Critical care : the official journal of the Critical Care Forum
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Cytomegalovirus (CMV) is a ubiquitous virus present in approximately two-thirds of the healthy population. This virus rarely causes an active disease in healthy individuals, but it is among the most common opportunistic infections in immunocompromised patients such as solid organ transplant recipients, patients receiving chemotherapy for cancer or patients with human immunodeficiency virus. Critically ill patients who are immunocompetent before intensive care unit admission may also become more prone to develop active CMV infection if they have prolonged hospitalizations, high disease severity, and severe sepsis. ⋯ The present issue of Critical Care brings a new study by Heininger and colleagues in which the authors found that patients with severe sepsis who developed active CMV infection had significantly longer intensive care unit and hospital stays, prolonged mechanical ventilation, but no changes in mortality compared to patients without CMV infection. We discuss the possible reasons for their findings (for example, selection bias and low (20%) statistical power to detect mortality endpoints), and also perform an update of our previous meta-analysis with the addition of Heininger and colleagues' study to verify whether the higher mortality rate with CMV holds. Our updated meta-analysis with approximately 1,000 patients shows that active CMV infection continues to be associated with a significant 81% higher mortality rate than that in critically ill patients without active CMV infection.
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Molecular biology has not yet fully reached its ambitious goals in clinical bacteriology. Notwithstanding the tremendous technical challenges, the detection of nucleic acids directly from the blood of septic patients has not been shown cost-effective or even clinically relevant. Yet the potential for rapid molecular detection of circulating DNA (DNAemia) coupled to an educated antimicrobial drug adaptation has been repetitively advocated as a predicted breakthrough. Why do we still remain in such uncertainty?
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The aim of this study was to evaluate dynamic indices of fluid responsiveness in a model of intra-abdominal hypertension. ⋯ In intra-abdominal hypertension, respiratory variations in stroke volume and arterial pressure remain indicative of fluid responsiveness, even if threshold values identifying responders and non-responders might be higher than during normal intra-abdominal pressure. Further studies are required in humans to determine these thresholds in intra-abdominal hypertension.
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In hypoxemic patients needing fiberoptic bronchoscopy (FOB), noninvasive ventilation (NIV) has been used to prevent gas-exchange deterioration associated with FOB and to compensate for the increase in work of breathing occurring during FOB, thus avoiding endotracheal intubation and its related complications. The application of NIV to allow FOB has been found of particular interest in the diagnosis of pneumonia in patients spontaneously breathing and in those who started NIV to assist FOB. There is less information for patients who were already receiving NIV for acute respiratory failure and who were scheduled to undergo FOB. In the previous issue of Critical Care, the study by Baumann and colleagues adds new information to this specific issue, addressing the feasibility and safety of FOB during NIV in patients with established hypoxemic respiratory failure.
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Editorial Comment
Short people got no reason: gender, height, and disparities in the management of acute lung injury.
Though the benefits of lung protective ventilation (LPV) in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) have been known for more than a decade, widespread clinical adoption has been slow. Han and colleagues demonstrate that women with ALI/ARDS are less likely than men to receive LPV, though this disparity resolves when the analysis is adjusted for patient height. This analysis identifies patient height as a significant factor in predicting provider adherence with LPV guidelines, and illuminates why some disparities in intensive care exist and how they may be resolved via improved utilization of evidence-driven protocols.