Minerva anestesiologica
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Corticosteroids are potent anti-inflammatory agents whose use has been life-saving in many diseases. Thus, it makes intuitive sense to use corticosteroids in septic shock, a disease where the inflammatory response is vigorously activated. Early studies examining the usage of corticosteroids in septic shock did not show any benefit, however, these studies administered very large doses. ⋯ Multi-center double blinded, randomized trials further added to the controversy without completely clarifying the issue. Moreover, the use of corticosteroids in critical illness must balance potential benefits with minimal side effects, however even such issues remain debatable as some studies show no untoward harm while other find the opposite. This review examines the use of corticosteroids in septic shock, discusses some of the shortcomings of the major clinical trials and outlines the most recent recommendations.
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Minerva anestesiologica · Feb 2011
Multicenter StudyPrehospital emergency physicians' experiences with advance directives in Germany: a questionnaire-based multicenter study.
Palliative medical emergencies and end-of-life decisions resulting from the exacerbation of cancer account for approximately 3% of all out-of-hospital emergency applications in Germany. Therefore, prehospital emergency physicians (EP) may be confronted with advance directives and ethical and end-of-life decisions. The purpose of the study was to identify EPs' knowledge about ethical and end-of-life decisions and their legal education and experiences concerning advance directives. ⋯ The prehospital emergency treatment of palliative care patients can be particularly challenging for any EP. A high percentage of the EPs in our study felt insecure in dealing with advance directives and ethical and end-of-life decisions in palliative care patients. Our results suggest that EPs may need more information and education about palliative medical care, legal issues and ethical and end-of-life decisions to provide adequate patient-oriented palliative care in prehospital emergency situations.
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Minerva anestesiologica · Feb 2011
ReviewSelective decontamination of the digestive tract as infection prevention in the critically ill. A level 1 evidence-based strategy.
Selective decontamination of the digestive tract (SDD) evolved into evidence-based medicine as a tool to prevent infections in critically ill patients. It significantly reduces mortality, pneumonia, bloodstream infections and the onset of resistance if the full four-component regimen is used. The use of only oral decontamination may reduce the incidence of pneumonia, but it has no significant impact on mortality. Moreover, the full SDD protocol significantly reduces the fecal carriage of multiresistant aerobic Gram-negative bacteria, whereas oral decontamination only is associated with increased carriage of multiresistant aerobic Gram-negative bacilli.
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Despite the remarkable advances in antibiotic therapies, diagnostic tools, prevention campaigns and intensive care, community-acquired pneumonia (CAP) is still among the primary causes of death worldwide, and there have been no significant changes in mortality in the last decades. The clinical and economic burden of CAP makes it a major public health problem, particularly for children and the elderly. ⋯ Particular attention is given to some aspects related to the clinical management of CAP, such as the microbial etiology and the available tools to achieve it, the usefulness of new and old biomarkers, and antimicrobial and other non-antibiotic adjunctive therapies. Possible scenarios in which pneumonia does not respond to treatment are also analyzed to improve clinical outcomes of CAP.