Journal of critical care
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Journal of critical care · Oct 2016
ReviewFluid management in sepsis: The potential beneficial effects of albumin.
Fluid administration is a key intervention in hemodynamic resuscitation. Timely expansion (or restoration) of plasma volume may prevent tissue hypoxia and help to preserve organ function. In septic shock in particular, delaying fluid resuscitation may be associated with mitochondrial dysfunction and may promote inflammation. ⋯ Fluid resuscitation with human albumin is less likely to cause nephrotoxicity than with artificial colloids, and albumin infusion has the potential to preserve renal function in critically ill patients. These properties may be of clinical relevance in circulatory shock, capillary leak, liver cirrhosis, and de-escalation after volume resuscitation. Sepsis is a candidate condition in which human albumin infusion to preserve renal function should be substantiated.
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Viewing the intensive care unit (ICU) as a control system with inputs (patients) and outputs (outcomes), we focus on actuation (therapies) of the system and how to enhance our understanding of status of patients and their trajectory in the ICU. To incorporate the results of these analytics meaningfully, we feel that a reassessment of predictive scoring systems and of ways to optimally characterize and display the patient's "state space" to clinicians is important. Advances in sensing (diagnostics) and computation have not yet led to significantly better actuation, and so we focus on ways that data can be used to improve actuation in the ICU, in particular by following therapeutic burden along with disease severity. This article is meant to encourage discussion about how the critical care community can best deal with the data they see each day, and prepare for recommendations that will inevitably arise from application of major federal and state initiatives in big data analytics and precision medicine.
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Journal of critical care · Oct 2016
ReviewAcetate-buffered crystalloid fluids: Current knowledge, a systematic review.
The concept of fluid resuscitation with balanced solutions containing acetate is relatively new. The knowledge about acetate mostly originates from nephrological research, as acetate was primarily used as a dialysis buffer where much higher doses of acetate are infused. The aim of this review is to give an overview of the advantages and disadvantages of an acetate-buffered crystalloid fluid when compared with other crystalloid infusates. ⋯ Acetate-buffered crystalloid solutes do have a favorable influence on microcirculation. To what extent the acetate-buffered crystalloids influence kidney function is controversially discussed and not yet clear. Metabolic alkalosis did not occur in a single study in humans after an acetate-buffered infusate; potassium levels stayed stable in all studies. Cardiac output and contractility seem to be positively influenced; nonetheless, data on maintenance of a target blood pressure remain inconclusive. Whether acetate-buffered crystalloid fluids lead to lower rates of acute kidney injury and increased survival when compared with normal saline is yet unclear and may depend on the amount of fluid administered.
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Journal of critical care · Oct 2016
Multicenter StudyEffects of propofol on vasopressor use in patients with sepsis and severe sepsis: A pilot study.
Propofol is one of the most commonly used sedatives in the intensive care unit (ICU) despite its undesirable hypotensive effects. The purpose of this study was to determine the effects of continuous intravenous (CIV) propofol on vasopressor requirements in mechanically ventilated patients with sepsis. ⋯ Continuous intravenous propofol for sedation did not increase vasopressor requirements in this septic population. Furthermore, CIV propofol was not associated with significant differences in the use of multiple vasopressors, change in mean arterial pressure, length of stay, or mortality.
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Journal of critical care · Oct 2016
ReviewHow is life support withdrawn in intensive care units: A narrative review.
Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS. ⋯ This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.