Critical care : the official journal of the Critical Care Forum
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Review
Bench-to-bedside review: endotoxin tolerance as a model of leukocyte reprogramming in sepsis.
Endotoxin tolerance is defined as a reduced responsiveness to a lipopolysaccharide (LPS) challenge following a first encounter with endotoxin. Endotoxin tolerance protects against a lethal challenge of LPS and prevents infection and ischemia-reperfusion damage. Endotoxin tolerance is paralleled by a dramatic reduction of tumor necrosis factor (TNF) production and some other cytokines in response to LPS. ⋯ Studies on cellular signaling within leukocytes from septic and SIRS patients reveal numerous alterations reminiscent of those observed in endotoxin tolerant cells. However, altered responsiveness to LPS of leukocytes from sepsis and SIRS patients is not synonymous with a global down-regulation of cellular reactivity. The term 'cellular reprogramming', which has been proposed to qualify the process of endotoxin tolerance, defines well the immune status of circulating leukocytes in septic and SIRS patients.
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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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Comparative Study
Arginine-vasopressin in catecholamine-refractory septic versus non-septic shock in extremely low birth weight infants with acute renal injury.
The aim of this study was to assess the efficacy of arginine-vasopressin (AVP) as a rescue therapy in catecholamine-refractory septic and non-septic shock in extremely low birth weight (ELBW) infants with acute renal injury. ⋯ AVP may be a promising rescue therapy in catecholamine-resistant shock in ELBW infants with acute renal injury. Larger prospective clinical trials are warranted to assess the efficacy and safety of AVP as a pressor adjunct in septic versus non-septic shock in ELBW infants.
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Shockable rhythms are rare in pediatric cardiac arrest and the results of defibrillation are uncertain. The objective of this study was to analyze the results of cardiopulmonary resuscitation that included defibrillation in children. ⋯ Defibrillation is necessary in 18% of children who suffer cardiac arrest. Termination of VF or PVT after the first defibrillation dose is achieved in a low percentage of cases. Despite a sustained ROSC being obtained in more than one-third of cases, the final survival remains low. The outcome is very poor when a shockable rhythm develops during resuscitation efforts. New studies are needed to ascertain whether the new international guidelines will contribute to improve the outcome of pediatric cardiac arrest.
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Review Historical Article
Bench-to-bedside review: human subjects research--are more standards needed?
There are many controversial issues surrounding ethics in study design and conduct of human subjects research. In this review we briefly touch on the origin of ethics in clinical research and how the current regulations and standards came into practice. ⋯ We address this question by reviewing and commenting on relevant literature. We conclude that what is needed are not more standards per se, but rather refinement and uniformity of current standards, and their interpretation and application both to protect human subjects and to advance medicine.