Critical care medicine
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Critical care medicine · Mar 2003
ReviewCritical care research on patients with advance directives or do-not-resuscitate status: ethical challenges for clinician-investigators.
Clinician-investigators face challenges in conducting research on critically ill patients when they have do-not-resuscitate orders, advance directives, or are in need of end-of-life care. Potential conflicts of interest for clinician-investigators include either financial stakes or academic and reputational stakes. The dual roles for intensive care unit physician or nurse clinician-investigators as healthcare professionals and scientists also present conflicts of interest, as does the dual purpose for the physical plant of the intensive care unit, which simultaneously serves as a site for patient care and a site for clinical research. ⋯ There are four values in tension for critical care clinician-investigators in relation to patients/human research subjects: curative intent, palliative intent, research, and fiduciary obligations. A patient's decision to participate in research does not relieve clinician-investigators of their obligation to serve patient/human research subject's interests, even when doing so involves decisions to limit or withdraw life-sustaining interventions or withdraw the patient/human research subject from research. Critical care research involving patients with advance directives or do-not-resuscitate status is both possible and desirable because it is just, respects patient autonomy, and results in study populations that better reflect the clinical population in all respects.
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Critical care medicine · Mar 2003
Comparative StudyRight atrial pressure as a measure of ventricular constraint arising from positive end-expiratory pressure during mechanical ventilation of the neonatal lamb.
By constraining the heart, the chest wall, lungs, and pericardium limit diastolic filling and thus have a major role in determining cardiac output. Although intermittent positive pressure ventilation and the application of positive end-expiratory pressure amplifies this constraint, no clinical method exists to assess the impact that positive end-expiratory pressure has on ventricular constraint in the newborn. In this study, we tested the hypothesis that a change in right atrial pressure (Pra) reflects the change in ventricular constraint associated with a change in airway pressure. ⋯ Our experiments demonstrate that, in the newborn and neonatal lamb, DeltaPra provides an accurate measure of the change in ventricular constraint that accompanies a change in airway pressure, and thus may provide a means of quantifying the magnitude of ventricular constraint imposed by positive end-expiratory pressure and mechanical ventilation during neonatal intensive care.
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Critical care medicine · Mar 2003
Bronchoalveolar interleukin-1 beta: a marker of bacterial burden in mechanically ventilated patients with community-acquired pneumonia.
To assess the relationship between concentrations of bronchoalveolar cytokines and bacterial burden (quantitative bacterial count) in intubated patients with a presumptive diagnosis of community-acquired pneumonia. ⋯ The common pathogens were similar to the core pathogens of hospital-acquired pneumonia, probably due to antibiotic effects, delayed sampling, and superimposed nosocomial infection. Since the concentration of bronchoalveolar lavage interleukin-1 beta was correlated with bacterial burden in the alveoli, it may be a marker for progressive and ongoing inflammation in patients who have not responded to pneumonia therapy and who have persistence of bacteria in the lung.
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Critical care medicine · Mar 2003
Randomized Controlled Trial Multicenter Study Clinical TrialEffects of drotrecogin alfa (activated) on organ dysfunction in the PROWESS trial.
To assess morbidity in patients with severe sepsis managed with and without drotrecogin alfa (activated). ⋯ Drotrecogin alfa (activated) demonstrated significant improvements in organ function compared with placebo in a large phase 3 clinical trial that has shown a mortality benefit in patients with severe sepsis.