Critical care : the official journal of the Critical Care Forum
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Three pulse contour systems for monitoring cardiac output - LiDCO Plus™, PiCCO Plus™ and FloTrac™ - were compared in postcardiac surgery patients. None of the three methods demonstrated good trending ability according to concordance analysis. Pulse contour systems remain unreliable in the haemodynamically unstable patient.
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Controversy exists about the benefit of screening for prevention of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs) and recent studies have shown conflicting results. The aim of this observational study was to describe and evaluate the association between MRSA incidence densities (IDs) and screening and control measures in ICUs participating in the German Nosocomial Infection Surveillance System. ⋯ The analysis shows that MRSA IDs and structural parameters differ considerably between ICUs. In response, ICUs have combined screening and control measures in many ways to achieve various individual solutions. The incidence of imported MRSA cases might be helpful for consideration in the planning of MRSA control programmes.
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Editorial Comment
Whole blood thromboelastometry: another Knight at the Roundtable?
Thromboelastography and thromboelastometry represent viscoelastic diagnostic methodologies with promising application to diseases of altered coagulation. Their use in trauma-induced coagulopathy as a means of assessing the real-time status of the patient's functional coagulation profile in addition to its impact on effective and appropriate use of blood product support has been gaining acceptance among trauma surgeons, anesthesiologists, and transfusion medicine specialists. However, the ability of viscoelastic testing to augment or supplant conventional coagulation testing for the diagnosis and management of trauma-induced coagulopathy remains controversial. Many of these issues pertain to the differences in methodology, instrumentation, logic, accessibility, ease of use, operator variability, and the method's relationship to patient care, blood product use, cost, and conventional testing algorithms.
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As your hospital's ICU director, you are approached by the hospital's administration to help solve ongoing problems with ICU bed availability. The ICU seems to be constantly full, and trauma patients in the emergency department sometimes wait up to 24 hours before receiving a bed. Additionally, the cardiac surgeons were forced to cancel several elective coronary-artery bypass graft cases because there was not a bed available for postoperative recovery. The hospital administrators ask whether you can decrease your ICU length of stay, and wonder whether they should expand the ICU to include more beds For help in understanding and optimizing your ICU's throughput, you seek out the operations management researchers at your university.
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The study by Dr Peiniger and colleagues in a recent issue of Critical Care indicates that transfusion strategies using an early and more balanced ratio between fresh frozen plasma and red blood cell transfusions provide a survival benefit in patients with acute traumatic coagulopathy requiring massive transfusion within the first 24 hours of hospitalization. However, this topic has never been explored in depth in patients with concomitant severe traumatic brain injury. While the study is retrospective and certainly not a substitute for a well-designed prospective trial, the authors nonetheless should be commended for addressing this issue with their current work. Currently, the optimum fluid resuscitation paradigm for patients with both severe traumatic brain injury and other injuries requiring significant volume resuscitation is not clear.