Critical care : the official journal of the Critical Care Forum
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Comparative Study
Use of an integrated clinical trial database to evaluate the effect of timing of drotrecogin alfa (activated) treatment in severe sepsis.
Several studies have indicated that early identification and treatment of patients with severe sepsis using standard supportive care improves outcomes. Earlier treatment with drotrecogin alfa (activated) (DrotAA) may also improve outcomes in severe sepsis. Using a recently constructed integrated severe sepsis database, our objectives in this study were to describe the influence of baseline clinical characteristics on timing of DrotAA treatment in patients with severe sepsis, to evaluate the efficacy of DrotAA with respect to timing of administration, and to examine the association between early intervention with DrotAA and patient outcomes, using adjustments for imbalances. ⋯ Using an integrated database of five severe sepsis trials and appropriate statistical adjustments to reduce sources of potential bias, earlier treatment with DrotAA seemed to be associated with a lower risk-adjusted mortality than later treatment. These data suggest that earlier treatment with DrotAA may provide most benefit for appropriate patients.
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Comparative Study
Oxidative stress is increased in critically ill patients according to antioxidant vitamins intake, independent of severity: a cohort study.
Critically ill patients suffer from oxidative stress caused by reactive oxygen species (ROS) and reactive nitrogen species (RNS). Although ROS/RNS are constantly produced under normal circumstances, critical illness can drastically increase their production. These patients have reduced plasma and intracellular levels of antioxidants and free electron scavengers or cofactors, and decreased activity of the enzymatic system involved in ROS detoxification. The pro-oxidant/antioxidant balance is of functional relevance during critical illness because it is involved in the pathogenesis of multiple organ failure. In this study the objective was to evaluate the relation between oxidative stress in critically ill patients and antioxidant vitamin intake and severity of illness. ⋯ The critical condition of patients admitted to the ICU is associated with worsening oxidative stress. Intake of antioxidant vitamins below 66% of RDA and alteration in endogenous levels of substances with antioxidant capacity are related to redox imbalance in critical ill patients. Therefore, intake of antioxidant vitamins should be carefully monitored so that it is as close as possible to RDA.
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From the report by Connors and coworkers in 1996 until now, much effort has been directed at demonstrating the safety and/or effectiveness of strategies based on pulmonary artery catheter (PAC) data. Although studies have failed to demonstrate a clear benefit of PAC use, neither have any corroborated the initial report of PAC-induced mortality. ⋯ The PAC has evolved since its initial presentation, and it now offers numerous parameters in addition to cardiac output and pressure measurement, such as mixed oxygen saturation and right ventricular ejection fraction. Because many techniques may be used to measure cardiac output, the indications for PAC use have become founded on other parameters that are useful in more specific situations, essentially involving the right circulation.
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Donation after circulatory death (DCD) can be performed on neurologically intact donors who do not fulfill neurologic or brain death criteria before circulatory arrest. This commentary focuses on the most controversial donor-related issues anticipated from mandatory implementation of DCD for imminent or cardiac death in hospitals across the USA. We conducted a nonstructured review of selected publications and websites for data extraction and synthesis. ⋯ Legislative abandonment of the dead donor rule to permit the recovery of transplantable organs is necessary in the absence of an adequate scientific foundation for DCD practice. The designation of organ procurement organizations or affiliates to obtain organ donation consent introduces self-serving bias and conflicts of interest that interfere with true informed consent. It is important that donors and their families are not denied a 'good death', and the impact of DCD on quality of end-of-life care has not been satisfactorily addressed to achieve this.
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The usefulness of parameters measured using the pulmonary artery catheter has been challenged because no benefit in patient outcome has been observed in clinical trials. However, technological advances have been made, including continuous measurement of cardiac output (CO), mixed venous saturation (SvO2), and right ventricle end-diastolic volume (CEDV) have been made. Pulmonary artery occlusion pressure (PAOP), CEDV and right atrial pressure (RAP) are not good predictors of fluid load responsiveness except when very low. ⋯ In this setting, a therapeutic decision to improve determinants of SvO2 should be considered with the help of all other PAC parameters. Technological improvement transforms PAC in a real time integrated physiological device and allows one to observe the impact of therapeutic intervention. What we need now is a clinical trial with a PAC-guided treatment algorithm taking into account the above integrated PAC parameters.