Critical care : the official journal of the Critical Care Forum
-
Nitric oxide (NO) is an endogenous mediator of vascular tone and host defence. Inhaled nitric oxide (iNO) results in preferential pulmonary vasodilatation and lowers pulmonary vascular resistance. ⋯ This 'Bench-to-bedside' review focuses on the mechanisms of action of iNO and its clinical applications, with emphasis on acute lung injury and the acute respiratory distress syndrome. Developments in our understanding of the cellular and molecular actions of NO may help to explain the hitherto disappointing results of randomised controlled trials of iNO.
-
Multicenter Study
Ventilator-associated pneumonia in patients undergoing major heart surgery: an incidence study in Europe.
Patients undergoing major heart surgery (MHS) represent a special subpopulation at risk for nosocomial infections. Postoperative infection is the main non-cardiac complication after MHS and has been clearly related to increased morbidity, use of hospital resources and mortality. Our aim was to determine the incidence, aetiology, risk factors and outcome of ventilator-associated pneumonia (VAP) in patients who have undergone MHS in Europe. ⋯ Patients undergoing aortic surgery and those with complicated post-intervention courses, requiring multiple transfusions or re-intervention, constitute a high-risk group probably requiring more active preventive measures.
-
Comment Review
Excess circulating angiopoietin-2 levels in sepsis: harbinger of death in the intensive care unit?
The early recognition and management of sepsis remain the greatest challenges in the field of critical care medicine. Endothelial injury is one of the hallmarks of sepsis, leading to capillary leak, microcirculatory dysfunction, organ failure, and eventual death in many critically ill patients. The angiogenic growth factors, angiopoietin (angpt)-1 and angpt-2, act upon the Tie-2 receptor in opposing roles. ⋯ In the study by Kümpers and colleagues in the previous issue of Critical Care, angpt-2 levels correlated with markers of tissue hypoxia, disease severity, and mortality in septic adults. However, the temporal kinetics of the angiopoietins were not assessed. It remains to be seen whether angpt-2 levels will function solely as an early marker of sepsis or whether the manipulation of the angpt/Tie-2 system will become a rational therapeutic target for the management of sepsis.
-
Randomized Controlled Trial Multicenter Study
Gastric tonometry versus cardiac index as resuscitation goals in septic shock: a multicenter, randomized, controlled trial.
Resuscitation goals for septic shock remain controversial. Despite the normalization of systemic hemodynamic variables, tissue hypoperfusion can still persist. Indeed, lactate or oxygen venous saturation may be difficult to interpret. Our hypothesis was that a gastric intramucosal pH-guided resuscitation protocol might improve the outcome of septic shock compared with a standard approach aimed at normalizing systemic parameters such as cardiac index (CI). ⋯ Our study failed to demonstrate any survival benefit of using pHi compared with CI as resuscitation goal in septic-shock patients. Nevertheless, a normalization of pHi within 24 hours of resuscitation is a strong signal of therapeutic success, and in contrast, a persistent low pHi despite treatment is associated with a very bad prognosis in septic-shock patients.
-
As the mortality from critical illness has improved in recent years, there has been increasing focus on patient outcomes after hospital discharge. Neuromuscular weakness acquired in the intensive care unit (ICU) is common, persistent, and often severe. Immobility due to prolonged bed rest in the ICU may play an important role in the development of ICU-acquired weakness. ⋯ Recent studies have demonstrated that early mobility in the ICU is safe and feasible, with a potential reduction in short-term physical impairment. However, early mobility requires a significant change in ICU practice, with reductions in heavy sedation and bed rest. Further research is required to determine whether early mobility in the ICU can improve patients' short-term and long-term outcomes.