Critical care : the official journal of the Critical Care Forum
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Although fever magnitude and etiology have been associated with outcomes of critically ill patients, possible associations between fever duration and mortality remain inconclusive. Since long-lasting fever is generally attributed to severe pathologic conditions, it is expected to be an indicator of adverse outcome. ⋯ Existing studies on these associations have been considerably limited because of methodological flaws, which may account for controversial findings that have been reported. Well-designed, large-sample studies using diverse measures of fever duration need to be conducted.
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Rapid diagnosis, appropriate management, and time are the key factors for improving survival rate in many emergency clinical scenarios such as acute myocardial infarction, pulmonary embolism, cerebral stroke, and severe sepsis. Clinical signs and electrocardiographic, radiological, and echographic investigations associated with biomarkers usually allow a quick diagnosis in all of the above situations, except severe sepsis, in which the diagnosis in the early phases is often only presumptive. ⋯ In this issue of Critical Care, Que and colleagues describe the prognostic value of pancreatic stone protein/regenerating protein (PSP/reg) concentration in patients with severe infections. The data reported are interesting, but several questions about this biomarker arise, and further studies are needed to understand its role in sepsis and clinical practice.
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Editorial Comment
Advancing the science of ventilator-associated pneumonia surveillance.
The landmark Study on the Efficacy of Nosocomial Infection Control definitively demonstrated that infection surveillance and control programs prevent hospital-acquired infections. The rise of public reporting, benchmarking, and pay for performance movements, however, has considerably changed the infection surveillance landscape in the 27 years since this study was published. ⋯ Surveillance definitions need to be revised to enhance objectivity and to ensure that they detect clinically meaningful events associated with compromised outcomes. The US Centers for Disease Control and Prevention recently released modified definitions for ventilator-associated events that have the potential to make safety surveillance for ventilated patients more credible and useful once again.
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Quality sleep is a problem for the critically ill who are cared for in an environment where interventions night and day are common, staff members are constantly present in relatively high numbers, and treatment is accompanied by a range of changing warning tones and alarms and lights. These critical care units are generally designed without a focus on patient comfort, sleep, and rest and often lack access to appropriate natural daylight. To add to this problem, critical illness, particularly sepsis, disrupts circadian rhythms and sleep patterns, and disruption of circadian rhythms, in turn, impairs immunity and contributes to delirium. ⋯ The study did not quantify adequacy of pain control in post-surgical patients and used patient reporting to assess sleep. Whether patients were receiving respiratory or other organ support was not reported. The potential benefit of earplugs is an important practical finding that could be implemented in most intensive care units.
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More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is the key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial therapy (Multicenter Intrapleural Sepsis Trial [MIST1]). ⋯ Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of hospital stay. Treatment with DNase alone or t-PA alone was ineffective.