Critical care : the official journal of the Critical Care Forum
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In 1982, the author attended a lecture by Professor Joseph Civetta dealing with the concept that, at times, the goal of care should be comfort rather than cure, and that inappropriate care prolonged dying and suffering. Efforts to improve end-of-life care subsequent to this had effects on care at a local level and at a state level. Intensive care providers should be leaders in the provision of appropriate and compassionate care at the end of life.
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Circulating inflammatory mediators spilling into the circulation from sites of active inflammation are considered the source of remote tissue injury and associated organ dysfunction in sepsis. Hemofiltration has been proposed as a therapy for sepsis based on its ability to remove circulating inflammatory mediators by sieving or by adsorption, or both. Designing devices and methods for sepsis therapy will require optimization of these two mechanisms. ⋯ It is important to recognize the limitations of conventional systems; Kellum and Dishart have extended our knowledge of hemofiltration filter adsorption, which is quite different from conventional hemoadsorption. If sepsis is a manifestation of a nonlinear dynamic control system out of control, then filtration at modest doses with a large pore filter may succeed as well as high-volume hemofiltration with a conventional cut-off filter. In the present paper, we will explore the strengths and the weaknesses of the 'Kellum and Dishart' study and discussing their findings in the light of the current available literature.
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Case Reports
Case report: Survival after deliberate strychnine self-poisoning, with toxicokinetic data.
Strychnine poisoning is uncommon, and in most severe cases, the patient dies before reaching hospital. The management of strychnine poisoning is well documented, although there are few data on the kinetics of elimination of strychnine after overdose. ⋯ Strychnine poisoning presents with classical features, and with early diagnosis and supportive management, the patient can survive. The initial serum concentration of 4.73 mg/l is the highest reported concentration in a patient who has survived. Previous reports of the elimination half-life have suggested it is between 10 and 16 hours, which conforms to the elimination data in our case.
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Dehydroepiandrosterone (DHEA) and its sulphate (DHEAS) are pleiotropic adrenal hormones with immunostimulating and antiglucocorticoid effects. The present study was conducted to evaluate the time course of DHEAS levels in critically ill patients and to study their association with the hypothalamic-pituitary-adrenal axis. ⋯ We identified extremely low DHEAS levels in septic shock and, to a lesser degree, in multiple trauma patients as compared with those of age- and sex-matched control patients. There appeared to be a dissociation between DHEAS (decreased) and cortisol (increased) levels, which changed only slightly over time. Nonsurvivors of sepsis and patients with relative adrenal insufficiency had the lowest DHEAS values, suggesting that DHEAS might be a prognostic marker and a sign of exhausted adrenal reserve in critical illness.