Critical care : the official journal of the Critical Care Forum
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Meta Analysis
Effects of steroids on reintubation and post-extubation stridor in adults: meta-analysis of randomised controlled trials.
The efficacy of steroid administration before planned tracheal extubation in critical care patients remains controversial with respect to the selection of patients most likely to benefit from this treatment. ⋯ The efficacy of steroids to prevent stridor and reintubation was only observed in a high-risk population, as identified by the cuff-leak test and when it was administered at least four hours before extubation. The benefit of steroids remains unclear when patients at high risk are not selected.
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Randomized Controlled Trial Comparative Study
Automatic versus manual pressure support reduction in the weaning of post-operative patients: a randomised controlled trial.
Reduction of automatic pressure support based on a target respiratory frequency or mandatory rate ventilation (MRV) is available in the Taema-Horus ventilator for the weaning process in the intensive care unit (ICU) setting. We hypothesised that MRV is as effective as manual weaning in post-operative ICU patients. ⋯ The duration of the automatic reduction of pressure support was similar to the manual one in the post-operative period in the ICU, but presented more complications, especially no adaptation to the MRV algorithm.
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A small group of patients account for the majority of peri-operative morbidity and mortality. These 'high-risk' patients have a poor outcome due to their inability to meet the oxygen transport demands imposed on them by the nature of the surgical response during the peri-operative period. ⋯ This goal directed therapy includes the use of fluid loading and inotropes, in order to optimize the preload, contractility and afterload of the heart whilst maintaining an adequate coronary perfusion pressure. Despite the benefits seen, it remains a challenge to implement this management due to difficulties in identifying these patients, scepticism and lack of critical care resources.
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Critically ill patients may require mechanical ventilatory support and short-term high-dose corticosteroid to treat some specific underlying disease processes. Diaphragm muscle inactivity induced by controlled mechanical ventilation produces dramatic alterations in diaphragm muscle structure and significant losses in function. Although the exact mechanisms responsible for losses in diaphragm muscle function are still unknown, recent studies have highlighted the importance of proteolysis and oxidative stress. ⋯ In animal models, studies on the influence of combined controlled mechanical ventilation and short-term high-dose methylprednisolone have given inconsistent results in regard to the effects on diaphragm muscle function. In the critically ill patient, further research is needed to establish the prevalence and mechanisms of ventilator-induced diaphragm muscle dysfunction, and the possible interaction between mechanical ventilation and the administration of high-dose corticosteroid. Until then, in caring for these patients, it is imperative to allow partial activation of the diaphragm, and to administer the lowest dose of corticosteroid for the shortest duration possible.
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Many studies have demonstrated that closed intensive care units (ICUs), staffed by trained intensivists, are associated with improved patient outcomes. However, the mechanisms by which ICU organizational factors, such as physician staffing, influence patient outcomes are unclear. One potential mechanism is the increased utilization of evidence-based practices in closed ICUs. ⋯ Although closed ICUs were independently associated with a modestly lower mean tidal volume, this finding did not explain the mortality benefit associated with a closed ICU model in this patient cohort. Future studies should evaluate other potential mechanisms by which closed ICUs improve patient outcomes. An improved understanding of these mechanisms may yield new targets for improving the quality of medical care for all ICU patients.