Critical care : the official journal of the Critical Care Forum
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Infective endocarditis remains a disease associated with high mortality in certain groups of patients, with death resulting primarily from central nervous system complications and congestive heart failure. Combined medical and surgical therapy reduces both early and late mortality in complicated cases, especially in patients with valvular dysfunction related to heart failure. In these patients, heart failure is the strongest indication for valve replacement. ⋯ Limited data suggest that such surgery is feasible, even in complicated cases necessitating admission to the intensive care unit, and carries an acceptable risk for in-hospital mortality. It is important that critically ill patients with infective endocarditis are enrolled into multicenter studies, using adequate severity scoring systems to assess the impact of clinical and imaging variables on patients' outcome. Until such data are obtained, clinical judgement is still the best tool in decision-making regarding the individual patient.
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To study incidence, clinical course and prognostic factors in patients admitted to medical intensive care units (ICUs) because of a complicated course of infective endocarditis. ⋯ The prognosis for patients with infective endocarditis requiring admission to a medical ICU is serious. Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.
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Over the past 12 years there have been 12 randomised control trials, involving 843 infants, evaluating the effect of salbutamol or albuterol on bronchiolitis. Of these, nine (75%) showed that bronchodilators had no effect. In three studies a small transient improvement in the acute clinical score was seen. ⋯ A significant improvement in pulmonary resistance was observed after nebulised adrenaline but not after salbutamol or albuterol. Currently there is no compelling evidence that bronchodilators have a role in the routine management of infants with bronchiolitis. There is better evidence for the use of nebulised adrenaline.
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Status epilepticus (SE) has an annual incidence exceeding 100,000 cases in the United States alone, of which more than 20% result in death. Thus, increased awareness of presentation, etiologies, and treatment of SE is essential in the practice of critical care medicine. ⋯ An overview of the systemic pathophysiologic effects of SE is presented. Finally, significant studies on the treatment of acute SE and refractory SE are reviewed, including the use of anticonvulsants, such as benzodiazepines, and other drugs.
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Although mechanical ventilation is instituted as a life-saving technique, it may lead to complications that can negatively impact on patients' morbidity and/or mortality. Ventilator associated pneumonia (VAP) is one such complication that is a common challenge to intensivists. Although most experts would agree that early 'appropriate' antibiotic use is essential in patients who develop VAP, the best diagnostic test to guide decision-making is far from clear. ⋯ However, this procedure has associated costs and potential complications, and its utility in VAP has been challenged. In this issue of Critical Care Forum, the two sides of this debate are brought forward with compelling arguments. The authors' arguments should fuel future trials.