Totem and taboo: fluids in sepsis. Critical Care 2011 15:164
Hilton, AK and Bellomo, R.
The need for early, rapid, and substantial fluid resuscitation in septic patients has long been an article of faith in the intensive care community, a tribal totem that is taboo to question. The results of a recent multicenter trial in septic children in Africa, published in The New England Journal of Medicine, powerfully challenge the fluid paradigm. The salient aspects of the trial need to be understood and reflected upon. In this commentary, we discuss the background to and findings of the trial and explain why they will likely trigger a re-evaluation of our thinking about fluids in sepsis, a re-evaluation that is already happening in the treatment of acute respiratory distress syndrome and acute kidney injury and in postoperative care.
Wednesday, 15 June 2011
Thursday, 10 March 2011
Utile or futile: Biomarkers in the ICU
Utile or futile: Biomarkers in the ICU. Critical Care 2011, 15:131
Balmelli, C., et al.
http://ccforum.com/content/15/2/131
Biomarkers complement other clinical information by proving quantitative information regarding a pathophysiological mechanism that can be used for the early diagnosis of a specific disease, to monitor and guide treatment, and to predict the risk of death or other adverse events.
Balmelli, C., et al.
http://ccforum.com/content/15/2/131
Biomarkers complement other clinical information by proving quantitative information regarding a pathophysiological mechanism that can be used for the early diagnosis of a specific disease, to monitor and guide treatment, and to predict the risk of death or other adverse events.
Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest
Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest. Critical Care 2011, 15:R90.
Bellomo, R., et al.
http://ccforum.com/content/15/2/R90
Hyperoxia has been recently reported as an independent risk factor for mortality in patients resuscitated from cardiac arrest. We examined the independent relationship between hyperoxia and outcome in such patients.
Bellomo, R., et al.
http://ccforum.com/content/15/2/R90
Hyperoxia has been recently reported as an independent risk factor for mortality in patients resuscitated from cardiac arrest. We examined the independent relationship between hyperoxia and outcome in such patients.
Activagted protein C in septic shock: a propensity-matched analysis
Activated protein C in septic shock: a propensity-matched analysis. Critical Care 2011, 15:R89
Sadaka, F., et al.
http://ccforum.com/content/15/2/R89
The use of human recombinant activated protein C (rhAPC) for the treatment of severe sepsis remains controversial despite multiple reported trials. The efficacy of rhAPC remains a matter of dispute. We hypothesized that patients with septic shock who were treated with rhAPC had an improved in-hospital mortality compared to patients with septic shock with similar acuity who did not receive rhAPC.
Sadaka, F., et al.
http://ccforum.com/content/15/2/R89
The use of human recombinant activated protein C (rhAPC) for the treatment of severe sepsis remains controversial despite multiple reported trials. The efficacy of rhAPC remains a matter of dispute. We hypothesized that patients with septic shock who were treated with rhAPC had an improved in-hospital mortality compared to patients with septic shock with similar acuity who did not receive rhAPC.
Tuesday, 8 March 2011
Quality of life after intensive care: A systematic review of the literature
Quality of life after intensive care: A systematic review of the literature. Critical Care Medicine, Vol 38(12), December 2010,p. 2386-2400.
Oeyen, S.G., et al.
http://journals.lww.com/ccmjournal/Abstract/2010/12000/Quality_of_life_after_intensive_care__A_systematic.18.aspx
Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.
Oeyen, S.G., et al.
http://journals.lww.com/ccmjournal/Abstract/2010/12000/Quality_of_life_after_intensive_care__A_systematic.18.aspx
Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.
Delirium duration and mortality in lightly sedated, mechanicaly ventilated intensive care patients
Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Critical Care Medicine, Vol 38(12), December 2010, p. 2311-2318.
Shehabi, Y., et al.
http://journals.lww.com/ccmjournal/Abstract/2010/12000/Delirium_duration_and_mortality_in_lightly.7.aspx
To determine the relationship between the number of delirium days experienced by intensive care patients and mortality, ventilation time, and intensive care unit stay.
