Critical care : the official journal of the Critical Care Forum
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Corticosteroid treatment of severe sepsis has been one of the most controversial clinical issues in critical care. In fact, few agents can claim to have been evaluated in scores of studies spanning 3-4 decades. ⋯ Recently, interest has resurfaced but this time the focus is on a steroid replacement approach for what has now been termed "relative adrenal insufficiency" rather than relying on the pharmacologic effects of steroids. This route holds promise, but proof remains lacking.
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The Life Support for Trauma and Transport (LSTAT trade mark ) is a self-contained, stretcher-based miniature intensive care unit designed by the United States Army to provide care for critically injured patients during transport and in remote settings where resources are limited. The LSTAT contains conventional medical equipment that has been integrated into one platform and reduced in size to fit within the dimensional envelope of a North Atlantic Treaty Organization (NATO) stretcher. This study evaluated the clinical utility of the LSTAT in simulated and real clinical environments. Our hypothesis was that the LSTAT would be equivalent to conventional equipment in detecting and treating life-threatening problems. ⋯ Preliminary evaluation of the LSTAT in simulated and postoperative environments demonstrated that the LSTAT provided appropriate equipment to detect and manage critical events in patient care. Further work in assessing LSTAT functionality in a higher-acuity environment is warranted.
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The review by Oliveira and colleagues on the subject of hypertonic saline resuscitation in sepsis (included in the present issue) suggests possible benefits for hypertonic saline. There is a firm experimental basis for the actions of hypertonic saline/hyperoncotic solutions in hemorrhagic hypotension, which include expansion of blood volume, improvement in cardiac index, favorable modulation of the immune system, and improvement in survival. ⋯ The major impact of early administration of hypertonic solutions may be attenuation of tissue injury, sepsis, and septic shock. Early and aggressive fluid resuscitation with hypertonic solutions to clinical end-points should be investigated in patients with systemic inflammatory response syndrome, sepsis, and septic shock.
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The use of corticosteroids in septic shock remains controversial. It has been demonstrated that high doses of steroids (30 mg/kg methylprednisolone) for short periods of time are not beneficial. ⋯ These positive effects have included reversal of shock, trends toward decreased organ system dysfunction and decreased mortality. Based on the high proportion of patients who have relative adrenal insufficiency, the benefits of low doses of steroids and the minimal risks, steroids should be used to treat septic shock.
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Hypothermia as a protectant of neurologic function in the treatment of cardiac arrest patients, although not a new concept, is now supported by two recent randomized, prospective clinical trials. The basic science research in support of the effects of hypothermia at the cellular and animal levels is extensive. The process of cooling for cerebral protection holds potential promise for human resuscitation efforts in multiple realms. It appears that, at least, those patients who suffer a witnessed cardiac arrest with ventricular fibrillation and early restoration of spontaneous circulation, such as those who were included in the European and Australian trials (discussed here), should be considered for hypothermic therapy.