Critical care : the official journal of the Critical Care Forum
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Editorial Comment
Is prolonged mechanical ventilation of cancer patients futile?
The issue of limiting life-sustaining treatments for intensive care unit (ICU) patients is complex. The ethical principles applied by ICU staff when making treatment-limitation decisions must comply with the law of their country. ⋯ In a study conducted by Shih and colleagues in patients with cancer in Taiwan, continuous mechanical ventilation for more than 21 days was associated with poor outcomes, particularly in the subgroups of patients with metastases, lung cancer, or liver cancer. These results highlight the need for appropriate legislation regarding the withdrawal of life-sustaining treatments in patients, especially those for whom no effective cancer treatments are available.
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When to commence renal replacement therapy (RRT) in the critically ill remains an unresolved issue. The study by Thakar and colleagues sheds some light on current practice through an international survey, demonstrating physicians' inclination to start RRT earlier when the severity of disease is higher. However, Clec'h and co-workers investigated the effect of RRT on hospital survival by performing a propensity analysis on the large multicentre French OUTCOMEREA database. They demonstrate that RRT does not confer survival benefit, with a delay in initiation being proposed as a contributing factor.
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Healthy piglets ventilated with no positive end-expiratory pressure (PEEP) and with tidal volume (VT) close to inspiratory capacity (IC) develop fatal pulmonary oedema within 36 h. In contrast, those ventilated with high PEEP and low VT, resulting in the same volume of gas inflated (close to IC), do not. If the real threat to the blood-gas barrier is lung overinflation, then a similar damage will occur with the two settings. If PEEP only hydrostatically counteracts fluid filtration, then its removal will lead to oedema formation, thus revealing the deleterious effects of overinflation. ⋯ High PEEP (and low VT) do not merely impede fluid extravasation but rather preserve the integrity of the blood-gas barrier in healthy lungs.
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Editorial Comment
Glycemic control in the critically ill - 3 domains and diabetic status means one size does not fit all!
Hyperglycemia, hypoglycemia, and increased glucose variability have each been shown to be independently associated with increased risk of mortality in the critically ill. Sechterberger and colleagues have completed a large observational cohort study that demonstrates that diabetic status modulates these relationships in clinically meaningful ways. These findings corroborate, in a strikingly consistent manner, those of another very recently published large observational study.
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Editorial Comment
The dichotomy of inhibiting nuclear factor kappa-B in pneumonia.
Activation of nuclear factor kappa-B (NF-κB) results in its translocation from the cytoplasm to the nucleus and binding to the promoters of a large number of genes, including those encoding proinflammatory cytokines and other mediators that can contribute to organ system dysfunction in severe infection. While inhibition of NF-κB activation has been proposed as a therapeutic approach in critical illness, several studies have indicated that such an approach may have deleterious effects in persistent infectious states, such as pneumonia. A new report from Devaney and colleagues shows that while inhibition of NF-κB may be useful in severe pneumonia associated with rapid progression to mortality, it leads to worsened pulmonary injury with increased bacterial numbers in the lungs in a model of prolonged pneumonia. Such data raise concerns about therapeutic approaches targeting NF-κB in critically ill patients with persistent infection.