Critical care : the official journal of the Critical Care Forum
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Review Meta Analysis Comparative Study
Gastric versus post-pyloric feeding: a systematic review.
Our objective was to evaluate the impact of gastric versus post-pyloric feeding on the incidence of pneumonia, caloric intake, intensive care unit (ICU) length of stay (LOS), and mortality in critically ill and injured ICU patients. ⋯ In this meta-analysis we were unable to demonstrate a clinical benefit from post-pyloric versus gastric tube feeding in a mixed group of critically ill patients, including medical, neurosurgical, and trauma ICU patients. The incidences of pneumonia, ICU LOS, and mortality were similar between groups. Because of the delay in achieving post-pyloric intubation, gastric feeding was initiated significantly sooner than was post-pyloric feeding. The present study, while providing the best current evidence regarding routes of enteral nutrition, is limited by the small total sample size.
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Acute respiratory distress syndrome (ARDS) and acute lung injury are among the most frequent reasons for intensive care unit admission, accounting for approximately one-third of admissions. Mortality from ARDS has been estimated as high as 70% in some studies. Until recently, however, no targeted therapy had been found to improve patient outcome, including mortality. ⋯ These data confirm the long-held suspicion that the role of mechanical ventilation for acute hypoxemic respiratory failure is more than supportive, in that mechanical ventilation can also actively contribute to lung injury. The mechanisms of the protective effects of low tidal volume ventilation in conjunction with positive end expiratory pressure are incompletely understood and are the focus of ongoing studies. The objective of the present article is to review the potential cellular mechanisms of lung injury attributable to mechanical ventilation in patients with ARDS and acute lung injury.
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Optimal positive end-expiratory pressure (PEEP) is an important component of adequate mechanical ventilation in acute lung injury and acute respiratory distress syndrome (ARDS). In the present study we tested the effect on gastric intramucosal pH of incremental increases in PEEP level (i.e. PEEP titration) to improve oxygenation in ARDS. Seventeen consecutive patients with ARDS, as defined by consensus criteria, were included in this clinical, prospective study. All patients were haemodynamically stable, and were not receiving vasopressors. From an initial level of 5 cmH2O, PEEP was titrated at 2 cmH2O increments until the partial arterial oxygen tension was 300 mmHg or greater, peak airway pressure was 45 cmH2O or greater, or mean arterial blood pressure decreased by 20% or more of the baseline value. Optimal PEEP was defined as the level of PEEP that achieved the best oxygenation. The maximum PEEP was the highest PEEP level reached during titration in each patient. ⋯ Incremental titration of PEEP based on improvement in oxygenation does not decrease gastric intramucosal perfusion when cardiac output is preserved in patients with ARDS.
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Clinical Trial
The Bair Hugger patient warming system in prolonged vascular surgery: an infection risk?
Use of the Bair Hugger forced-air patient warming system during prolonged abdominal vascular surgery may lead to increased bacterial contamination of the surgical field by mobilization of the patient's skin flora. ⋯ The use of this warming system does not lead to increased bacterial contamination of the operating theatre atmosphere, and it is unlikely to affect the surgical field adversely.
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Fever is a common response to sepsis in critically ill patients. Fever occurs when either exogenous or endogenous pyrogens affect the synthesis of prostaglandin E2 in the pre-optic nucleus. Prostaglandin E2 slows the rate of firing of warm sensitive neurons and results in increased body temperature. ⋯ HSPs act as molecular chaperones, and new data suggest they may also have an anti-inflammatory role. HSPs and the heat shock response appear to inhibit the activation of NF-kappabeta, thus decreasing the levels of proinflammatory cytokines. The anti-inflammatory effects of HSPs, coupled with improved survival of animal models with fever and infection, call into question the routine practice of treating fever in critically ill patients.