Critical care : the official journal of the Critical Care Forum
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The Surviving Sepsis Campaign guidelines for the management of severe sepsis and septic shock recommend that the initial hemodynamic resuscitation be done according to the protocol used by Rivers and colleagues in their well-known early goal-directed therapy (EGDT) study. However, it may well be that their patients were much sicker on admission than many other septic patients. Compared with other populations of septic patients, the patients of Rivers and colleagues had a higher incidence of severe comorbidities, a more severe hemodynamic status on admission (excessively low central venous oxygen saturation [ScvO2], low central venous pressure [CVP], and high lactate), and higher mortality rates. ⋯ The EGDT protocol uses target values for CVP and ScvO2 to guide hemodynamic management. However, filling pressures do not reliably predict the response to fluid administration, while the ScvO2 of septic patients is characteristically high due to decreased oxygen extraction. For all these reasons, it seems that the hemodynamic component of the Surviving Sepsis Campaign guidelines cannot be applied to all septic patients, particularly those who develop sepsis during their hospital stay.
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Multicenter Study Comparative Study
Intensive care for the adult population in Ireland: a multicentre study of intensive care population demographics.
This prospective observational study was conducted to describe the nature of the intensive care population across Ireland, identify adherence to international benchmarks of practice, and describe patient outcomes in critically ill patients. ⋯ Intensive care medicine in Ireland serves a patient population with high requirement for mechanical ventilation and support of the function of multiple organs. The overall mortality compares favourably with international benchmarks.
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Critically ill patients with a tracheostomy who are recovering from respiratory failure eventually require evaluation for airway decannulation. Although expert recommendations guide decisions for managing decannulation, few if any investigative data exist to inform evidence-based care. Consequently, practice variation limits the effectiveness of weaning from tracheostomy. ⋯ Pending completion of such studies, this report underscores the problem of practice variation in managing tracheotomized patients after critical illness. An important implication of the study is that care providers should recognize our knowledge deficit and develop systematic protocols for improving patient care using quality improvement techniques. Such models exist in the literature for adult patients and for children with tracheostomies who are managed by expert teams with requisite knowledge and skills.
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Functional residual capacity (FRC) reference values are obtained from spontaneous breathing patients, and are measured in the sitting or standing position. During mechanical ventilation FRC is determined by the level of positive end-expiratory pressure (PEEP), and it is therefore better to speak of end-expiratory lung volume. Application of higher levels of PEEP leads to increased end-expiratory lung volume as a result of recruitment or further distention of already ventilated alveoli. The aim of this study was to measure end-expiratory lung volume in mechanically ventilated intensive care unit (ICU) patients with different types of lung pathology at different PEEP levels, and to compare them with predicted sitting FRC values, arterial oxygenation, and compliance values. ⋯ End-expiratory lung volume measured at 5 cmH2O PEEP was markedly lower than predicted sitting FRC values in all groups. Only in patients with secondary lung disorders were PEEP-induced changes in end-expiratory lung volume the result of derecruitment. In combination with compliance, end-expiratory lung volume can provide additional information to optimize the ventilator settings.
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Editorial Comment
Procalcitonin in liver transplant patients--yet another stone turned.
Liver transplantation has been reported to initiate increases in procalcitonin levels, in the absence of bacterial infection. The results of a study investigating the course of procalcitonin levels over several days after liver transplantation in noninfected patients were recently reported in Critical Care. ⋯ This new information gives us hope that procalcitonin can be used as a marker of bacterial infection in these patients. Further studies of patients undergoing liver transplantation with and without bacterial infection are needed.