Shehabi, Y., et al.
http://journals.lww.com/ccmjournal/Abstract/2010/12000/Delirium_duration_and_mortality_in_lightly.7.aspx
To determine the relationship between the number of delirium days experienced by intensive care patients and mortality, ventilation time, and intensive care unit stay.
Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality
Septic shock: A multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Critical Care Medicine, Vol 39(2),
February 2011, p. 252-258.
Schramm, G.E., et al.
http://journals.lww.com/ccmjournal/Abstract/2011/02000/Septic_shock__A_multidisciplinary_response_team.2.aspx
To evaluate the impact of weekly feedback to clinicians and the activation of a sepsis response team on the process of care and hospital mortality in patients with severe sepsis or septic shock.
February 2011, p. 252-258.
Schramm, G.E., et al.
http://journals.lww.com/ccmjournal/Abstract/2011/02000/Septic_shock__A_multidisciplinary_response_team.2.aspx
To evaluate the impact of weekly feedback to clinicians and the activation of a sepsis response team on the process of care and hospital mortality in patients with severe sepsis or septic shock.
Corticosteroid therapy for patients in septic shock: some progress in a difficult decision
Corticosteroid therapy for patients in septic shock: Some progress in a difficult decision. Critical Care Medicine Vol 39(3), March 2011, p. 571-574
Sprung, C.L., et al.
http://journals.lww.com/ccmjournal/Abstract/2011/03000/Corticosteroid_therapy_for_patients_in_septic.20.aspx
Reversible adrenal insufficiency has been frequently diagnosed in critically ill patients with sepsis who have either low basal cortisol levels or low cortisol responses to adrenocorticotrophic hormone (ACTH) stimulation. It is generally accepted that a phenomenon called “endotoxin tolerance” contributes to immunosuppression during sepsis. The present study was to investigate whether endotoxin tolerance occurs in the adrenal gland, leading to hyporesponsiveness of adrenal gland during sepsis.
Sprung, C.L., et al.
http://journals.lww.com/ccmjournal/Abstract/2011/03000/Corticosteroid_therapy_for_patients_in_septic.20.aspx
Reversible adrenal insufficiency has been frequently diagnosed in critically ill patients with sepsis who have either low basal cortisol levels or low cortisol responses to adrenocorticotrophic hormone (ACTH) stimulation. It is generally accepted that a phenomenon called “endotoxin tolerance” contributes to immunosuppression during sepsis. The present study was to investigate whether endotoxin tolerance occurs in the adrenal gland, leading to hyporesponsiveness of adrenal gland during sepsis.
Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock
Effect of transcutaneous electrical muscle stimulation on muscle volume in patients with septic shock. Critical Care Medicine Vol 39(3), March 2011, p.456-461
Poulsen, J.B., et al.
http://journals.lww.com/ccmjournal/Abstract/2011/03000/Effect_of_transcutaneous_electrical_muscle.5.aspx
Intensive care unit admission is associated with muscle wasting and impaired physical function. We investigated the effect of early transcutaneous electrical muscle stimulation on quadriceps muscle volume in patients with septic shock.
Poulsen, J.B., et al.
http://journals.lww.com/ccmjournal/Abstract/2011/03000/Effect_of_transcutaneous_electrical_muscle.5.aspx
Intensive care unit admission is associated with muscle wasting and impaired physical function. We investigated the effect of early transcutaneous electrical muscle stimulation on quadriceps muscle volume in patients with septic shock.
How did you sleep in the ICU?
How did you sleep in the ICU? Critical Care 2011, 15:408.
