Crit Care Resusc
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Extracorporeal membrane oxygenation (ECMO) is a controversial means of life support, particularly in adults. Ongoing refinements in circuit technology and widening global experience have led to ECMO being applied to a broader group of conditions than acute respiratory failure and cardiogenic shock. Septicaemia is no longer viewed as a contraindication to ECMO. ⋯ The last indication is generally more applicable in children than adults, because of differences in the cardiovascular response to severe sepsis seen across age groups. ECMO has a role as rescue therapy in patients with severe sepsis who would otherwise die of either hypoxaemia or inadequate cardiac output. This review describes the basic technique and application of ECMO in neonates, older children, and adults with sepsis.
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Review Meta Analysis Comparative Study
Loop diuretics in the management of acute renal failure: a systematic review and meta-analysis.
Loop diuretics are commonly used in critically ill patients with acute renal failure (ARF), but their effect on clinical outcome remains uncertain. We systematically reviewed the literature comparing loop diuretics with control in the management of ARF. ⋯ Loop diuretics were not associated with improved mortality or rate of independence from RRT, but were associated with shorter duration of RRT and increased urine output. However, these findings have limited relevance to critically ill patients. The relative paucity of high-quality data assessing the value of loop diuretics in ARF for the critically ill suggests a need for a suitably powered randomised trial.
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Review
Heparin-induced thrombocytopenia without thrombosis: an evidence-based review of current literature.
There has been a recent change in the management guidelines for patients with heparin-induced thrombocytopenia with the addition of a recommendation to commence parenteral anticoagulation in patients with isolated HIT without evidence of thrombosis. We assessed the evidence supporting this recommendation, to answer the following questions: in a patient with isolated HIT, should alternative anticoagulation be commenced, what alternative agent should be used, what is the recommended duration of anticoagulation, and when should warfarin be used? ⋯ Although patients with isolated HIT are at considerable risk of new thrombosis, there is limited evidence to support or reject the use of non-heparin anticoagulation in this group. Non-randomised, historically controlled trials support the use of lepirudin and argatroban; evidence favouring danaparoid is limited to large case series and one retrospective observational study. Duration of parenteral anticoagulation and warfarin use are guided by consensus opinion alone.
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The use of catecholamines to defend and resuscitate patients with septic shock remains a cornerstone of intensive care medicine. The pharmacological support of the failing circulation during sepsis and septic shock should be directed at augmenting perfusion of vital organs and facilitating venous return, rather than peripheral arterial vasoconstriction. There appears to be a teleological rationale for primary use of catecholamines to augment failing endogenous neurohumoral and neuroendocrine cardiovascular systems. ⋯ Supplemental endocrine replacement therapy with low-dose corticosteroids and vasopressin appears biologically plausible and has an emerging role. Results of large-scale, high-quality trials of endogenous catecholamines for sepsis and septic shock are awaited. These may provide additional, important information for evidence-based guidelines, which currently remain of limited clinical utility.
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Sepsis continues to be a major cause of morbidity and mortality. Evidence is emerging from observational studies and basic science research that statins (3-hydroxy, 3-methylglutaryl coenzyme A [HMG CoA] reductase inhibitors) might be associated with reduced mortality in sepsis. Statins have become the most widely used drugs for lowering serum cholesterol levels, being used by at least 15% of patients requiring admission to hospital, and this number is growing each year. ⋯ It suggests an urgent need to investigate the pharmacology of these drugs and reappraise their therapeutic indications in critically ill patients. This may provide new insights into the role of lipids and the endothelium in sepsis. Statins are significantly cheaper than other therapies that have been shown to improve outcome in sepsis, and the demonstration of a mortality benefit would have enormous cost-benefit implications.