Critical care : the official journal of the Critical Care Forum
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Despite effective antibiotic therapy, about one-third of patients admitted to an intensive care unit (ICU) with severe community-acquired pneumonia (CAP) and organ dysfunction die within a month. This high death rate demonstrates the need for additional interventions. Both animal models and clinical data suggest that pathological expression of tissue factor (TF), with consequent activation of coagulation and inflammatory processes, contributes to the morbidity and mortality associated with CAP. ⋯ Enrolment was completed in July 2008 but data are not yet available. The primary outcome measure is 28-day all-cause mortality. In addition to short-term and long-term survival, the study is collecting data on adverse events (particularly when related to bleeding or thrombosis) and the effect of tifacogin on disease progression, resource use, and duration of ICU and hospital stay.
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Comparative Study
The impact of the severity of sepsis on the risk of hypoglycaemia and glycaemic variability.
The purpose of this study was to assess the relation between glycaemic control and the severity of sepsis in a cohort of patients treated with intensive insulin therapy (IIT). ⋯ Patients with severe sepsis and septic shock who were given IIT had a high risk of hypoglycaemia and hyperglycaemia. Among these patients even with a higher target BG level, IIT mandates an increased awareness of the occurrence of critical hypoglycaemia, which is related to the severity of the septic episode.
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Over the past several years, the implementation of therapeutic hypothermia has provided an exciting opportunity toward improving survival from out-of-hospital cardiac arrest. There are compelling data to support the prompt use of therapeutic hypothermia for initial survivors from out-of-hospital cardiac arrest, but animal data have suggested that initiation of therapeutic hypothermia during the intra-arrest period may significantly improve outcomes even further. In the first feasibility study in humans, Bruel and colleagues report on the implementation of this intra-arrest approach among patients suffering out-of-hospital cardiac arrest, an exciting prospect that is discussed in the present commentary.
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Editorial Comment
An anti-inflammatory role for tranexamic acid in cardiac surgery?
Pro- and anti-inflammatory cytokines are elevated after cardiac surgery. The control of the release of these major paracrine proteins is becoming clearer and they have been shown to be involved in the activation of the coagulation/fibrinolysis pathway, among other cascades. The association of a predominance of pro-inflammatory cytokines with morbidity in some patients, particularly following cardiac surgery, is well described but still incompletely understood. Clinical studies elucidating how clinicians may influence this cytokine release directly will improve our knowledge of the processes involved and could ultimately show benefit in better outcomes for patients.
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Analgesic and sedative medications are widely used in intensive care units to achieve patient comfort and tolerance of the intensive care unit environment, and to eliminate pain, anxiety, delirium and other forms of distress. Surveys and prospective cohort studies have revealed wide variability in medication selection, monitoring using sedation scales, and implementation of structured treatment algorithms among practitioners in different countries and regions of the world. Successful management of analgesia and sedation incorporates a patient-based approach that includes detection and management of predisposing and causative factors, including delirium; monitoring using analgesia and sedation scales and other instruments; proper medication selection, with an emphasis on analgesia-based drugs; and incorporation of structured strategies that have been demonstrated to reduce likelihood of excessive or prolonged sedation.