Critical care : the official journal of the Critical Care Forum
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Multicenter Study
Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study.
Higher lactate concentrations within the normal reference range (relative hyperlactatemia) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death. ⋯ In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations > 0.75 mmol.L-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed.
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The major interventional trials of intensive insulin therapy in critically ill patients have reached divergent results. The present viewpoint article explores some of the potential reasons, including differences in monitoring technology and protocol design and performance, the occurrence of severe hypoglycemia and changes in the standard of care since publication of the landmark single-center trial. Recently published data detailing the deleterious effect of hypoglycemia are discussed, as is the emerging body of literature describing the important impact of glycemic variability on the risk of mortality in heterogeneous populations of acutely ill and severely ill patients. These new findings have important implications for the design of future interventional trials of intensive insulin therapy in the intensive care unit setting.
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Comparative Study
Cross-comparison of cardiac output trending accuracy of LiDCO, PiCCO, FloTrac and pulmonary artery catheters.
Although less invasive than pulmonary artery catheters (PACs), arterial pulse pressure analysis techniques for estimating cardiac output (CO) have not been simultaneously compared to PAC bolus thermodilution CO (COtd) or continuous CO (CCO) devices. ⋯ Although PAC (COTD/CCO), FloTrac, LiDCO and PiCCO display similar mean CO values, they often trend differently in response to therapy and show different interdevice agreement. In the clinically relevant low CO range (< 5 L/min), agreement improved slightly. Thus, utility and validation studies using only one CO device may potentially not be extrapolated to equivalency of using another similar device.
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Comment Review
Open the lung with high-frequency oscillation ventilation or conventional mechanical ventilation? It may not matter!
The 'open lung' approach has been proposed as a reasonable ventilation strategy to mitigate ventilator-induced lung injury (VILI) and possibly reduce acute respiratory distress syndrome (ARDS)-related mortality. However, several randomized clinical trials have failed to show any significant clinical benefit of a ventilation strategy applying higher positive end-expiratory pressure (PEEP) and low tidal volume. ⋯ Inappropriate values for end-inspiratory or end-expiratory pressure have clear potential to damage a lung predisposed to VILI. In the heterogeneous environment of the ARDS 'baby lung', lung recruitment and the avoidance of tidal overstretch with high-frequency oscillation ventilation or conventional mechanical ventilation, guided by respiratory mechanics, appears to reduce VILI.
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Comparative Study
Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis.
Intensive care unit (ICU) patients and family members repeatedly note accurate and timely communication from health care providers to be crucial to high-quality ICU care. Practice guidelines recommend improving communication. However, few data, particularly in surgical ICUs, exist on health care provider opinions regarding whether communication is effective. ⋯ ICU nurses, surgeons, and ICU intensivists and NPs varied widely in their satisfaction with communication relating to prognosis. Clinician groups also varied in whether they thought that they had opportunities to communicate prognosis and whether their concerns were valued by other provider groups. These results hint at the nuanced and complicated relationships present in surgical ICUs. Further validation studies and further evaluations of patient and family member perspectives are needed.