Critical care : the official journal of the Critical Care Forum
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In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as state-of-the-art and not questioned any longer. This might be a reason why there are many examples of "strange" treatments in medical history that have been applied in the absence of evidence and later abandoned for good reasons. ⋯ Modern concepts based on adequate analgesia and moderate to no sedation appear to be more suitable. In conclusion, dogmas are still common in clinical practice. Since science rather than fiction should govern our actions in intensive care medicine, it is important to remain critical and challenge long established concepts, especially when the underlying evidence is weak or non-existing.
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Our current understanding of protective measures for avoiding ventilator-induced lung injury (VILI) has evolved from targeting low tidal volumes to lowering plateau and driving pressure. Even when pressures across the lung are reliably estimated, however, pressures alone cannot accurately gauge the injury risk; apart from flow rate, inspired oxygen fraction, and currently unmeasurable features of the mechanical microenvironment such as geometry, structural fragility, and vascular perfusion, the frequency with which high-risk tidal cycles are applied must help determine the intensity of potentially damaging energy application. Recognition of a strain threshold for damage by transpulmonary pressure, coupled with considerations of total energy load and strain intensity, has helped shape the unifying concept of VILI generation dependent upon the power transferred from the ventilator to the injured lungs. Currently, under-recognized contributors to the injury process must be addressed to minimize the risk imposed by ventilatory support.
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Multicenter Study
Incidence and outcome of invasive candidiasis in intensive care units (ICUs) in Europe: results of the EUCANDICU project.
The objective of this study was to assess the cumulative incidence of invasive candidiasis (IC) in intensive care units (ICUs) in Europe. ⋯ The cumulative incidence of IC in 23 European ICUs was 7.07 episodes per 1000 ICU admissions. Future in-depth analyses will allow explaining part of the observed between-center variability, with the ultimate aim of helping to improve local infection control and antifungal stewardship projects and interventions.
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This paper discusses the physiological and technological concepts that might form the future of critical care medicine. Initially, we discuss the need for a personalized approach and introduce the concept of personalized physiological medicine (PPM), including (1) assessment of frailty and physiological reserve, (2) continuous assessment of organ function, (3) assessment of the microcirculation and parenchymal cells, and (4) integration of organ and cell function for continuous therapeutic feedback control. To understand the cellular basis of organ failure, we discuss the processes that lead to cell death, including necrosis, necroptosis, autophagy, mitophagy, and cellular senescence. ⋯ In addition to pharmacological therapeutic options, placement and control of artificial organs to support or replace failing organs will be central in the ICU in vivo of the future. Remote monitoring and control of these biosensors and artificial organs will be made using adaptive physiological mathematical modeling of the critically ill patient. The current state of these developments is discussed.
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Limited critical care subspecialty training and experience is available in many low- and middle-income countries, creating barriers to the delivery of evidence-based critical care. We hypothesized that a structured tele-education critical care program using case-based learning and ICU management principles is an efficient method for knowledge translation and quality improvement in this setting. ⋯ Weekly, structured case-based tele-education offers an attractive option for knowledge translation and quality improvement in the emerging ICUs in low- and middle-income countries.