Critical care : the official journal of the Critical Care Forum
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To gain insight into factors that might affect results of future case-control studies, we performed an analysis of children with sepsis and purpura admitted to the paediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital (Rotterdam, The Netherlands). ⋯ Age and gender are determinants of severity of paediatric sepsis and purpura. Survival rates have improved during the last two decades.
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Comparative Study
Discordance between microvascular permeability and leukocyte dynamics in septic inducible nitric oxide synthase deficient mice.
Microvascular dysfunction causing intravascular leakage of fluid and protein contributes to hypotension and shock in sepsis. We tested the hypothesis that abrogation of inducible nitric oxide synthase (iNOS) activation would decrease leukocyte rolling, leukocyte adhesion, and microvascular leakage in sepsis. We compared wild-type mice made septic by cecal ligation and puncture with mice deficient in iNOS. ⋯ Leukocyte adhesion and vascular leakage were discordant in this setting. The finding that septic iNOS-deficient mice exhibited less microvascular leakage than wild-type septic mice despite equivalent increases in leukocyte adhesion suggests an important role for nitric oxide in modulating vascular permeability during sepsis.
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In a recent issue of Critical Care, Mally and colleagues reported outcomes from an observational study of out-of-hospital cardiac arrests in Slovenia. Multivariable analysis identified independent predictors for hospital discharge, including higher end-tidal carbon dioxide (ETCO2) levels, higher mean arterial pressure (MAP) and the recency (years) of the arrest. ETCO2 has been previously demonstrated to correlate with cardiac index, and predict successful resuscitation. ⋯ During this period a number of factors could have contributed to the improved outcome. These include new guidelines, the awareness of the importance of good CPR (including avoidance of hyperventilation), and better post-resuscitation care (including therapeutic hypothermia). It is hard to unravel the actual contribution of these factors to the final outcome, but the authors should be commended for their excellent overall results, and their thought provoking manuscript.
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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.
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Editorial Comment
Perioperative goal directed haemodynamic therapy--do it, bin it, or finally investigate it properly?
The literature concerning the use of goal directed haemodynamic therapy (GDHT) in high risk surgical patients has been importantly increased by the study of Lopes and colleagues. Using a minimally invasive assessment of fluid status and pulse pressure variation monitoring during mechanical ventilation, improvements were seen in post-operative complications, duration of mechanical ventilation, and length of hospital and intensive care unit (ICU) stay. Many small studies have shown improved outcome using various GDHT techniques but widespread implementation has not occurred. Those caring for perioperative patients need to accept the published evidence base or undertake a larger, multi-centre study.