Journal of intensive care medicine
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J Intensive Care Med · Jan 2011
Randomized Controlled TrialCURB-65, PSI, and APACHE II to assess mortality risk in patients with severe sepsis and community acquired pneumonia in PROWESS.
Patients with community-acquired pneumonia (CAP) comprised 35.6% of the overall phase 3 Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study and 33.1% of the placebo arm. We investigated the use of CURB-65, the Pneumonia Severity Index (PSI), and Acute Physiology and Chronic Health Evaluation II (APACHE II) prediction scores to identify the CAP population from the PROWESS placebo arm at the greatest mortality risk. ⋯ Despite early diagnosis and appropriate antibiotic therapy, conventionally treated CAP with PSI = 5, CURB-65 3, or APACHE II 25 has an unacceptably high mortality. In this study, PSI, CURB-65, and APACHE II scoring systems perform similarly in predicting the 28-day and in-hospital mortality; however, differences in the categorization of severe CAP were observed and there was a significant mortality in patients with a CURB-65 <3 and PSI <5.
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J Intensive Care Med · Jan 2011
ReviewA review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients.
Extracorporeal membrane oxygenation (ECMO) comprises a commonly used method of extracorporeal life support. It has proven efficacy and is an accepted modality of care for isolated respiratory or cardiopulmonary failure in neonatal and pediatric populations. ⋯ As such, all intensivists should be familiar with the evidence-base and principles of ECMO in adult population. The purpose of this article is to review the evidence and to describe the fundamental steps in initiating, adjusting, troubleshooting, and terminating ECMO so as to familiarize the intensivist with this modality.
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J Intensive Care Med · Nov 2010
Antimicrobial treatment and clinical outcomes of carbapenem-resistant Acinetobacter baumannii ventilator-associated pneumonia.
Carbapenem-resistant (CR) Acinetobacter baumannii is an important pathogen in ventilator-associated pneumonia (VAP), but therapeutic options are limited. We describe the clinical outcomes of the largest case series of CR-Acinetobacter VAP reported to date. ⋯ Our results demonstrated that CR-Acinetobacter VAP can be effectively treated with second-line agents. However, colistin-related nephrotoxicity was much higher than recently reported and decreased susceptibility to tigecycline emerged on therapy demonstrating the limitations of alternative regimens.
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Antibacterial resistance is increasing throughout the world, while the development of new agents is slowly progressing. In addition, the increasing prevalence of fluoroquinolone resistance may force many practitioners to choose an aminoglycoside agent in gram-negative regimens. ⋯ Clinical application includes the treatment of bacteremia, endocarditis, health-care and nosocomial pneumonias, intra-abdominal infections, and others. Nephrotoxicity and ototoxicity are potential risks of aminoglycoside therapy that may be minimized with serum monitoring and short courses of therapy.
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J Intensive Care Med · Nov 2010
Preliminary experience with clevidipine in the pediatric population.
Clevidipine is a third-generation calcium channel antagonist of the dihydropyridine group. Like nicardipine, its primary physiologic effect is vasodilation, primarily of the arterial system with limited effects on capacitance vessels. Unlike other direct-acting vasodilators, it has an ultrashort half-life due to its metabolism by nonspecific blood and tissue esterases. ⋯ The clevidipine infusion was started at 0.5 to 1 μg/kg per minute and titrated up to 3.5 μg/kg per minute as needed. No excessive hypotension was noted; however, intermittent doses of metoprolol were required to control reflex tachycardia in 2 of the 10 patients and an elevated triglyceride level was noted in 1 patient. Our preliminary experience demonstrates the efficacy of clevidipine for blood pressure control during the perioperative period.