Critical care : the official journal of the Critical Care Forum
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Editorial Comment
The gut-brain axis in the critically ill: Is glucagon-like peptide-1 protective in neurocritical care?
Enteral nutrient is a potent glucagon-like peptide-1 (GLP-1) secretagogue. In vitro and animal studies indicate that GLP-1 has immune-modulatory and neuroprotective effects. To determine whether these immune-modulatory and neuroprotective effects of GLP-1 are beneficial in the critically ill, studies achieving pharmacological GLP-1 concentrations are warranted.
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Editorial Comment
Recognition of hypovolemic shock: using base deficit to think outside of the ATLS box.
Base deficit has frequently been utilized as an informal adjunct in the initial evaluation of trauma patients to assess the extent of their physiologic derangements. However, the current Advanced Trauma Life Support (ATLS) classification system for hypovolemic shock does not include base-deficit measurements and relies primarily on alterations in vital signs (heart rate, systolic blood pressure) and mental status (Glasgow Coma Scale) to estimate blood loss. ⋯ The proposed system showed a greater correlation with transfusion requirements, need for massive transfusion, and mortality when compared with the ATLS classification system. Based on these findings, base-deficit measurement should be strongly considered during the initial trauma evaluation to identify the presence of hypovolemic shock and to guide blood product administration.
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Ranieri VM, Thompson BT, Barie PS, Dhainaut JF, Douglas IS, Finfer S, Gårdlund B, Marshall JC, Rhodes A, Artigas A, Payen D, Tenhunen J, Al-Khalidi HR, Thompson V, Janes J, Macias WL, Vangerow B, Williams MD: Drotrecogin alfa (activated) in adult patients with septic shock. N Engl J Med 2012, 366:2055-2064. ⋯ DrotAA did not significantly reduce mortality at 28 or 90 days, as compared with placebo, in patients with septic shock.
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Editorial Comment
The liver in sepsis: shedding light on the cellular basis of hepatocyte dysfunction.
Liver dysfunction is believed to contribute to the metabolic derangements of critical illness. The cellular basis of liver dysfunction is poorly understood and its consequences largely unknown. ⋯ Using two imaging techniques to track the clearance of biotransformed dyes by the liver in a rat model of intra-abdominal infection, the authors show that the predominant defect in sepsis lies in the excretion of biotransformed molecules from the hepatocyte into the bile canaliculi. Their work both points to a new aspect of hepatic dysfunction through focus on a role in the metabolic derangements of sepsis and suggests a possible strategy to diagnose and monitor this process in critically ill patients.
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In critical illness, four measures of glycaemic control are associated with ICU mortality: mean glucose concentration, glucose variability, the incidence of hypoglycaemia (≤2.2 mmol/l) or low glucose (2.3 to 4.7 mmol/l). Underlying diabetes mellitus (DM) might affect these associations. Our objective was to study whether the association between these measures of glycaemic control and ICU mortality differs between patients without and with DM and to explore the cutoff value for detrimental low glucose in both cohorts. ⋯ Mean glucose and high glucose variability are related to ICU mortality in the non-DM cohort but not in the DM cohort. Hypoglycaemia (≤2.2 mmol/l) was associated with ICU mortality in both. The cutoff value for detrimental low glucose is higher in the non-DM cohort (4.9 mmol/l) than in the DM cohort (3.5 mmol/l). While hypoglycaemia (≤2.2 mmol/l) should be avoided in both groups, DM patients seem to tolerate a wider glucose range than non-DM patients.