Franck, L., et al.
http://ccforum.com/content/15/2/408
Patient sleep is extremely disturbed in the intensive care unit. We explored the memorization of sleep disturbances during a phone interview of 60 patients using the Basic Nordic Sleep Questionnaire. Half of them reminded sleep deprivation and one third of them had a decreased long term quality of sleep. Protocols to improve sleep quality are necessary
Franck, L., et al.
http://ccforum.com/content/15/2/408
Patient sleep is extremely disturbed in the intensive care unit. We explored the memorization of sleep disturbances during a phone interview of 60 patients using the Basic Nordic Sleep Questionnaire. Half of them reminded sleep deprivation and one third of them had a decreased long term quality of sleep. Protocols to improve sleep quality are necessary
Inspiratory muscle strength training improves weanting outcome in failure to wean patients: a randomized trial
Inspiratory muscle strength training improves weaning outcome in failure to
wean patients: a randomized trial. Critical Care 2011, Vol 15(2):R84
Martin, A.D., et al.
http://ccforum.com/content/15/2/R84
Most patients are readily liberated from mechanical ventilation (MV) support, however, 10% - 15% of patients experience failure to wean (FTW). FTW patients account for approximately 40% of all MV days and have significantly worse clinical outcomes. MV induced inspiratory muscle weakness has been implicated as a contributor to FTW and recent work has documented inspiratory muscle weakness in humans supported with MV.
wean patients: a randomized trial. Critical Care 2011, Vol 15(2):R84
Martin, A.D., et al.
http://ccforum.com/content/15/2/R84
Most patients are readily liberated from mechanical ventilation (MV) support, however, 10% - 15% of patients experience failure to wean (FTW). FTW patients account for approximately 40% of all MV days and have significantly worse clinical outcomes. MV induced inspiratory muscle weakness has been implicated as a contributor to FTW and recent work has documented inspiratory muscle weakness in humans supported with MV.
Thursday, 3 March 2011
Delirium in the ICU: time to probe the hard questions
Delirium in the ICU: time to probe the hard questions. Critical Care 2011 15:118
Stevens, R.D., et al.
Prevalent in critically ill patients, delirium remains poorly understood and difficult to treat. In a cross-sectional study conducted in 12 countries, delirium was identified in close to one third of patients and was independently associated with increased mortality. While such epidemiological accounts represent an important cornerstone for research, scientific efforts are needed to elucidate the causes of delirium and the mechanisms underlying its association with poor outcomes.
Stevens, R.D., et al.
Prevalent in critically ill patients, delirium remains poorly understood and difficult to treat. In a cross-sectional study conducted in 12 countries, delirium was identified in close to one third of patients and was independently associated with increased mortality. While such epidemiological accounts represent an important cornerstone for research, scientific efforts are needed to elucidate the causes of delirium and the mechanisms underlying its association with poor outcomes.
Sizing the lung of mechanically ventilated patients
Sizing the lung of mechanically ventilated patients. Critical Care 2011, 15:R60
Mattingley, J.S., et al
http://ccforum.com/content/15/1/R60
This small observational study was motivated by our belief that scaling the tidal volume in mechanically ventilated patients to the size of the injured lung is safer and more "physiologic" than scaling it to predicted body weight, i.e. its size before it was injured. We defined Total Lung Capacity (TLC) as the thoracic gas volume at an airway pressure of 40 cm H2O and tested if TLC could be inferred from the volume of gas that enters the lungs during a brief "recruitment" maneuver.
Mattingley, J.S., et al
http://ccforum.com/content/15/1/R60
This small observational study was motivated by our belief that scaling the tidal volume in mechanically ventilated patients to the size of the injured lung is safer and more "physiologic" than scaling it to predicted body weight, i.e. its size before it was injured. We defined Total Lung Capacity (TLC) as the thoracic gas volume at an airway pressure of 40 cm H2O and tested if TLC could be inferred from the volume of gas that enters the lungs during a brief "recruitment" maneuver.
Blood purification for sepsis
Blood purification for sepsis. Critical Care 2011 15:205.
Kellum, J.
