Critical care : the official journal of the Critical Care Forum
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Previous cost-effectiveness analyses (CEA) reported that Drotrecogin alfa (DrotAA) is cost-effective based on a Phase III clinical trial (PROWESS). There is little evidence on whether DrotAA is cost-effective in routine clinical practice. We assessed whether DrotAA is cost-effective in routine practice for adult patients with severe sepsis and multiple organ systems failing. ⋯ DrotAA is cost-effective in routine practice for severe sepsis patients with three to five organ systems failing. For patients with two organ systems failing, this study could not provide unequivocal evidence on the cost-effectiveness of DrotAA.
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Current guidelines recommend maintaining central venous oxygen saturation (ScvO2) higher than 70% in patients with severe sepsis and septic shock. As high levels of ScvO2 may reflect an inadequate use of oxygen, our aim was to evaluate the relation between maximal ScvO2 levels (ScvO2max) and survival among intensive care unit (ICU) patients with septic shock. ⋯ Our findings raise concerns about high levels of ScvO2 in patients with septic shock. This may reflect the severity of the shock with an impaired oxygen use. Future strategies may target an optimization of tissue perfusion in this specific subgroup of patients.
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Fluid resuscitation is a cornerstone of intensive care unit patient care, but prediction of the cardiovascular response remains difficult, despite many efforts in clinical research. The concept of responders and nonresponders illustrates such a difficulty. Many techniques have been tested, from strictly non-invasive to invasive, delivering various parameters related to the fluid challenge response. ⋯ This published study tested in the postoperative period of cardiovascular surgery the prediction obtained with filling pressures and the diastolic volume. When left ventricular function (global ejection fraction) is adequate, the volume before fluid administration seems to predict well the fluid challenge response; whereas when the global ejection fraction is poor, the filling pressure seems more suitable. The present commentary discusses the main physiological issues related to these findings, with some methodological aspects.
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Prevalent in critically ill patients, delirium remains poorly understood and difficult to treat. In a cross-sectional study conducted in 12 countries, delirium was identified in close to one third of patients and was independently associated with increased mortality. While such epidemiological accounts represent an important cornerstone for research, scientific efforts are needed to elucidate the causes of delirium and the mechanisms underlying its association with poor outcomes.
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Cross-talk between the coagulation system and inflammatory reactions during sepsis causes organ damage followed by multiple organ dysfunction syndrome or even death. Therefore, anticoagulant therapies have been expected to be beneficial in the treatment of severe sepsis. Recombinant human soluble thrombomodulin (rhTM) binds to thrombin to inactivate coagulation, and the thrombin-rhTM complex activates protein C to produce activated protein C. The purpose of this study was to examine the efficacy of rhTM for treating patients with sepsis-induced disseminated intravascular coagulation (DIC). ⋯ We found that rhTM administration may improve organ dysfunction in patients with sepsis-induced DIC. Further clinical investigations are necessary to evaluate the effect of rhTM on the pathophysiology of sepsis-induced DIC.