Critical care : the official journal of the Critical Care Forum
-
Randomized Controlled Trial Multicenter Study Observational Study
Co-enrollment of critically ill patients into multiple studies: patterns, predictors and consequences.
Research on co-enrollment practices and their impact are limited in the ICU setting. The objectives of this study were: 1) to describe patterns and predictors of co-enrollment of patients in a thromboprophylaxis trial, and 2) to examine the consequences of co-enrollment on clinical and trial outcomes. ⋯ Co-enrollment was strongly associated with features of the patients, research personnel, setting and study. Co-enrollment had no impact on trial results, and appeared safe, acceptable and feasible. Transparent reporting, scholarly discourse, ethical analysis and further research are needed on the complex topic of co-enrollment during critical illness.
-
Review Case Reports
Recombinant factor VIIa for uncontrollable bleeding in patients with extracorporeal membrane oxygenation: report on 15 cases and literature review.
Bleeding is the most frequent complication in patients receiving venoarterial or venovenous extracorporeal membrane oxygenation (ECMO). Recombinant activated factor VII (rFVIIa) has been used in these patients with conflicting results. We describe our experience with rFVIIa for refractory bleeding in this setting and review the cases reported in the literature. ⋯ rFVIIa use for intractable hemorrhaging in patients receiving ECMO controlled bleeding, without major thrombotic events, and with 60% dying. Hence, its use warrants discussion, and clinicians should be aware of the possibility of potentially life-threatening systemic thrombosis, emboli, or circuit clotting. Whether rFVIIa can save the lives of such patients remains to be determined.
-
During the past 50 years, caring for the critically ill has become increasingly complex and the need for an intensivist has become more evident. Management by intensivists has become a quality indicator for many ICUs. Numerous small studies have demonstrated the beneficial effect of intensivists on outcomes in the critically ill, and some clinicians have advanced the argument that a night-time intensivist is essential for the care of critically ill patients. ⋯ In this methodologically rigorous trial, there was no difference in outcomes between the intensivist and control group, which consisted of in-house resident coverage at night with availability by telephone of fellows and intensivists. These two robust studies clearly suggest that night-time intensivists do not improve mortality in ICUs managed by intensivists during the day. Though possibly beneficial in low-intensity environments, the widespread drive to add night-time intensivist coverage may have been premature.
-
Editorial Comment
A week seems to be weak: tailoring duration of antibiotic treatment in Gram-negative ventilator-associated pneumonia.
The optimal length of antimicrobial therapy has not been extensively studied for a great majority of infections and, in critically ill patients affected by ventilator-associated pneumonia, is a persisting and unsolved issue confronting clinicians. The integration of biomarkers, clinical judgment, and microbiologic eradication might help to define a shorter duration for some ventilator-associated pneumonia episodes due to non-fermenting Gram-negative bacilli, but until these strategies are implemented in clinical practice for individualizing antibiotic treatment, a short-course duration does not seem to tailor a long benefit.