Critical care : the official journal of the Critical Care Forum
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Patients with intracranial hemorrhage due to traumatic brain injury are at high risk of developing venous thromboembolism including deep vein thrombosis (DVT) and pulmonary embolism (PE). Thus, there is a trade-off between the risks of progression of intracranial hemorrhage (ICH) versus reduction of DVT/PE with the use of prophylactic anticoagulation. Using decision analysis modeling techniques, we developed a model for examining this trade-off for trauma patients with documented ICH. ⋯ Our model showed no clear advantage to providing or withholding anticoagulant prophylaxis for DVT/PE prevention at 24 hours after traumatic brain injury associated with ICH. Therefore randomized controlled trials are justifiable and needed to guide clinicians.
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Inefficient clearance of copious respiratory secretion is a cause of non-invasive positive pressure ventilation (NPPV) failure, especially in chronic respiratory patients with community-acquired-pneumonia (CAP) and impaired consciousness. We postulated that in such a clinical scenario, when intubation and conventional mechanical ventilation (CMV) are strongly recommended, the suction of secretions with fiberoptic bronchoscopy (FBO) may increase the chance of NPPV success. The objective of this pilot study was, firstly, to verify the safety and effectiveness of early FBO during NPPV and, secondly, to compare the hospital outcomes of this strategy versus a CMV-based strategy in patients with decompensated chronic obstructive pulmonary disease (COPD) due to CAP who are not appropriate candidates for NPPV because of inefficient mucous clearance and hypercapnic encephalopathy (HE). ⋯ In patients with decompensated COPD due to CAP who are candidates for CMV because of HE and inability to clear copious secretions, NPPV with early therapeutic FBO performed by an experienced team is a feasible, safe and effective alternative strategy.
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Critically ill patients requiring mechanical ventilation frequently suffer from intensive care unit delirium, a syndrome associated with numerous poor measured outcomes. The relationship between delirium, sepsis, and sedation is complex. A discussion of the recent study ('Effect of dexmedetomidine versus lorazepam on outcome in patients with sepsis: an a priori-designed analysis of the MENDS [maximizing efficacy of targeted sedation and reducing neurological dysfunction] randomized controlled trial') by Pandharipande and colleagues is presented in this commentary.
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Neuropeptides arginine-vasopressin (AVP), apelin (APL), and stromal-derived factor-1α (SDF-1α) are involved in the dysfunction of the corticotropic axis observed in septic ICU patients. Study aims were: (i) to portray a distinctive stress-related neuro-corticotropic systemic profile of early sepsis, (ii) to propose a combination data score, for aiding ICU physicians in diagnosing sepsis on admission. ⋯ The stress response of early admitted ICU patients is different in septic vs. non-septic conditions. A proposed combination of variable score analyses will tentatively help in refining bedside diagnostic tools to efficiently diagnose sepsis after further validation.
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Sepsis in critically ill patients is almost associated with bad prognosis and its early detection may improve the prognosis. However, it is difficult to monitor the immunological state of these patients depending on the traditional markers of infection or inflammatory mediators. Accelerated lymphocyte death may reflect good idea about the prognosis especially when combined with 20S proteasome determinations, a recently discovered marker for muscle degradation in patients with sepsis. The hypothesis of the present study is to evaluate the role of serum 20S proteasome at early diagnosis of sepsis and its correlation with lymphocyte apoptosis to predict prognosis and consequently the early interference in critically ill patients suffering from a broad range of diseases in the intensive care unit. ⋯ The correlation of median values of 20S proteasome and the percentage of apoptotic lymphocyte median values could be a good indicator of patient prognosis and survival in critically ill patients.