Critical care : the official journal of the Critical Care Forum
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Randomized Controlled Trial
Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445].
Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery. ⋯ Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission.
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Comment Comparative Study
Prediction of ventilation weaning outcome: children are not little adults.
Prediction of ventilation weaning outcome in children is important, as unsuccessful extubation increases both morbidity and mortality. Adult weaning criteria are poor predictors of weaning outcome in children for several possible reasons: the length of mechanical ventilation is generally much shorter, and the weaning failure rate is lower in children (thus larger patient numbers are required); integrated weaning indices, such as the rapid shallow breathing index, do not account for normal developmental changes in respiratory function; and the heterogeneity of mechanically ventilated children is greater than in adults. The challenge remains to find universal weaning outcome predictors in children.
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Severe sepsis is more and more frequent, especially because of an increased rate of immunocompromised patients. Despite the improvement in the overall prognosis of HIV/AIDS patients and the improvement of global ICU care, the prognosis of HIV/ADS patients hospitalized in ICU with severe sepsis remained poor. ⋯ However, medical literature suggests that ICU prognosis of immunocompromised (especially cancer) patients should be largely improved by early ICU admission and by an early institution of supportive techniques. This strategy should be used in HIV/AIDS patients with severe sepsis.
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The Surviving Sepsis Campaign (SSC) is an international effort to reduce mortality in severe sepsis and septic shock. The campaign included the creation of evidence-based guidelines sponsored and endorsed by 11 international organizations. ⋯ In this issue of Critical Care, Gao et al. have evaluated performance at their institution by using a close adaptation of the two SSC bundle sets and demonstrated an association between 100% compliance with the bundle elements and clinical outcome. The next step will be to demonstrate that the use of education and feedback for performance improvement will increase compliance and decrease mortality in the patient population in general.
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Cardiac troponins are highly sensitive and specific indicators of myocardial injury. Although the mechanism of this injury is not entirely clear, it carries important prognostic information. ⋯ The current study is an important first step in trying to determine the exact frequency of MI among critically ill patients with elevated troponin. At present, the rate of MI in these patients is unknown and its implications on outcome and management will have to await future prospective clinical trials.