Current opinion in critical care
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Curr Opin Crit Care · Oct 2019
ReviewIntravenous immunoglobulin for adjunctive treatment of severe infections in ICUs.
This review focuses on the emerging literature regarding the use of intravenous immunoglobulins (IVIg) in critically ill patients with severe infections. The aim is to provide an accessible summary of the most recent evidence of IVIg use in sepsis and septic shock and to help clinicians to understand why there is still equipoise regarding the potential benefit of this adjunctive therapy in this setting. ⋯ Insufficient evidence is available to support IVIg use in sepsis and septic shock, apart from the specific case of streptococcal toxic shock syndrome. Current literature suggests that IVIg efficacy in sepsis or septic shock could depend on the IVIg preparation (IgM-enriched or minimal IgM), time of administration (<24 h), dose, and the inflammatory/immunomodulation profile of the patients. Investigator-initiated research, incorporating these parameters, is warranted to determine whether IVIg benefits critically ill patients with severe infection.
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In this review, we focus on the dual face of antibiotic therapy in the critically ill that must harmonize the need for early, appropriate and adequate antibiotic therapy in the individual-infected patient with the obligation to limit antibiotic selection pressure as much as possible to preserve its future potential. ⋯ Reconciling antibiotic efficacy with the limitations of their use is feasible but requires a dedicated and sustained effort throughout the whole process of clinical decision-making, from initial suspicion of sepsis to its definitive treatment.
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Curr Opin Crit Care · Oct 2019
ReviewDefining standard of practice: pros and cons of the usual care arm.
The aim of this review is to describe the use of usual care arms in randomized trials. ⋯ Usual care control arms may enhance generalizability while introducing significant limitations. Potential solutions include the use of pretrial surveys to evaluate the extent to which a protocolized control arm reflects the current standard of care and the implementation of adaptive trials.
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Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity. ⋯ The present review summarizes current knowledge on pathogenesis and clinical manifestations of severe influenza. Immunological dysfunction during viral infection correlates with severity and mortality among ICU patients. A theranostics strategy should be implemented to improve outcomes.
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Curr Opin Crit Care · Oct 2019
ReviewPopulation enrichment for critical care trials: phenotypes and differential outcomes.
Sepsis and acute respiratory distress syndrome (ARDS) are two heterogenous acute illnesses where numerous RCTs have indeterminate results. We present a narrative review on the recent developments in enriching patient populations for future sepsis and ARDS trials. ⋯ Enrichment reduces heterogeneity and will enhance the sensitivity of future trials. However, enrichment, even when it identifies more homogenous populations, may not be efficient to deploy in trials or clinical practice.