Critical care : the official journal of the Critical Care Forum
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Fresh blood has many potential advantages over older blood, but there is no evidence that these properties translate into clinical benefit for intensive care patients. The observational multicenter study by Karam and colleagues provides some evidence suggesting that blood stored for less than 14 days is better than older blood in terms of new organ failure and reduction in length of stay in pediatric intensive care units. ⋯ As a consequence, it is ethical and certainly pertinent to conduct a randomized clinical trial in order to test the hypothesis that fresh blood might reduce mortality. The rationale is strong and the potential benefit of fresh blood is substantial.
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Recruitment maneuvers have been the subject of intense investigation. Their role in the acute care setting is debated given the lack of information on their influence on clinical outcomes. ⋯ Another possible downside is bacterial translocation secondary to lung overdistention, as suggested by experimental and initial clinical data. When a recruitment maneuver is performed, the patho-physiological consequences of lung recruitment should guide clinicians more than oxygenation improvement alone.
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Comment Letter
Increased blood flow by insulin infusion targeting normoglycemia in patients with severe sepsis: friend or foe?
A small study in patients with severe sepsis suggested that insulin infused to normalize blood glucose levels increased forearm flow. This clinical observation supports the effect of insulin on the endothelium, as previously shown by in vitro studies and by in vivo animal models of critical illness, but the clinical consequences remain unclear.
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Goal-directed therapy (GDT) can be a vague term, meaning different things to different people and, depending on the clinical environment, sometimes even different things to the same person. It can refer to perioperative fluid management, clinicians driving oxygen delivery to supramaximal values, early treatment of sepsis in the emergency department, and even to restriction of perioperative crystalloids with the goal of maintaining preadmission body weight. Understandably, strong opinions about GDT vary; some clinicians consider it essential for perioperative care, others completely ineffective in critically ill patients. This commentary aims to further position the excellent review by Lees and colleagues in the context of the critical care and perioperative setting.