Current opinion in critical care
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The sympathetic-parasympathetic balance may be altered in critically ill patients. Assessment of autonomic function provides information concerning prognosis, pathogenesis, and treatment strategies in ICU-relevant disorders. Proven tools are heart rate variability, baroreflex sensitivity, and, with limitations, cardiac chemoreflex sensitivity. ⋯ In addition, a model is introduced for investigating the impaired autonomic function in multiple organ dysfunction syndrome and sepsis, integrating extrinsic mechanisms and factors that are intrinsic to the cardiac tissue. By this combined approach, the authors hope to gain insight into the pathogenesis of multiple organ dysfunction syndrome. New pathophysiologic concepts are needed for the development of treatment strategies for this life-threatening disease.
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Curr Opin Crit Care · Oct 2001
ReviewClinical impact of novel anticoagulation strategies in sepsis.
Derangements in coagulation and fibrinolysis are frequent complications of systemic infection, and septic shock is the most common recognized cause of disseminated intravascular coagulation. Anticoagulant therapy has been used as a treatment strategy for severe sepsis for several decades without compelling evidence of efficacy until the 2001 publication of the phase III trial with recombinant human activated protein C. ⋯ The molecular mechanisms by which the clotting system interacts with the innate immune response have greatly facilitated the understanding of coagulation and the pathophysiology of septic shock. Anticoagulants such as recombinant human activated protein C and related agents may become the mainstay of adjuvant therapies for severe sepsis in the near future.
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Bone marrow transplantation and stem cell transplantation have become standard therapies offering potential cures for a number of hematologic malignancies and immunologic disorders. Severe infection remains a life threatening complication after transplantation, contributes significantly to morbidity, and may necessitate admission to the ICU. It is estimated that between 20 and 40% of patients receiving bone marrow transplant will require ICU admission in the initial posttransplantation phase. ⋯ Moreover, risk factors identifying patients who will benefit most from intensive support are poorly defined. However, it is generally accepted that respiratory failure requiring invasive mechanical ventilation is associated with a poor prognosis in this patient group. Early involvement of intensivists in the management of critical illness in transplant recipients is likely to continue to improve survival in this group of patients.