Critical care : the official journal of the Critical Care Forum
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Randomized Controlled Trial Comparative Study
A prospective randomized open-label crossover trial of regional citrate anticoagulation vs. anticoagulation free liver dialysis by the Molecular Adsorbents Recirculating System.
The Molecular Adsorbent Recycling System (MARS) is used to treat patients with liver failure. Observational data suggest that citrate anticoagulation during MARS is feasible. Comparative studies on the optimal anticoagulation regimen during MARS are lacking. The aim of the current study was to evaluate two heparin-free anticoagulation regimens. ⋯ Regional citrate anticoagulation in patients with liver failure is feasible. Citrate anticoagulation provides superior patency of the extracorporeal circuit. Avoidance of anticoagulation during MARS results in significant loss of treatment efficacy, due to treatment downtime. Additional studies are required to identify the optimal anticoagulation regimen for extracorporeal circulation in patients with liver failure.
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Multicenter Study Observational Study
Assessment of candidemia-attributable mortality in critically ill patients using propensity score matching analysis.
Candidemia in critically ill patients is usually a severe and life-threatening condition with a high crude mortality. Very few studies have focused on the impact of candidemia on ICU patient outcome and attributable mortality still remains controversial. This study was carried out to determine the attributable mortality of ICU-acquired candidemia in critically ill patients using propensity score matching analysis. ⋯ ICU-acquired candidemia in critically ill patients is not associated with an increase in either ICU or hospital mortality.
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Resuscitation of septic patients by means of one or more fluid boluses is recommended by guidelines from multiple relevant organizations and as a component of surviving sepsis campaigns. The technique is considered a key and life-saving intervention during the initial treatment of severe sepsis in children and adults. Such recommendations, however, are only based on expert opinion and lack adequate experimental or controlled human evidence. ⋯ In this pointof-view critique, we will argue that such therapy has weak physiological support, has limited experimental support, and is at odds with emerging observational data in several subgroups of critically ill patients or those having major abdominal surgery. Finally, we will argue that this paradigm is now challenged by the findings of a large randomized controlled trial in septic children. In the present article, we contend that the concept of large fluid bolus resuscitation in sepsis needs to be investigated further.
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Acute lung injury (ALI) remains a major cause of morbidity and mortality in critically ill patients. Despite improved understanding of the pathogenesis of ALI, supportive care with a lung protective strategy of mechanical ventilation remains the only treatment with a proven survival advantage. ⋯ Improved early identification of at-risk patients provides new opportunities for risk factor modification to prevent the development of ALI and novel patient groups to target for early treatment of ALI before progression to the need for mechanical ventilation. This review will discuss current strategies that target prevention of ALI and some of the most promising pharmacologic agents for early treatment of ALI prior to the onset of respiratory failure that requires mechanical ventilation.
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Increasing complexity and costs are a fundamental problem in critical care medicine, leading researchers to study opportunities and threats to continue to provide high-quality care in a more efficient health system. Over the past decades, we have learned from industrial methods that quality improvement and resource management can help achieve these results. Last year, Critical Care published a number of papers that highlight key points of critical care resource management. Each of these is grouped into one of three broad categories, based on domains of quality: (a) outcomes, in which we review long-term outcome data with an emphasis on the aging population, strategies to help mitigate the psychological burden of critical care, adverse events, and the appropriate use of resources, such as prolonged mechanical ventilation and intensive care unit (ICU) beds; (b) processes of care, in which we review variability in the provision of critical care, owing to gender, insurance status, and delays in ICU admission; knowledge translation studies in critical care; goal-directed therapy for postoperative patients and decision-making in the ICU; and (c) structure, in which we review strategies to improve quality through changes in design and the structural limitations to provide care in resource-limited settings.