Critical care : the official journal of the Critical Care Forum
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Case Reports
Re-examining ethical obligations in the intensive care unit: HIV disclosure to surrogates.
Physicians treating newly incapacitated patients often must help navigate surrogate decision-makers through a difficult course of treatment decisions, while safeguarding the patient's autonomy. We offer guidance for intensive care physicians who must frequently address the difficult questions concerning disclosure of confidential information to surrogates. ⋯ This balanced consideration of the direct duties of physicians to patients, and their indirect duties to surrogates and third-party contacts, may be used as a framework for considering other ethical obligations in the intensive care unit. We also provide a tabulation of individual US state laws relevant to disclosure of HIV status.
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Comparative Study
Erythropoietin improves skeletal muscle microcirculation and tissue bioenergetics in a mouse sepsis model.
The relationship between oxygen delivery and consumption in sepsis is impaired, suggesting a microcirculatory perfusion defect. Recombinant human erythropoietin (rHuEPO) regulates erythropoiesis and also exerts complex actions promoting the maintenance of homeostasis of the organism under stress. The objective of this study was to test the hypothesis that rHuEPO could improve skeletal muscle capillary perfusion and tissue oxygenation in sepsis. ⋯ rHuEPO produced an immediate increase in capillary perfusion and decrease in NADH fluorescence in skeletal muscle. Thus, it appears that rHuEPO improves tissue bioenergetics, which is sustained for at least six hours in this murine sepsis model.
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Editorial Comment
Corticosteroids to prevent postextubation upper airway obstruction: the evidence mounts.
Intubation of the airway can lead to laryngotracheal injury, resulting in extubation failure from upper airway obstruction (UAO). A number of factors can help to identify patients who are at greatest risk for postextubation UAO. Three randomized controlled trials demonstrate that prophylactic corticosteroids decrease the risk for postextubation UAO and probably the need for re-intubation.
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Comparative Study
Causes of metabolic acidosis in canine hemorrhagic shock: role of unmeasured ions.
Metabolic acidosis during hemorrhagic shock is common and conventionally considered to be due to hyperlactatemia. There is increasing awareness, however, that other nonlactate, unmeasured anions contribute to this type of acidosis. ⋯ Large amounts of unmeasured anions were generated after hemorrhage in this highly standardized model of hemorrhagic shock. Capillary electrophoresis suggested that the hitherto unmeasured anions citrate and acetate, but not sulfate, contributed significantly to the changes in strong ion gap associated with induction of shock.
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Editorial Comment
Improvements in the outcome of children with meningococcal disease.
Recent years have seen a marked reduction in the mortality of children with meningococcal disease in paediatric intensive care units (PICU); the reasons for this improvement are multifactorial. The mortality rates for critically ill children overall have improved and reasons for this are probably increased centralisation of PICU services and that fewer critically ill children are now looked after on adult units. Specific treatment pathways for sepsis have improved with the publication of clinical guidelines for children and initiatives such as the Surviving Sepsis Campaign. There is a continuing need to focus on the care delivered to children before reaching PICU and to minimise the morbidity suffered by survivors of this disease.