Current opinion in critical care
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Curr Opin Crit Care · Oct 2005
ReviewNutrition and infection in the intensive care unit: what does the evidence show?
Nutrition support when applied appropriately, can improve clinical outcomes, particularly the incidence of infections. The Canadian Clinical Practice Guidelines for Nutrition Support, published in October 2003, summarized the evidence on nutrition support in the critically ill patient and provided recommendations aimed at maximizing the benefits of nutrition support while minimizing the risks. The purpose of this review is to highlight recent advances in nutrition research in critically ill adult patients, particularly with respect to minimizing infection. The newly published data will be used to update the Canadian Clinical Practice Guidelines. ⋯ This review provides insights into the results of recent randomized trials on nutrition support in critically ill patients. The Canadian Clinical Practice Guidelines for nutrition support help intensive care unit clinicians to keep abreast of emerging evidence and the impact of nutrition support practices on outcomes such as infections.
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Curr Opin Crit Care · Oct 2005
ReviewThe applications of B-type natriuretic peptide measurement in the intensive care unit.
Plasma B-type natriuretic peptide levels are used to screen for cardiac dysfunction in the emergency department and outpatient population. However, in the critically ill patient elevated plasma B-type natriuretic peptide levels do not necessarily reflect just ventricular dysfunction, as there are important confounding factors to consider. This review summarizes the recent advances in the application of B-type natriuretic peptide measurement in the intensive care unit. ⋯ B-Type natriuretic peptide is potentially a very useful diagnostic tool in the intensive care unit. To date there have been few studies and the results are often contradictory, mainly due to the special setting of the intensive care unit, which is constantly exposed to hemodynamically unstable patients, different case mixes as well as vigorous treatments. All of these are potential confounders to B-type natriuretic peptide levels and make interpretations of B-type natriuretic peptide difficult. We need more research on these confounding factors to accentuate the positive value of B-type natriuretic peptide in the intensive care unit.
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There is considerable evidence that dysregulation of the coagulation and fibrinolytic systems plays a major role in the pathophysiology of severe sepsis, with a special focus on the protein C system. Conversely, there is an approval for use of recombinant human activated protein C in the more severe patients. This review highlights recent findings about the biology of the protein C system and of other important coagulation components such as tissue factor, platelets, and protein S, with an effort to link fundamental data and recent clinical findings. ⋯ The comprehension of the protein C pathway is undoubtedly progressing both in experimental and clinical settings. In parallel, some promising other coagulant pathways are also under investigation in the sepsis context, with a hope for major clinical implications in the future.
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Curr Opin Crit Care · Oct 2005
ReviewGlucocorticoids in the treatment of severe sepsis and septic shock.
Septic shock remains one of the leading causes of death in intensive care units. In recent years, there is general use of low to moderate doses of corticosteroids in the treatment of septic shock. However, there are wide variations in the practical modality of this treatment, mainly with regard to patients' selection, treatment's dose, timing, route of administration, duration, and weaning. This review provides opinion-based guidelines for the use of corticosteroids in severe sepsis and septic shock. ⋯ In septic shock, intravenous hydrocortisone should be started immediately after a 250 microg corticotropin test, at a dose of 200-300 mg per day. When adrenal insufficiency is confirmed, treatment should be continued at full doses for 7 days. Otherwise, hydrocortisone should be stopped. It is worth considering adding enteral fludrocortisone at a dose of 50 microg per day for 7 days. In severe sepsis, despite growing evidence to support the use of a moderate dose of corticosteroids, the efficacy and safety of this treatment needs to be assessed in a large-scale study.
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Recent studies have provided a better understanding of the molecular mechanisms responsible for hemolytic uremic syndromes. In this review, we summarize biochemical and genetic data that may lead to new clinical approaches. ⋯ Shiga-like toxin-1 and Shiga-like toxin-2 regulate genes that encode for chemokines, cytokines, cell adhesion molecules, and transcription factors involved in immune response and apoptosis. Mutations in factor H, membrane cofactor protein and factor I have recently been identified. Reduced expression of compliment regulators might prevent restriction of complement deposition on glomerular endothelial cells, leading to microvascular cell damage and tissue injury. Shiga-like toxin hemolytic uremic syndrome in children has a favorable prognosis in 90% of cases; kidney transplantation shows a good graft survival rate (80%) in children who progress to end stage renal disease. As for non-Shiga-like toxin hemolytic uremic syndrome, treatment with plasma infusion or exchange has been used with controversial effects. Kidney transplantation is not recommended in those patients with mutations in factor H and factor I; however, a kidney transplant corrects membrane cofactor protein dysfunction. These findings vividly underscore the clinical heterogeneity of outcomes depending upon the nature of the underlying cause of the disease.