mechanism of this injury is not entirely clear, it carries important prognostic information. ⋯ The current study is an important first step in trying to determine the exact frequency of MI among critically ill patients with elevated troponin. At present, the rate of MI in these patients is unknown and its implications on outcome and management will have to await future prospective clinical trials.
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Direct haemoperfusion with polymyxin B-immobilized fibre (PMX-F) is a promising treatment for Gram-negative sepsis in critically ill patients. Indeed, it has been used routinely in Japan for a decade. Recent evidence presented in this journal suggests that PMX-F can have a positive impact on outcome in patients with sepsis, although other reports in the literature have presented confusing or even conflicting results. This commentary considers whether the available evidence allows us to establish an appropriate role for PMX-F treatment in sepsis and what further work is needed.