Critical care : the official journal of the Critical Care Forum
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Editorial Comment
Why high suPAR is not super--diagnostic, prognostic and potential pathogenic properties of a novel biomarker in the ICU.
The soluble urokinase plasminogen activator receptor (suPAR) has been suggested as a biomarker that reflects immune cell activation. In critically ill patients, several independent investigations have reported elevated suPAR in conditions of systemic inflammatory response syndrome (SIRS), bacteriemia, sepsis, and septic shock, in which high circulating suPAR levels indicated an unfavorable prognosis. ⋯ High systemic levels indicated an adverse prognosis. This study expands our knowledge of the diagnostic power of suPAR, confirms its prognostic value, and raises the demand for future studies investigating the pathogenic involvement of suPAR.
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Dynamic variables of fluid responsiveness are useful guides for fluid management in patients under controlled positive pressure ventilation. In the previous issue of Critical Care, Jacques and colleagues show that these variables remain reliable predictors of fluid responsiveness in a porcine model of intra-abdominal hypertension, but threshold values are higher than during normal intra-abdominal pressure. ⋯ This study suggests that intra-abdominal pressure must be measured in critically ill patients, and 'supranormal' values of dynamic variables should be analyzed with caution. The 'fluid responsive part' of an increased dynamic variable in such patients may be estimated by measuring its change during a fluid challenge.
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Editorial Comment
The good and the bad of diabetes mellitus in the critically ill.
Diabetes mellitus is increasingly prevalent and associated with significant end organ damage that one may presume to impact upon critical illness. However, Siegelaar and colleagues present data that suggest, excepting those patients admitted to a cardiac intensive care unit, the presence of diabetes mellitus is not associated with increased mortality in critically ill patients. ⋯ Nevertheless, the results are consistent with many risk-adjustment models used in the critically ill, and clinical practice that tolerates mild hyperglycaemia. Is it even possible that diabetes mellitus is protective?
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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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In the last decade, moderate hypothermia has become the mainstay of treatment in the post-resuscitation period. However, for the damaged brain, optimizing oxygen transport, including arterial oxygenation, may also be important. ⋯ In an elegant study using a Cox proportional hazards model combined with sensitivity analyses and time period matching, the authors show no independent association between hyperoxia and in-hospital mortality. The present commentary discusses these contradictory findings and suggests a practical solution to solve these differences.