Critical care : the official journal of the Critical Care Forum
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In 2006, Critical Care provided important and clinically relevant research data in the field of multiple organ failure, sepsis, and shock. This review summarizes the results of the experimental studies and clinical trials and discusses them in the context of the relevant scientific and clinical background.
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Several hospitals have been developing programmes for organ donation after cardiac death. Such programmes offer options for organ donation to patients who do not meet brain-death criteria but wish to donate their organs after withdrawal of life-support. These programmes also increase the available organ pool at a time when demand exceeds supply. ⋯ Donation after cardiac death clearly carries a number of important ethical issues with it. In the present issue of Critical Care two established groups debate the ethical acceptability of using medications/interventions in potential organ donors for the sole purpose of making the organs more viable. Such debates will be an increasingly common component of intensivists' future practice.
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Review
Clinical review: timing and dose of continuous renal replacement therapy in acute kidney injury.
The optimal management of renal replacement therapy (RRT) in acute kidney injury (AKI) remains uncertain. Although it is well accepted that initiation of RRT in patients with progressive azotemia prior to the development of overt uremic manifestations is associated with improved survival, whether there is benefit to even earlier initiation of therapy is uncertain. ⋯ Several studies have suggested that more intensive delivery of CRRT during AKI is associated with improved survival, although results of trials have been inconsistent. Two large multicenter randomized clinical trials addressing this question are currently underway and should provide more definitive data within the next two years.
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Multicenter Study
The impact of the introduction of critical care outreach services in England: a multicentre interrupted time-series analysis.
Critical care outreach services (CCOS) have been widely introduced in England with little rigorous evaluation. We undertook a multicentre interrupted time-series analysis of the impact of CCOS, as characterised by the case mix, outcome and activity of admissions to adult, general critical care units in England. ⋯ The observational nature of the study limits its ability to infer causality. Although associations were observed with characteristics of patients admitted to critical care units, there was no clear evidence that CCOS have a big impact on the outcomes of these patients, or for characteristics of what should form the optimal CCOS.
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Endothelium dysfunction is one of the hallmarks of sepsis. Looney and Mattay, in the previous issue of Critical Care, highlight the role of activated protein C (APC) as a protective endothelial drug in septic situations. Nevertheless, the results of in vivo studies are less explicit and it remains uncertain whether these properties are relevant in human septic shock. ⋯ Nevertheless, if rAPC is efficient when infused in the early phase of septic challenge, we thus need to treat our patients earlier. At the least, genetically engineered variants have been designed with greater anti-apoptotic activity and reduced anticoagulant activity relative to wild-type APC. Further studies are needed to demonstrate the usefulness of these variants in septic shock therapy.