Critical care : the official journal of the Critical Care Forum
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Editorial Comment
Oral care and pulmonary infection - the importance of plaque scoring.
Improving the quality of oral hygiene is recognised as an important counter measure for reducing the incidence of ventilator-associated pneumonia amongst critically ill patients. Toothbrushing physically disrupts the dental plaque that acts as a reservoir for pulmonary infection and therefore has the potential to reduce the incidence of ventilator-associated pneumonia. ⋯ The diagnosis of ventilator-associated pneumonia is prone to bias and future studies of oral care interventions should focus on measures of oral cleanliness such as plaque and gingival scores. Once the optimal strategy for oral hygiene is defined in the critically ill, larger studies focussing on ventilator-associated pneumonia or mortality can be conducted.
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Due to complexities in its measurement, adequacy of ventilation is seldom used to categorize disease severity and guide ventilatory strategies. Ventilatory ratio (VR) is a novel index to monitor ventilatory adequacy at the bedside. VR=(VEmeasured × PaCO₂measured)/(VEpredicted × PaCO₂ideal). VEpredicted is 100 mL.Kg-1.min-1 and PaCO₂ideal is 5 kPa. Physiological analysis shows that VR is influenced by dead space (VD/VT) and CO₂ production (VCO₂). Two studies were conducted to explore the physiological properties of VR and assess its use in clinical practice. ⋯ VR is an easy to calculate bedside index of ventilatory adequacy and appears to yield clinically useful information.
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Neurally adjusted ventilatory assist operates through recordings of electrical activity of the diaphragm (EAdi). Barwing and colleagues found increases in EAdi in weaning-failure patients, although the values were not significantly different from weaning-success patients. Future studies will need to carefully control for the considerable biological noise evident in EAdi recordings.
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Marked dysnatremia is associated with increased mortality in patients admitted to intensive care. However, new evidence suggests that even mild deviations from normal and simple variability of sodium values may also be significant. Should these findings prompt clinicians to re-evaluate the approach to fluid management in this setting? Sodium disorders, on one hand, are known to result from overzealous administration or restriction of free water or sodium ions. ⋯ It may be prudent to pay closer attention to these values, especially when abnormal, when fluctuating or when an adverse trend is present. More frequent measurements of sodium in blood, urine and drainage fluids, and appropriate adjustment of the sodium content of prescribed fluids, may be indicated. Until more light can be shed on the pathophysiology of dysnatremia in the critically ill, we should assume that better control of plasma sodium levels may yield better outcomes.