Critical care : the official journal of the Critical Care Forum
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Acute lung injury (ALI) and the acute respiratory distress syndrome are complex syndromes because both inflammatory and coagulation cascades cause lung injury. Transport of salt and water, repair and remodeling of the lung, apoptosis, and necrosis are additional important mechanisms of injury. Alveolar edema is cleared by active transport of salt and water from the alveoli into the lung interstitium by complex cellular mechanisms. ⋯ This update reviews specifically the evidence on the effects of beta-2 agonists in human ALI and in models of ALI. The available evidence suggests that beta-2 agonists may be efficacious therapy in ALI. Further randomized controlled trials of beta agonists in pulmonary edema and in acute lung injury are necessary.
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In a recent issue of the British Journal of Anaesthesia, Moloney and Griffiths reviewed clinically pertinent issues surrounding the management of the acute respiratory distress syndrome (ARDS) patient, particularly as it pertains to the treatment of ventilator induced/associated lung injury (VILI). In addition to highlighting the important observations that have contributed to further our understanding of the relationship between the mechanical ventilator and inflammatory lung injury, the authors also offer a concise reappraisal of the clinical strategies used to minimize VILI in ARDS. Special emphasis is placed on the theory of biotrauma, which attempts to explain how multi-organ failure may develop in patients who ultimately succumb to this syndrome.
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Vogelzang et al. retrospectively assessed a derivative marker of blood glucose control over time in the intensive care unit (ICU), "the hyperglycemic index" (HGI), in relation to outcome. The HGI predicted mortality better than other indices of blood glucose control that do not take the duration of hyperglycemia into account. This provided further support to the concept of maintaining normoglycemia with insulin throughout intensive care in order to improve outcome. ⋯ This, however, implies similar sampling frequency for the compared algorithms. Just as we prefer continuous, online display of blood pressure and/or cardiac output for optimal titration of inotropes and vasopressors, a continuous display of blood glucose levels is mandatory for optimal titration of insulin therapy in ICU. We anxiously await the development and validation of such devices.
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This review introduces nonparametric methods for testing differences between more than two groups or treatments. Three of the more common tests are described in detail, together with multiple comparison procedures for identifying specific differences between pairs of groups.
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Recruitment is a dynamic physiological process that refers to the reopening of previously gasless lung units. Cumulating evidence has led to a better understanding of the rules that govern both recruitment and derecruitment during mechanical ventilation of patients with acute respiratory distress syndrome. ⋯ We also describe alternate techniques that have been proposed to assess recruitment at the bedside. Whether recruitment should be optimized remains an ongoing controversy that warrants further clinical investigation.