Sepsis is the primary cause of death in the intensive care unit. Extracorporeal blood purification therapies have been proposed for patients with sepsis in order to improve outcomes since these therapies can alter the host inflammatory response by non-selective removal of inflammatory mediators and/or bacterial products. Recent technological progress has increased the number of techniques available for blood purification and their performance.In this overview, we report on the latest advances in blood purification for sepsis, how they relate to current concepts of disease, and we review the current evidence for high-volume hemofiltration, cascade hemofiltration, hemoadsorption, coupled plasma filtration adsorption, high-adsorption hemofiltration and high cut-off hemofiltration/hemodialysis. Promising results have been reported with all these blood purification therapies showing that they are well tolerated, effective in clearing inflammatory mediators and/or bacterial toxins from the plasma and efficacious for improvement various physiologic outcomes (e.g. hemodynamics, oxygenation). However, numerous questions remain unanswered including the timing, duration and frequency of these therapies in the clinical setting. Large multicenter trials evaluating the ability of these therapies to improve clinical outcomes (i.e. mortality or organ failure), rather than surrogate markers such as plasma mediator clearance or transient improvement in physiologic variables, are required to define the precise role of blood purification in the management of sepsis.
Kellum, J.
Sepsis is the primary cause of death in the intensive care unit. Extracorporeal blood purification therapies have been proposed for patients with sepsis in order to improve outcomes since these therapies can alter the host inflammatory response by non-selective removal of inflammatory mediators and/or bacterial products. Recent technological progress has increased the number of techniques available for blood purification and their performance.In this overview, we report on the latest advances in blood purification for sepsis, how they relate to current concepts of disease, and we review the current evidence for high-volume hemofiltration, cascade hemofiltration, hemoadsorption, coupled plasma filtration adsorption, high-adsorption hemofiltration and high cut-off hemofiltration/hemodialysis. Promising results have been reported with all these blood purification therapies showing that they are well tolerated, effective in clearing inflammatory mediators and/or bacterial toxins from the plasma and efficacious for improvement various physiologic outcomes (e.g. hemodynamics, oxygenation). However, numerous questions remain unanswered including the timing, duration and frequency of these therapies in the clinical setting. Large multicenter trials evaluating the ability of these therapies to improve clinical outcomes (i.e. mortality or organ failure), rather than surrogate markers such as plasma mediator clearance or transient improvement in physiologic variables, are required to define the precise role of blood purification in the management of sepsis.
Immunity, inflammation and sepsis: new insights and persistent questions
Immunity, inflammation and sepsis: new insights and persistent questions.
Critical Care 2011 15:124
Frazier, W.J.
Sepsis is now understood to affect a variety of changes in the host, chief among them being alterations in immune system function. Proper immune function involves a competent proinflammatory response to stimuli as well as a regulated counteracting force to restore homeostasis and prevent systemic inflammation and organ dysfunction. Broad-spectrum suppression of the inflammatory response has not been shown to be beneficial to patients suffering from septic disease. In fact, sepsis-related immune suppression has become increasingly recognized as an important contributor to late morbidity and mortality in the critically ill. Giamarellos-Bourboulis and colleagues detail the impaired ability of septic patients to produce proinflammatory cytokines upon ex-vivo stimulation, and introduce altered caspase-1activity as potentially contributory to this process. Proper understanding of the cellular and molecular events resulting in immune suppression following sepsis are important in the identification of new strategies for treatment and the ideal timing of therapy.
Critical Care 2011 15:124
Frazier, W.J.
Sepsis is now understood to affect a variety of changes in the host, chief among them being alterations in immune system function. Proper immune function involves a competent proinflammatory response to stimuli as well as a regulated counteracting force to restore homeostasis and prevent systemic inflammation and organ dysfunction. Broad-spectrum suppression of the inflammatory response has not been shown to be beneficial to patients suffering from septic disease. In fact, sepsis-related immune suppression has become increasingly recognized as an important contributor to late morbidity and mortality in the critically ill. Giamarellos-Bourboulis and colleagues detail the impaired ability of septic patients to produce proinflammatory cytokines upon ex-vivo stimulation, and introduce altered caspase-1activity as potentially contributory to this process. Proper understanding of the cellular and molecular events resulting in immune suppression following sepsis are important in the identification of new strategies for treatment and the ideal timing of therapy.
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