Critical care : the official journal of the Critical Care Forum
-
Review Comparative Study
Bench-to-bedside review: Developmental influences on the mechanisms, treatment and outcomes of cardiovascular dysfunction in neonatal versus adult sepsis.
Sepsis is a significant cause of morbidity and mortality in neonates and adults, and the mortality rate doubles in patients who develop cardiovascular dysfunction and septic shock. Sepsis is especially devastating in the neonatal population, as it is one of the leading causes of death for hospitalized infants. In the neonate, there are multiple developmental alterations in both the response to pathogens and the response to treatment that distinguish this age group from adults. ⋯ In addition, recent research has demonstrated that the mechanisms, inflammatory response, response to treatment and outcome of neonatal sepsis vary not only from that of adults, but vary among neonates based on gestational age. The goal of the present article is to review key pathophysiologic aspects of sepsis-related cardiovascular dysfunction, with an emphasis on defining known differences between adult and neonatal populations. Investigations of these relationships may ultimately lead to 'neonate-specific' therapeutic strategies for this devastating and costly medical problem.
-
Comparative Study
Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock.
In seriously ill patients, etomidate gives cardiovascular stability at induction of anaesthesia, but there is concern over possible adrenal suppression. Etomidate could reduce steroid synthesis and increase the need for vasopressor and steroid therapy. The outcome could be worse than in patients given other induction agents. ⋯ Etomidate use for critically ill patients should consider all of these issues and not simply the possibility of adrenal suppression, which may not be important when steroid supplements are used.
-
In the previous issue of Critical Care Chenaud and colleagues found that most intensive care unit patients who had given informed consent for their participation in a clinical trial could not recall either the purpose of the trial or its related risks several days later. These findings should remind us that informed consent is a process, not an event, but they should not be interpreted to mean that recall is, of itself, a useful criterion for evaluating either the validity or the quality of the informed consent process. On an entirely separate note, the decision of the authors not to obtain informed consent for this study itself raises interesting questions about the ethics of doing research on the ethics of doing research.
-
The results of a recently published Canadian study suggest that bronchoalveolar lavage and endotracheal aspiration are associated with similar clinical outcomes and similar overall use of antibiotics in critically ill patients with suspected ventilator-associated pneumonia (VAP). The study, however, does not provide convincing information on the best strategy to diagnose VAP, to accurately choose initial treatment and to exclude VAP in order to avoid administering antibiotics to patients without bacterial infection. ⋯ In summary, because antimicrobial treatment was initiated in all suspected patients and was rarely withheld in patients with negative cultures, the study does not suggest an appropriate strategy for improving the use of antibiotics in intensive care unit patients. Such a strategy has two requirements: immediate administration of adequate therapy in patients with true VAP, and avoidance of administering antibiotics in patients without bacterial infection.