Critical care : the official journal of the Critical Care Forum
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Until relatively recently, critical illness was considered as a separate entity and the intensive care unit (ICU), often a little cut-off from other areas of the hospital, was in many cases used as a last resort for patients so severely ill that it was no longer possible to care for them on the general ward. However, we are increasingly realizing that critical illness should be seen as just one part of the patient's disease trajectory and how the patient is managed before and after ICU admission has an important role to play in optimizing outcomes. Identifying critical illness early, before it reaches a stage where it is life-threatening, is a challenge and requires a combination of improved and more frequent or continuous monitoring of at-risk patients, staff training to recognize when a patient is deteriorating, a system to "call for help," and an effective response to that call. ⋯ Early intensivist input may also be important for patients undergoing interventions that are likely to result in ICU admission, e.g., transplantation or cardiac surgery. The patient's continuum after ICU discharge must also be taken into account during their ICU stay, with attempts made to limit the longer-term physical and psychological consequences of critical illness as much as possible. Minimal sedation, good communication, and early mobilization are three factors that can help patients survive their ICU stay with minimal sequelae.
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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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Review
Host-pathogen interaction during mechanical ventilation: systemic or compartmentalized response?
Patients admitted to the intensive care unit (ICU) often require invasive mechanical ventilation. Ventilator-associated lower respiratory tract infections (VA-LRTI), either ventilator-associated tracheobronchitis (VAT) or ventilator-associated pneumonia (VAP), are the most common complication among this patient cohort. VAT and VAP are currently diagnosed and treated as separate entities, viewed as binary disease elements despite an inherent subjectivity in distinguishing them clinically. ⋯ Taking this model from the realm of theory to the bedside will require a greater understanding of inflammatory and immune pathways, and the development of novel disease-specific biomarkers and diagnostic techniques. Advances will lead to early initiation of optimal bespoke antimicrobial therapy, where the intensity and duration of therapy are tailored to clinical, immune and biomarker response. This approach will benefit towards a personalized treatment.
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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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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.