Other bulletins in this series include:

Breast Surgery

Tuesday, 2 September 2014

The opportunity cost of futile treatment in the ICU

The opportunity cost of futile treatment in the ICU. Critical Care Medicine, Sept 2014, Vol. 42(9), p.1977-82.

Huynh, T.N. et al.


When used to prolong life without achieving a benefit meaningful to the patient, critical care is often considered “futile.” Although futile treatment is acknowledged as a misuse of resources by many, no study has evaluated its opportunity cost, that is, how it affects care for others. Our objective was to evaluate delays in care when futile treatment is provided.

Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients?

Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients? A meta-analysis of randomized controlled trials. Critical Care 2014, 18: R111

Gu, X. et al.


Comprehensively evaluating the efficacy and safety of high-frequency oscillatory ventilation (HFOV) is
important to allow clinicians who are using or considering this intervention to make appropriate decisions.
Although HFOV seems not to increase the risk of barotrauma or hypotension, and reduces the risk of oxygenation failure, it does not improve survival in adult acute respiratory distress syndrome patients.

High-frequency oscillatory ventilation in adults

High-frequency oscillatory ventilation in adults: handle with care. Critical Care 2014, 18: 464

Ferguson, N.D.


In the previous issue of Critical Care, Gu and colleagues reported the results of a systematic review
and meta-analysis of randomized trials comparing high-frequency oscillatory ventilation (HFOV) with
conventional ventilation in adults with acute respiratory distress syndrome (ARDS). In contrast to findings of prior meta-analyses, their main finding was that, despite reducing risks of oxygenation failure, HFOV does not improve survival in adults with ARDS.

Conservative fluid therapy in septic shock

Conservative fluid therapy in septic shock: an example of targeted therapeutic minimization. Critical Care 2014, 18: 481

Chen, C. and Kollef, M.H.


Intravenous fluids (IVFs) represent a basic therapeutic intervention utilized in septic shock. Unfortunately, the
optimal method for administering IVFs to maximize patient outcomes is unknown. A meta-analysis of
four randomized trials of goal-directed therapy did not demonstrate a significant reduction in mortality
(odds ratio 0.609; 95% confidence interval 0.363 to 1.020; P = 0.059), whereas 18 trials with historical
controls showed a significant increase in survival (odds ratio 0.580; 95% confidence interval 0.501 to
0.672; P < 0.0001). Based on these data, clinicians should be aware of the potential for harm due to
the excessive administration of IVFs to patients with septic shock.

Septic acute kidney injury

Septic acute kidney injury: molecular mechanisms and the importance of stratification and targeting therapy. Critical Care 2014, 18: 501.

Morrell, E.D., et al.


The most common cause of acute kidney injury (AKI) in hospitalized patients is sepsis. However, the molecular pathways and mechanisms that mediate septic AKI are not well defined. Experiments performed over the past 20 years suggest that there are profound differences in the pathogenesis between septic and ischemic AKI. Septic AKI often occurs independently of hypoperfusion, and is mediated by a concomitant pro- and anti-inflammatory state that is activated in response to various pathogen-associated molecular patterns, such as endotoxin, as well as damage-associated molecular patterns. These molecular patterns are recognized by Toll-like receptors (TLRs) found in the kidney, and effectuate downstream inflammatory pathways. Additionally, apoptosis has been proposed to play a role in the pathogenesis of septic AKI. However, targeted therapies designed to mitigate the above aspects of the inflammatory state, TLR-related pathways, and apoptosis have failed to show significant clinical benefit. This failure is likely due to the protean nature of septic AKI, whereby different patients present at different points along
the immunologic spectrum. While one patient may benefit from targeted therapy at one end of the spectrum,
another patient at the other end may be harmed by the same therapy. We propose that a next important step in septic AKI research will be to identify where patients lie on the immunologic spectrum in order to appropriately target therapies at the inflammatory cascade, TLRs, and possibly apoptosis.