American journal of surgery
-
A number of management issues confront the clinician treating a critically ill patient with drotrecogin alfa (activated) (Xigris; Eli Lilly and Company, Indianapolis, IN), a compound documented to significantly reduce the risk of 28-day all-cause mortality in patients with severe sepsis. The management issues that will be discussed include differentiating drug effect from the hemostatic changes of sepsis, prevention and management of bleeding during drotrecogin alfa (activated) infusion, treatment considerations in the patient with thrombocytopenia or disseminated intravascular coagulation, thromboprophylaxis in drug-treated patients, and the use of drotrecogin alfa (activated) in patients requiring renal replacement therapy. Proper adherence to principles described in this article can facilitate patient management and reduce the risk of bleeding.
-
The integrity of the hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress. Relative adrenal insufficiency has been implicated in poor outcome from systemic inflammatory states; however, whether low endogenous glucocorticoid levels are adaptive or pathologic remains controversial. The purpose of this study was to prospectively evaluate the cortisol response and determine the incidence of occult adrenal insufficiency after severe trauma. ⋯ Serum cortisol levels increased immediately and gradually returned towards normal after severe trauma. Occult adrenal insufficiency was common (60%) in this small group of severely injured patients. This did not, however, affect mortality in these patients. Further study is needed to delineate the role of occult adrenal insufficiency after severe injury.
-
Critically ill patients encounter many obstacles, such as acute renal failure, that increases length of stay as well as hospital cost. Dialysis in these patients is often ineffective thereby prolonging the inevitable and significantly increasing the cost of care. A dialysis program that could improve patient care, potentially improve outcome and be "revenue neutral" would be ideal. ⋯ An in-house CRRT program improved patient care by providing dialysis in patients who normally would not tolerate the procedure. Although there was a loss of revenue, CRRT in the burn patients appeared "revenue neutral." Although not specifically studied in this review, based on published data, mortality rates in this population were lower than expected especially in critically ill burn patients.