Critical care : the official journal of the Critical Care Forum
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Recommendations for sedation regimes in the intensive care unit (ICU) have evolved over the last decade based on findings that relate the clinical approach to improved patient outcomes. Martin and co-workers conducted two surveys into German sedation practice covering the time period during which these changes occurred and as such provide an insight into how these recommendations are being incorporated into everyday clinical practice.
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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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Comment
Good night, sleep tight: the time is ripe for critical care providers to wake up and focus on sleep.
The role of sleep during recovery from acute illness has been overlooked for decades. Advances in the support of critically ill patients have been made in mechanical ventilation, specialized nutrition support, highly specific antibiotic therapy, and early rehabilitation. However, the promotion of sleep - a basic tenet for survival - has been actively ignored by critical care providers. Bourne and coworkers recently conducted a small clinical trial that describes improved sleep efficiency with oral melatonin use in critically ill patients.
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In this issue of Critical Care, Dr Haenggi and co-workers present a study evaluating bispectral index (BIS), state entropy (SE) and response entropy in 44 patients sedated in the intensive care unit (ICU). As in recent studies attempting to correlate frontal electroencephalogram (EEG) measurements with clinical evaluations of sedative efficacy, there is considerable overlap in numerical EEG values and different clinical levels of sedation. This precludes the use of these monitors for monitoring or titrating sedation in the critically ill. ⋯ Meanwhile, clinical sedation protocols have emerged, improving important endpoints in critically ill patients needing sedation. A major underlying problem in applying EEG monitors in the ICU is that they have been developed for measuring anesthetic depth and the related risk of recall, rather than the acknowledged endpoints of sedation, namely reduction of anxiety and discomfort. Until an 'objective' monitor is developed to measure the degree of such symptoms, physicians should continue treating patients and not numbers.
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The pathogenesis of septic acute kidney injury (AKI) is not well understood. In the present issue of Critical Care, the combined clinical and experimental study from Mariano's group provides new insight into the disease. The study shows that plasma from septic burn patients with acute renal failure initiated pro-apoptotic effects and functional alterations in renal tubular cells and podocytes in vitro that correlated with the degree of proteinuria and renal dysfunction. ⋯ Sepsis and burn had additive effects. Apart from increasing our understanding of the pathogenesis of septic AKI, the study justifies further research on therapeutic interventions in several directions. These include the binding and elimination of the source of endotoxin by selective decontamination of the digestive tract, the blocking of apoptotic pathways, or the extracorporeal removal of circulating toxic mediators using high permeability hemofiltration or coupled plasma filtration and absorption.