Critical care : the official journal of the Critical Care Forum
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This study pools data from the UK Intensive Care National Audit and Research Center (ICNARC) Case Mix Programme (CMP) to evaluate the case mix, outcome and activity for 17,326 patients with severe acute kidney injury (AKI) occurring during the first 24 hours of admission to intensive care units (ICU). ⋯ Severe AKI accounts for over 9% of all bed-days in adult, general ICUs, representing a considerable drain on resources. Although nonoliguric AKI continues to confer a survival benefit, overall survival from AKI in the ICU and survival to leave hospital remains poor. The use of APACHE II score measured during the first 24 hours of ICU stay performs well as compared with SHARF T0, SHARF II0 and the Mehta score, but it lacks perfect calibration.
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Comparative Study
Drotrecogin alfa (activated): real-life use and outcomes for the UK.
In March 2001, the results of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study were published, which indicated a 6.1% absolute reduction in 28-day mortality. Drotrecogin alfa (activated; DrotAA) was subsequently approved for use in patients with severe sepsis. ⋯ Use of DrotAA was approximately one in 16 for admissions meeting the definition for severe sepsis and with two or more organs failing. Patients receiving DrotAA were younger and more severely ill but were less likely to have serious conditions in their past medical history. Nonrandomized estimates for the effectiveness of DrotAA were consistent with the findings of PROWESS. DrotAA appeared not to be effective in patients with less severe disease.
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The revised Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis and septic shock have recently been published. These guidelines represent the end product of an intense process and provide a template approach to the early resuscitation and support of patients with sepsis, based on a synthesis of evidence that has been shown to improve the outcome of the septic patient. The SSC guidelines arose from a recognition that care of the septic patient was suboptimal for at least three reasons. ⋯ Secondly, even when sepsis was recognized, the urgency of treatment was underappreciated - and so haemodynamic resuscitation was tentative, and the administration of effective antibiotic therapy was often delayed. Finally, treatment was often suboptimal, and failed to take advantage of emerging insights into optimal approaches to patient management. The revised guidelines are far from perfect, but they represent the best available synthesis of contemporary knowledge in this area and as such should be promoted.
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Comment
Ocular sonography in patients with raised intracranial pressure: the papilloedema revisited.
Invasive devices are recommended for the early detection of raised intracranial pressure (ICP) after severe traumatic brain injury. Owing to contraindication or local issues, however, invasive ICP monitoring is not always possible. Moreover, a significant proportion of moderate traumatic brain injury patients (managed without invasive ICP) will develop raised ICP. ⋯ Soldatos and colleagues report the usefulness of ocular sonography in the diagnosis of raised ICP. Focusing on cerebrospinal fluid accumulation around the retrobulbar optic nerve, they show interesting results for the optic nerve sheath diameter in the diagnosis of raised ICP. If confirmed by further studies, and despite important limitations related to sonography, this technique could serve as a screening test in patients at risk for raised ICP, when invasive monitoring is not possible or is not clearly recommended.
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Imported falciparum malaria is characterized by a broad spectrum of potentially life-threatening complications that may arise even after initiation of appropriate antimalarial drug therapy. Hence, at Heidelberg University Hospital, all patients with newly diagnosed falciparum malaria are initially treated in the intermediate care unit (IMC) or intensive care unit (ICU). The present study was undertaken to evaluate critically the benefit of this strategy, which includes daily consultation with senior specialists in tropical medicine. ⋯ This retrospective evaluation demonstrated favourable therapeutic results in hospitalized patients with imported falciparum malaria. Both initial treatment in the medical IMC/ICU and close collaboration between intensivists and specialists in tropical medicine may improve disease outcome among affected patients. Prospective studies are needed to confirm these preliminary findings.