Critical care : the official journal of the Critical Care Forum
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Several studies link hematological dysfunction to severity of sepsis. Previously we showed that platelet-derived microparticles from septic patients induce vascular cell apoptosis through the NADPH oxidase-dependent release of superoxide. We sought to further characterize the microparticle-dependent vascular injury pathway. ⋯ We showed that, in sepsis, NO and bacterial elements are responsible for type-specific platelet-derived exosome generation. Those exosomes have an active role in vascular signaling as redox-active particles that can induce endothelial cell caspase-3 activation and apoptosis by generating superoxide, NO and peroxynitrite. Thus, exosomes must be considered for further developments in understanding and treating vascular dysfunction in sepsis.
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Recombinant human activated protein C (rhAPC) has been reported to be cost-effective in severely ill septic patients in studies using data from a pivotal randomized trial. We evaluated the cost-effectiveness of rhAPC in patients with severe sepsis and multiple organ failure in real-life intensive care practice. ⋯ This study, conducted in matched patient populations, demonstrated that in real-life clinical practice the probability that rhAPC will be cost-effective if one is willing to pay 50,000 euros per life-year gained is 74.5%.
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Severe acute pancreatitis (SAP) requiring admission to a critical care unit is associated with high mortality and long lengths of stay. We describe the case mix, outcome, and activity of admissions with SAP who were identified from a high-quality clinical database. ⋯ SAP requiring critical care is associated with high mortality and long length of stay. The modified Glasgow criteria represent a simple measure of severity but were not designed to predict hospital mortality. It may be possible to develop a specific model for risk prediction in patients with SAP requiring critical care.
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Editorial Comment
Perioperative goal directed haemodynamic therapy--do it, bin it, or finally investigate it properly?
The literature concerning the use of goal directed haemodynamic therapy (GDHT) in high risk surgical patients has been importantly increased by the study of Lopes and colleagues. Using a minimally invasive assessment of fluid status and pulse pressure variation monitoring during mechanical ventilation, improvements were seen in post-operative complications, duration of mechanical ventilation, and length of hospital and intensive care unit (ICU) stay. Many small studies have shown improved outcome using various GDHT techniques but widespread implementation has not occurred. Those caring for perioperative patients need to accept the published evidence base or undertake a larger, multi-centre study.
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Most prognostic models rely on variables recorded within 24 hours of admission to predict the mortality rate of patients in the intensive care unit (ICU). Although a significant number of patients die after discharge from the ICU, there is a paucity of data related to predicting hospital mortality based on information obtained at ICU discharge. It is likely that experienced intensivists may be able to predict the likelihood of hospital death at ICU discharge accurately if they incorporate patients' age, preferences regarding life support, comorbidities, prehospital quality of life, and clinical course in the ICU into their prediction. However, if it is to be generalizable and reproducible and to perform well without bias, then a good prediction model should be based on objectively defined variables.