Critical care : the official journal of the Critical Care Forum
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Clinical Trial
Drotrecogin alfa (activated) may attenuate severe sepsis-associated encephalopathy in clinical septic shock.
Sepsis-associated encephalopathy (SAE) is a diffuse cerebral dysfunction induced by the immuno-inflammatory response to infection. Elevated levels of the brain-specific S100B protein are present in many septic patients and reflect the severity of SAE. Adjunctive treatment with drotrecogin alfa (activated) (DrotAA), the human recombinant form of activated protein C, has been shown to improve mortality in patients with severe sepsis-induced organ failure. We studied the effect of DrotAA on S100B levels in patients with acute septic shock who presented with increased baseline values of this biomarker. ⋯ S100B-positivity is present in more than half of the patients with septic shock. When increased S100B levels are used as a surrogate for SAE, adjunctive DrotAA treatment seems to beneficially affect the evolution of severe SAE as discriminated by an admission GCS <13.
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Endothelial injury has emerged as a crucial early event in the pathogenesis of microcirculatory dysfunction, capillary leakage and multiorgan dysfunction syndrome. The endothelial-specific angiopoietin (Ang)/Tie2 ligand-receptor system has been identified recently as a nonredundant regulator of endothelial responsiveness. Ang-1 is a Tie2 agonist and promotes endothelial stabilization and quiescence, whereas Ang-2 is a Tie2 antagonist and promotes endothelial activation, destabilization, and inflammation. ⋯ In the previous issue of Critical Care, Mankhambo and colleagues report on angiogenic factors in Malawian children with severe bacterial infection. Among those children, diminished levels of the vessel-protective factor Ang-1 remained a significant predictor of outcome after multivariate adjustment. Whether low Ang-1 represents an important risk factor of adverse outcome in critically ill adults remains to be seen.
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Studies have demonstrated that optimising the circulating volume reduces morbidity after major surgery. This optimisation is usually achieved through maximisation of the stroke volume guided by oesophageal Doppler. New monitoring parameters of preload responsiveness using information from the arterial trace are now showing some promise in achieving the same goal. The present commentary examines these new parameters with respect to improving outcomes for the high-risk surgical patient.
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The aim of this study was to examine whether the patterns of diffusion-weighted imaging (DWI) abnormalities and quantitative regional apparent diffusion coefficient (ADC) values can predict the clinical outcome of comatose patients following cardiac arrest. ⋯ The patterns of brain injury in early diffusion-weighted imaging (DWI) (less than or equal to five days after resuscitation) and the quantitative measurement of regional ADC may be useful for predicting the clinical outcome of comatose patients after cardiac arrest.
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Biguanide poisoning is associated with lactic acidosis. The exact mechanism of biguanide-induced lactic acidosis is not well understood. In the previous issue of Critical Care, Protti and colleagues demonstrated that biguanide-induced lactic acidosis may be due in part to a reversible inhibition of mitochondrial respiration. Thus, in the absence of an antidote, increased drug elimination through dialysis is logical.