Critical care medicine
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Critical care medicine · Dec 2008
ReviewPropagation prevention: a complementary mechanism for "lung protective" ventilation in acute respiratory distress syndrome.
To describe the clinical implications of an often neglected mechanism through which localized acute lung injury may be propagated and intensified. ⋯ The diffuse injury that characterizes acute respiratory distress syndrome is often considered a process that begins synchronously throughout the lung, mediated by inhaled or blood-borne noxious agents. Relatively little attention has been paid to possibility that inflammatory lung injury may also begin focally and propagate sequentially via the airway network, proceeding mouth-ward from distal to proximal. Were this true, modifications of ventilatory pattern and position aimed at geographic containment of the injury process could help prevent its generalization and limit disease severity. The purposes of this communication are to call attention to this seldom considered mechanism for extending lung injury that might further justify implementation of low tidal volume/high positive end-expiratory pressure ventilatory strategies for lung protection and to suggest additional therapeutic measures implied by this broadened conceptual paradigm.
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Critical care medicine · Dec 2008
Randomized Controlled Trial Comparative StudyIntensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients.
The role of intensive insulin therapy in medical surgical intensive care patients remains unclear. The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients. ⋯ Intensive insulin therapy was not associated with improved survival among medical surgical intensive care unit patients and was associated with increased occurrence of hypoglycemia. Based on these results, we do not advocate universal application of intensive insulin therapy in intensive care unit patients.
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Critical care medicine · Dec 2008
Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality.
This study investigates the possibility of a relationship between oversedation and mortality in mechanically ventilated patients. The presence of burst suppression, a pattern of severely decreased brain wave activity on the electroencephalogram, may be unintentionally induced by heavy doses of sedatives. Burst suppression has never been studied as a potential risk factor for death in patients without a known neurologic disorder or injury. ⋯ The presence of burst suppression, which was unexpectedly high in this medical intensive care unit population, was an independent predictor of increased risk of death at 6 months. This association should be studied prospectively on a larger scale in mechanically ventilated, critically ill patients.
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Critical care medicine · Dec 2008
Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study.
To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer. ⋯ Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.
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Critical care medicine · Dec 2008
Angiotensin converting enzyme insertion/deletion genetic polymorphism: its impact on renal function in critically ill patients.
Previous clinical studies have suggested an association between the insertion/deletion (I/D) genetic polymorphism of angiotensin converting enzyme and acute or chronic diseases. We aimed to test the prognostic value of the I-allele, which is associated with lower angiotensin converting enzyme activity, on acute kidney injury. ⋯ These data confirm the key role of the renin-angiotensin system to maintain glomerular filtration rate, and highlight an association between a genetic factor and susceptibility to and prognosis of acute kidney disease.