Critical care : the official journal of the Critical Care Forum
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Randomized Controlled Trial Multicenter Study Comparative Study
High frequency oscillatory ventilation compared with conventional mechanical ventilation in adult respiratory distress syndrome: a randomized controlled trial [ISRCTN24242669].
To compare the safety and efficacy of high frequency oscillatory ventilation (HFOV) with conventional mechanical ventilation (CV) for early intervention in adult respiratory distress syndrome (ARDS), a multi-centre randomized trial in four intensive care units was conducted. ⋯ No significant differences were observed, but this trial only had power to detect major differences in survival without oxygen or on ventilator. In patients with ARDS and higher baseline OI, however, there might be a treatment benefit of HFOV over CV. More research is needed to establish the efficacy of HFOV in the treatment of ARDS. We suggest that future studies are designed to allow for informative analysis in patients with higher OI.
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Randomized Controlled Trial Comparative Study
Lactate concentration gradient from right atrium to pulmonary artery.
We compared simultaneous measurements of blood lactate concentration ([Lac]) in the right atrium (RA) and in the pulmonary artery (PA). Our aim was to determine if the mixing of right atrial with coronary venous blood, having substantially lower [Lac], results in detectable decreases in [Lac] from the RA to the PA. ⋯ We found decreases in [Lac] from the RA to PA in this sample of critically ill individuals. We conclude that parallel decreases in SO2 and [Lac] from the RA to PA support the hypothesis that these gradients are produced by mixing RA with coronary venous blood of lower SO2 and [Lac]. The present study is a preliminary observation of this phenomenon and further work is needed to define the physiological and clinical significance of Delta[Lac].
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Review Comparative Study
Equipment review: the success of early goal-directed therapy for septic shock prompts evaluation of current approaches for monitoring the adequacy of resuscitation.
A recent trial utilizing central venous oxygen saturation (SCVO2) as a resuscitation marker in patients with sepsis has resulted in its inclusion in the Surviving Sepsis Campaign guidelines. We review the evidence behind SCVO2 and its relationship to previous trials of goal-directed therapy. ⋯ It is unlikely that any single technology can improve outcome if isolated from an organized pattern of early recognition, algorithmic resuscitation, and frequent reassessment. This article includes a response to the journal's Health Technology Assessment questionnaire by the manufacturer of the SCVO2 catheter.
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An increasing number of diagnostic imaging procedures requires the use of intravenous radiographic contrast agents, which has led to a parallel increase in the incidence of contrast-induced nephropathy. Risk factors for development of contrast-induced nephropathy include pre-existing renal dysfunction (especially diabetic nephropathy and multiple myeloma-associated nephropathy), dehydration, congestive heart failure and use of concurrent nephrotoxic medication (including aminoglycosides and amphotericin B). Because contrast-induced nephropathy accounts for a significant increase in hospital-acquired renal failure, several strategies to prevent contrast-induced nephropathy are currently advocated, including use of alternative imaging techniques (for which contrast media are not needed), use of (the lowest possible amount of) iso-osmolar or low-osmolar contrast agents (instead of high-osmolar contrast agents), hyperhydration and forced diuresis. ⋯ Since only one (nonrandomized) study has been performed in intensive care unit patients, at present it is difficult to draw firm conclusions about preventive measures for contrast-induced nephropathy in the critically ill. Further studies are needed to determine the true role of these preventive measures in this group of patients who are at risk for contrast-induced nephropathy. Based on the available evidence, we advise administration of N-acetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions.
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Advanced age is thought to be associated with increased mortality in critically ill patients. This report reviews available data on factors that determine outcome, on the value of prognostic models, and on preferences regarding life-sustaining treatments in (very) elderly intensive care unit (ICU) patients. ⋯ We advocate the development of new prognostic models, validated in elderly ICU patients, that predict not only survival but also functional and cognitive status after discharge. Such a model may support informed decision making with respect to patients' preferences.