Crit Care Resusc
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The use of intensive insulin therapy (IIT) to maintain blood glucose level below 8.3 mmol/L is recommended for management of severe sepsis by the Surviving Sepsis guidelines. The recent trials reporting reduced morbidity and mortality in critically ill patients treated with IIT require careful examination, including the subsequent post-hoc analyses. ⋯ Patients with severe sepsis are likely to benefit from IIT based on metabolic effects and their prolonged stays in the intensive care unit. The current evidence suggests IIT should be implemented, aiming for the lowest glycaemic range that can be safely achieved while avoiding hypoglycaemia.
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Randomized Controlled Trial
Comparison of normal or heparinised saline flushing on function of arterial lines.
Heparin is used as a flush solution for intravenous and intra-arterial lines, but has a number of drug interactions, as well as potentially serious side effects. ⋯ Heparin as a continuous flush at 3 units/hour does not improve the function of arterial lines compared with a continuous normal-saline flush.
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To measure functional outcome of long-stay intensive care unit patients in the Australian population. ⋯ Of 68 long-stay ICU patients, an average of 2 years after discharge, 50% were alive, including 25% living normal active lives. The remaining 25% described some disability. In most cases (88%), this was mild: only two patients (3% of the total group) depended on daily support. No patients were left in a persistent vegetative state.
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Case Reports
Suxamethonium-induced hyperkalaemia in a patient with a normal potassium level before rapid-sequence intubation.
The use of suxamethonium (succinylcholine) for rapid-sequence intubation may be limited by hyperkalaemia. Modest pre-induction hyperkalaemia is usually disregarded. We present a patient who underwent emergency surgery for a perforated peptic ulcer after being bedbound for 26 days because of a head injury. ⋯ Blood tests during resuscitation showed a serum potassium level of 8.8 mmol/L. Immobilisation, denervation and intra-abdominal infection were risk factors for hyperkalaemia in this patient. This report reinforces the need to identify risk factors for hyperkalaemia before administration of suxamethonium, even when serum potassium levels are normal.
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Case Reports
Severe pneumonia with pneumatoceles and patent foramen ovale in an infant: optimal ventilation strategy?
We discuss a case of severe pneumonia with pneumatoceles in a 2-month old infant. Despite peak and plateau airway pressures kept below 30 and 25 cmH(2)O, respectively, the infant developed bilateral pneumothorax and pneumomediastinum caused by pneumatocele rupture, necessitating bilateral intercostal drainage. Application of positive end-expiratory pressure (PEEP) of 10 cmH(2)O at FIO(2) of 0.7 worsened oxygenation, and transthoracic echocardiography showed right-to-left shunting of blood through the patent foramen ovale. ⋯ The open lung strategy of higher increments of PEEP and lower FIO(2) for lung protective ventilation actually proved deleterious to our patient. We conclude that a subset of patients with acute respiratory distress syndrome with refractory hypoxaemia may have right-to-left shunting of blood through a patent foramen ovale. This can be detected by echocardiography, and these patients may benefit from a ventilation strategy aimed at lowering pulmonary vascular resistance.