Critical care : the official journal of the Critical Care Forum
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The rapid institution of therapeutic hypothermia after cardiac arrest has become an accepted practice. In the previous issue of Critical Care, Haugk and colleagues present a retrospective analysis of 13 years of experience with therapeutic hypothermia at their center that suggests an association between rate of cooling and less favorable neurological outcomes. The association most likely reflects easier cooling in patients more severely brain injured by their initial cardiac arrest, and should not lead clinicians to abandon or slow their efforts to achieve post-resuscitative cooling.
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Pleural effusions are common in mechanically ventilated patients but what is their significance and how should we manage them? What do we know? What don't we know? What didn't we know we knew? How should we resolve the unknowns?
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Editorial Comment
Is (1→3)-β-D-glucan the missing link from bedside assessment to pre-emptive therapy of invasive candidiasis?
Invasive candidiasis is a frequent life-threatening complication in critically ill patients. Early diagnosis followed by prompt treatment aimed at improving outcome by minimizing unnecessary antifungal use remains a major challenge in the ICU setting. Timely patient selection thus plays a key role for clinically efficient and cost-effective management. ⋯ A single positive BG value in medical patients admitted to the ICU with sepsis and expected to stay for more than 5 days preceded the documentation of candidemia by 1 to 3 days with an unprecedented diagnostic accuracy. Applying this one-point fungal screening on a selected subset of ICU patients with an estimated 15 to 20% risk of developing candidemia is an appealing and potentially cost-effective approach. If confirmed by multicenter investigations, and extended to surgical patients at high risk of invasive candidiasis after abdominal surgery, this bayesian-based risk stratification approach aimed at maximizing clinical efficiency by minimizing health care resource utilization may substantially simplify the management of critically ill patients at risk of invasive candidiasis.
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In the previous issue of Critical Care, Takala and colleagues presented the results of a multicenter study to investigate whether the early presence of less invasive hemodynamic monitoring improves outcome in patients admitted with hemodynamic instability to the intensive care unit. The authors' results suggest that it makes no difference. We discuss these findings and compare them to the literature on early goal-directed therapy in which monitors are used early but with a protocol.
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The study by Yang and colleagues examined 81 patients with septic shock due to pneumonia, along with 20 patients with pneumonia without organ dysfunction. Their major findings were that circulating levels of soluble vascular endothelial cell growth factor receptor-1 (sVEGFR-1) and urokinase-type plasminogen activator (uPA) were associated with organ dysfunction and mortality, whereas vascular endothelial cell growth factor (VEGF) levels had no such predictive power. Yang and colleagues are to be complimented for a well-conducted study of a reasonably (and helpfully!) homogeneous population of patients with sepsis that carefully and comprehensively analyzed the relationship between sVEGFR-1, uPA, VEGF and clinical outcome. The study serves not only to provide evidence in support of new diagnostic biomarker targets in sepsis, but also to augment the growing evidence of an important role of the endothelium in sepsis in general, and the VEGF signaling axis in particular.