Crit Care Resusc
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The role of glucocorticoid supplementation in septic shock remains contentious. In septic shock, the driver for steroid therapy is the premise that there is relative adrenal insufficiency (based on reduced plasma cortisol and blunted cortisol response to corticotropin). ⋯ Published evidence indicates that there are cellular adaptations in stress, such as pre-receptor upregulation of cortisol, altered receptor density and gene transcription changes, none of which are reflected by plasma cortisol level. This leads us to postulate that the lack of a clearly defined plasma response in severe stress and the presence of an adequate response at the cellular level suggest it is a "sick euadrenal state", analogous to the sick euthyroid state, and not a sick adrenal indicating adrenal insufficiency.
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Randomized Controlled Trial
Effects of saline or albumin resuscitation on standard coagulation tests.
To explore whether fluid resuscitation with normal saline or 4% albumin is associated with differential changes in routine clinical coagulation tests. ⋯ Administration of albumin or of larger fluid volumes is associated with a prolongation of APTT. In ICU patients, the choice and amount of resuscitation fluid may affect a routinely used coagulation test.
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There is now significant evidence that initial use of the correct antibiotic saves more lives than virtually all other intensive care therapy. This means covering all possible causative organisms with the initial empirical choice. For nosocomial sepsis, broad-spectrum antibiotics must be started as soon as the relevant samples have been taken for culture, with de-escalation of therapy targeted to the causative organisms when results and susceptibilities are available. ⋯ We have shown that some patients with normal serum creatinine levels have very high creatinine clearance rates; in ICU patients with sepsis, blood pressure and tissue perfusion are maintained with large fluid loads and inotropic agents, thereby raising creatinine clearance. High clearances produce low trough concentrations of antibiotic, with important implications for underdosing and the development of antibiotic resistance. The new paradigm for treating sepsis, particularly nosocomial sepsis, is: get it right the first time, hit hard up front, and use large doses of broad-spectrum antibiotics for a short period.
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The concept of relative adrenal insufficiency in patients with severe sepsis continues to be controversial. This arises in part from the lack of an accepted "gold standard" for the diagnosis of adrenal insufficiency in the critically ill. Historically, assessment of adrenal function in this population has relied on measurement of plasma total cortisol level, in a blood sample taken either at random or as part of a corticotropin stimulation test. ⋯ We review the mechanisms known to affect tissue glucocorticoid activity and examine how they may be modified by critical illness. These include both free and interstitial cortisol concentrations, intracellular cortisol generation, and glucocorticoid-receptor activity and density. Changes in these factors are not reflected in plasma total cortisol concentrations, and more sophisticated techniques, including genetic transcriptional surveys, may be required to reveal the role of glucocorticoid insufficiency in critical illness.
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Multicenter Study
Withholding and withdrawal of life-sustaining therapies in intensive care: an Australian experience.
Withholding and withdrawal of treatment in intensive care is currently widely accepted, but little has been published about Australian practice. ⋯ In this population of critically ill patients, most deaths occurred after discussion of end-of-life decisions and withholding or withdrawal of treatment.