Critical care : the official journal of the Critical Care Forum
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Every day, critical care physicians around the world face the same challenge of the optimal timing of antimicrobial administration: when to start and when to stop antibiotics. Duration of antibiotic therapy for sepsis is mostly based on expert opinion, but its reduction is arguably the most promising approach to decrease emergence and selection of antibiotic resistance. The study by Hochreiter and colleagues presents another piece of evidence suggesting that procalcitonin may indeed be a valuable diagnostic parameter to guide antibiotic treatment duration, despite the ongoing controversy about the diagnostic accuracy of pro-calcitonin.
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Effectiveness and efficiency of care of the critically ill patient are subject to a number of systemic influences, including skills of individual physicians/nurses (technical and non-technical), team-working in the intensive care unit (ICU), and the ICU environment. We first discuss the paper of Fackler and colleagues as a contribution to the systems approach to clinical performance in the context of intensive care. We then highlight features of care delivery that are unique to intensive care and discuss the need for better understanding of human and non-human elements of the system of care of the critically ill patient as a driver for improvement of care delivery.
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Sepsis-induced myocardial dysfunction has traditionally been thought of as principally affecting systolic heart function. One of the primary reasons for this concept is that systolic dysfunction is relatively easy to conceptualize, visualize, and measure. With the advent of preload-independent measurements for diastolic function, both measurement and conceptual difficulties are being resolved, and a new realm of evidence is beginning to emerge regarding the aberrations that are found during cardiac relaxation in sepsis. A recent article in Critical Care brings this issue into sharper focus.
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Comment
Implementation of an evidence-based sepsis program in the intensive care unit: evident or not?
Severe sepsis and septic shock are among the most serious health conditions and are associated with unwelcome clinical, social, and economic outcomes. With the introduction of the Surviving Sepsis Campaign guidelines, the campaign leaders aimed to reduce mortality from severe sepsis by at least one quarter by 2009 by means of a six-point action plan, namely, building awareness among health care professionals, improving early and accurate disease recognition and diagnosis, increasing the use of appropriate treatments and interventions, education, getting better post-intensive care unit access, and developing standard processes of care. However, adherence to these recommendations is a first but crucial step in obtaining these goals. A comprehensive evaluation of both, adherence to a sepsis program and whether this results in better outcomes for patients, is therefore essential to guide informed decision-making regarding the implementation of such an evidence-based protocol.
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Since the 1970s, N-acetylcysteine (NAC) has shown proven efficacy as an antidote for acetaminophen (APAP) poisoning and APAP-induced liver failure for early presenters. The current evidence of benefits of NAC for late presenters is controversial because of the poor understanding of the mechanism of late toxicity. ⋯ Cytokine and growth factor signalling pathways are recognised to be involved in the process of liver regeneration and apoptosis. This research paper generates several issues related to the future management of APAP-induced liver failure and research into the mechanism of toxicity, especially of late toxicity.