Current opinion in critical care
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Curr Opin Crit Care · Dec 2004
ReviewThe acute respiratory distress syndrome network controversy: lessons and legacy.
Several of the Acute Respiratory Disease Syndrome Network clinical trials embrace a clinical trial design that evaluates contrasting strategies, one or both of which represents only a segment of standard practices. Such a trial design has engendered ethical controversy regarding the value of such trials and their ability to protect human subjects. During the past year, commentators have continued to reflect on the significance of such trials. ⋯ The controversy related to and the impact of the Acute Respiratory Disease Syndrome Network clinical trial design on clinical practice offer an opportunity to explore the trade-offs between explanatory and pragmatic types of clinical trials. Such discussions will lead to a clearer understanding of the value of both types of clinical trials and the optimal ethical conduct of such trials.
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Despite advances in the care of the injured, the morbidity and mortality of traumatic hemorrhage remain a significant problem. Traumatologists continue to look for ways to treat bleeding and prevent the sequelae of hemorrhagic shock. Recombinant factor VIIa, developed for the treatment of patients with hemophilia, has been used with some success in acute bleeding associated with injuries. ⋯ Although case experience is encouraging, no level 1 evidence has been published that demonstrates clinical or economic benefit of the use of recombinant factor VIIa in trauma patients. Many questions remain to be answered, ideally through randomized, prospective clinical trials. In particular, the issues of patient selection, ideal dosing, and factors associated with futile administration need to be elucidated.
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Curr Opin Crit Care · Dec 2004
ReviewPatient care versus research: does clinical research provide individual benefit to patients enrolled in trials?
Historically, clinical research and patient care have long been intertwined. Until the mid-1970s, physicians in both North America and Europe considered that research on their patients was an integral part of the care that they delivered to them. In the United States, it was after the recommendations of the Belmont report, in 1979, that both medical activities were clearly separated. But, in Europe, the concept of "individual direct benefit from research" is still prevailing in some national legislation. ⋯ The European directive on clinical research, voted on in 2001 and still in the process of being implemented in national laws of the European Union Member States, mandates clarification of these issues. All European investigators are concerned because the framework of regulations governing clinical research will be markedly altered. The replacement of the distinction between research with and without direct benefit by the evaluation of the risk/benefit ratio by ethics committees is one of the most important changes that is due to happen soon.
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Curr Opin Crit Care · Dec 2004
ReviewLipids in the nutritional support of the critically ill patients.
This review reports recent findings on lipid use in artificial nutrition in patients with acute respiratory failure or severe sepsis or undergoing major surgery. It examines current knowledge of fatty acid safety, biologic effects, and the impact on patients' morbidity and mortality. The newly emerging area of genotypic influence and timing of immunonutrition is also discussed. ⋯ Overall, lipids, in particular n-3 fatty acids, emerge as powerful nutrients with pharmacologic properties potentially improving prognosis in critically ill patients. However, heterogeneity in study design makes the interpretation of available studies difficult. Consequently, larger prospective, randomized, double-blind trials with comparable methodologies are necessary for detailed evaluation of the pharmacologic impact of lipids. In addition, a better knowledge of the influence of genotypic variation and postinjury inflammatory/immune temporal patterns may improve our current therapeutic use of various fatty acids.
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The management of the traumatically injured patient has evolved during the past half century despite continually high morbidity and mortality rates. The management of the trauma victim requires timely intervention and damage control in an attempt to maintain normal hemodynamic parameters and adequate systemic perfusion. There is a fine balance between oxygen delivery and consumption, and when this is perturbed, oxygen debt may ensue. The presence of ongoing oxygen debt is rather deleterious, resulting in an inflammatory cascade that can lead to multisystem organ dysfunction. The rapid identification and restoration of oxygen debt are central to the resuscitation of the critically ill patient, be it the result of sepsis or trauma. ⋯ This review addresses (1) resuscitation end points to optimize cardiac function, (2) resuscitation end points to assess the microcirculation, (3) recent developments in the management of hypotensive hemorrhagic shock, and (4) the translation of early goal-directed therapy from septic shock to use in trauma. Past findings are reflected on and direction for future investigation and clinical practice based on recent clinical advances is provided.