Critical care : the official journal of the Critical Care Forum
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Comment Review
Measuring the anticoagulant effect of low molecular weight heparins in the critically ill.
Antithrombotic prophylaxis in critically ill patients frequently fails. Venous thromboembolism is associated with adverse clinical outcomes, including a prolonged intensive care unit stay and death. ⋯ In the previous issue of the journal, Rommers and colleagues examined whether subcutaneous edema reduces absorption of a low molecular weight heparin; although small, and thus underpowered, the authors failed to find any relationship between the level of low molecular weight heparin and the presence of edema. These findings provide reassurance that subcutaneously administered medications may be used in critically ill patients with edema.
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Whether it is the primary reason for admission or a complication of critical illness, upper gastrointestinal bleeding is commonly encountered in the intensive care unit. In this setting, in the absence of endoscopy, intensivists generally provide supportive care (transfusion of blood products) and acid suppression (such as proton pump inhibitors). ⋯ However, its precise role in patients with upper gastrointestinal bleeding is not necessarily clear and the drug is associated with significant costs. In this issue of Critical Care, two expert teams debate the merits of using octreotide in non-variceal upper gastrointestinal bleeding.
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Comparative Study
Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: results of an experimental study in adult sheep.
Extracorporeal lung assist, an extreme resource in patients with acute respiratory failure (ARF), is expanding its indications since knowledge about ventilator-induced lung injury has increased and protective ventilation has become the standard in ARF. ⋯ We obtained a significant reduction of PaCO2 using low blood flow rates, if compared with other techniques. Percutaneous venous access, simplicity of circuit, minimal anticoagulation requirements, blood flow rate, and haemodynamic impact of this device are more similar to renal replacement therapy than to common extracorporeal respiratory assistance, making it feasible not only in just a few dedicated centres but in a large number of intensive care units as well.
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The use of pulmonary artery catheters (PACs) during cardiac surgery varies considerably depending on local policy, ranging from use in 5-10% of the patient population to routine application. However, as in other clinical fields, recent years have witnessed a progressive decline in PAC use. ⋯ On this basis we can identify five groups: patients with impaired left ventricular systolic function; those with impaired right ventricular systolic function; those with left ventricular diastolic dysfunction; those with an acute ventricular septal defect; and those with a left ventricular assist device. This review highlights the specific role of PAC-derived haemodynamic data for each category.
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Critical care physicians often find themselves prognosticating for their patients, attempting to predict patient survival as well as disability. In the case of neurologic injury, this can be especially difficult. A frequent cause of coma in the intensive care unit is resuscitation following cardiac arrest, for which mortality and severe neurologic disability remain high. ⋯ Finally, neurologic damage may persist long after the patient's recovery from critical illness, as is the case for cognitive dysfunction detected months and years after critical illness. Psychiatric impairment including depression or post-traumatic stress disorder may also arise. Mechanisms contributing to each of these entities are reviewed.