Critical care : the official journal of the Critical Care Forum
-
Management of the early stage of sepsis is a critical issue. As part of it, infection control including appropriate antibiotic therapy administration should be prompt. However, microbiological findings, if any, are generally obtained late during the course of the disease. The potential interest of procalcitonin (PCT) as a way to assess the clinical efficacy of the empirical antibiotic therapy was addressed in the present study. ⋯ In our study in an ICU, appropriateness of the empirical antibiotic therapy and the overall survival were associated with a greater decline in PCT between D2 and D3. Further studies are needed to assess the utility of the daily monitoring of PCT in addition to clinical evaluation during the early management of sepsis.
-
Comment Comparative Study
Resuscitation of hemorrhagic shock with normal saline versus lactated Ringer's: effects on oxygenation, extravascular lung water, and hemodynamics.
Which type of fluid to use in the resuscitation from hemorrhagic shock, within and between crystalloids or colloids, is still a matter of debate. In this context, with respect to organ dysfunction, early detection of lung injury is widely considered of particular clinical importance. ⋯ Ringer's lactate had more favorable effects than normal saline, however, on extravascular lung water, pH, and blood pressure but not on oxygenation. Although several pathophysiological aspects remain unanswered, these data are interesting in so far as they indicate that clinically applied amounts of crystalloids per se do not negatively influence pulmonary function, while with larger amounts the type of fluid has different effects on the extent of fluid extravasation in the lungs.
-
The need to achieve adequate tissue oxygen delivery early in patients with septic shock is well established. However, it is less well recognized that tissue hypoperfusion can exist despite normalization of systemic hemodynamics. Efforts to resuscitate septic patients until adequate tissue perfusion has been achieved can potentially improve outcome. ⋯ The intensive care unit length of stay and 28-day mortality did not differ between groups, but more patients in the cardiac index group were in the target range, both at baseline and after resuscitation, as compared with the gastric mucosal pH group. In contrast to cardiac index, gastric mucosal pH at baseline and at 24 and 48 hours predicted mortality. Whether other targets for the chosen variables, or different and--in particular--earlier resuscitation efforts would have favored one group cannot be concluded from the data provided.
-
Haenggi and colleagues report considerable intra- and inter-individual variability in derived electroencephalogram (EEG) parameters (Bispectral Index (BIS), response entropy and state entropy) recorded in volunteers sedated with midazolam or dexmedetomidine infusions titrated to modified Ramsay scores of 2, 3 and 4, and a remifentanil infusion at a fixed target concentration. Possible explanations for the low, variable and fluctuating EEG parameters are that volunteers were intermittently asleep, and that remifentanil gave rise to a low amplitude, slowed EEG pattern despite maintained consciousness. BIS and entropy values should be interpreted in combination with clinical findings in patients sedated with these agents.
-
Renal replacement therapy (RRT) is a fully established treatment for critically ill patients with acute kidney injury (AKI) but there are no scientifically established criteria when to initiate it. Our objectives were to describe the epidemiology of critically ill patients with AKI receiving RRT and to evaluate the relationship between biochemical, physiological and comorbid factors at time of RRT and ICU mortality. ⋯ Oligoanuria, acidosis and concomitant dysfunction of other organs at time of RRT were associated with poor survival. In contrast, serum creatinine and urea levels only had a weak correlation with outcome after RRT.