Critical care : the official journal of the Critical Care Forum
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The translation of knowledge into rational care is as essential and pressing a task as the development of new diagnostic or therapeutic devices, and is arguably more important. The emerging science of health care delivery has identified the central role of human factor ergonomics in the prevention of medical error, omission, and waste. Novel informatics and systems engineering strategies provide an excellent opportunity to improve the design of acute care delivery. In this article, future hospitals are envisioned as organizations built around smart environments that facilitate consistent delivery of effective, equitable, and error-free care focused on patient-centered rather than provider-centered outcomes.
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We review key research papers in cardiology and intensive care published during 2011 in Critical Care and quote related studies published in other journals whenever appropriate. Papers are grouped into the following categories: cardiovascular therapies, mechanical therapies, biomarkers, prognostic markers, hemodynamic monitoring, cardiovascular diseases, microcirculation, hypertension in critically ill patients, and miscellaneous.
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Critical care patients frequently receive blood transfusions. Some reports show an association between aged or stored blood and increased morbidity and mortality, including the development of transfusion-related acute lung injury (TRALI). However, the existence of conflicting data endorses the need for research to either reject this association, or to confirm it and elucidate the underlying mechanisms. ⋯ In this in vivo ovine model, both recipient and blood product factors contributed to the development of TRALI. Sick (LPS infused) sheep rather than healthy (saline infused) sheep predominantly developed TRALI when transfused with supernatant from stored but not fresh PRBC. "Stored PRBC" induced a more severe injury than "stored PLT" and had a different storage lesion profile, suggesting that these outcomes may be associated with storage lesion factors unique to each blood product type. Therefore, the transfusion of fresh rather than stored PRBC may minimise the risk of TRALI.
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Observational Study
Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study.
Liver failure patients might be at risk for citrate accumulation during continuous venovenous hemodialysis (CVVHD) with regional citrate anticoagulation. The aim of this study was to investigate the predictive capability of baseline liver function parameters regarding citrate accumulation, expressed as an increase in the calcium total/calcium ionized (Ca(tot)/Ca(ion)) ratio ≥ 2.5, and to describe the feasibility of citrate CVVHD in liver failure patients. ⋯ Despite substantial accumulation of citrate in serum, CVVHD with regional citrate anticoagulation seems feasible in patients with severely impaired liver function. Citrate accumulation in serum is reflected by an increase in the Ca(tot)/Ca(ion) ratio. To identify patients at risk for citrate accumulation in terms of a Ca(tot)/Ca(ion) ratio ≥ 2.5, baseline serum lactate (threshold ≥ 3.4 mmol/l) and prothrombin time (threshold ≤ 26%) may be useful for risk prediction in daily clinical practice. Careful monitoring of electrolytes and acid-base status is mandatory to ensure patient safety.
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Myocardial depression in septic patients is well recognized yet still poorly understood. The prognostic significance in terms of overall mortality when it is identified, remains in dispute. Parameters of left ventricular function measured by tissue Doppler imaging may assist in resolving whether dysfunction identified early in the course of sepsis is a good prognostic sign.