Critical care : the official journal of the Critical Care Forum
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To examine the effects of positive end-expiratory pressure (PEEP) on intra-abdominal pressure (IAP) in patients with acute lung injury (ALI). ⋯ PEEP is a contributing factor that impacts IAP values. It seems necessary to take into account the level of PEEP whilst interpreting IAP values in patients under mechanical ventilation.
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Current evidence suggests that critically ill patients tolerate anaemia well and that blood transfusions may increase the risk of adverse outcomes. Dr Sakr and colleagues present a contradictory analysis of a surgical ICU cohort, finding an association between blood transfusions and lower hospital mortality after adjustment for a range of potential confounders. Analyses of this kind are interesting and provocative, but are limited by residual confounding and bias by indication. The data emphasise the need for additional high quality trials of transfusion practice in critical care.
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Studies in intensive care unit (ICU) patients have suggested that anemia and blood transfusions can influence outcomes, but these effects have not been widely investigated specifically in surgical ICU patients. ⋯ In this group of surgical ICU patients, anemia was common and was associated with higher morbidity and mortality. Higher hemoglobin concentrations and receipt of a blood transfusion were independently associated with a lower risk of in-hospital death. Randomized control studies are warranted to confirm the potential benefit of blood transfusions in these subpopulations.
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Four ethical issues loom over the study by Lieberman and colleagues--the absence of informed consent, the study being non-interventional in situations that typically call for life-saving interventions, the bias involved in doctors that study their own problematic practice and monopoly over intensive care unit triage, and ageism. We learn that the Israeli doctors in this study never make no-treatment decisions regarding patients in need of mechanical ventilation. They are complicit with botched standards of care for these patients, however, accepting without much doubt an ethos of scarce resources and poor managerial habits. The main two practical lessons to be taken from this study are that, for patients in need of mechanical ventilation, compromised care is better than a policy of intubation only when the intensive care unit is available, and that vigorous efforts are needed in order to extirpate ageism.
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Biography Historical Article
Clinical review: Guyton--the role of mean circulatory filling pressure and right atrial pressure in controlling cardiac output.
Arthur Guyton's concepts of the determinative role of right heart filling in cardiac output continue to be controversial. This paper reviews his seminal experiments in detail and clarifies the often confusing concepts underpinning his model. ⋯ Further concerns have been raised in regard to the artificial experimental preparations that Guyton used. Recently reported measurements in humans support Guyton's theoretical and animal work.