Crit Care Resusc
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Editorial Comment
Why predict time to death after withdrawal of life-sustaining therapy?
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Multicenter Study
Prediction of death after withdrawal of life-sustaining treatments.
To assess the predictive value of respiratory and haemodynamic variables and opinion of the intensivist for determining how soon death occurs after withdrawal of life-sustaining treatments (WLST). ⋯ It is possible to predict the time from WLST to death accurately using a tool that combines GCS, respiratory and haemodynamic parameters and intensivist opinion. These results require validation in a large multicentre study.
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Review
Restrictive red blood cell transfusion strategies in critical care: does one size really fit all?
Many intensive care patients receive red blood cell transfusions. International clinical practice has recently changed, with a decrease in the "trigger" haemoglobin concentration used for red blood cell transfusions in critically ill patients. This change has been driven by increasing awareness of the infectious and non-infectious complications of allogeneic red blood cell transfusion, the perennial blood supply shortages, and most importantly by the Transfusion Requirements in Critical Care (TRICC) study, which suggested that a restrictive transfusion strategy (a transfusion trigger of 70 g/L and a post-transfusion goal of 70-90 g/L) may be equivalent to a liberal transfusion strategy (a transfusion trigger of 100 g/L and a posttransfusion goal of 100-120 g/L) in non-shocked ICU patients. ⋯ Despite this, and a number of important methodological issues that limit the generalisation of the TRICC results to patients with ischaemic heart disease, the TRICC authors, subsequent guidelines and recent reviews have recommended a restrictive strategy in ICU patients with ischaemic heart disease. This conclusion and the change in clinical practice that followed these publications are premature. In determining the appropriate trigger for transfusion of allogeneic blood, the physician should ideally weigh the risk-benefit profile for each individual patient, for each unit of blood administered.
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Case Reports
Paradoxical and severe hypotension in response to adrenaline infusions in massive quetiapine overdose.
Atypical antipsychotics (quetiapine, olanzapine, risperidone and clozapine) are increasingly prescribed in Australia, and emergency departments report growing rates of overdose of these agents. As these drugs are comparatively new, the spectrum of toxicity may be unfamiliar to critical care physicians. Severe hypotension is a recognised consequence of quetiapine poisoning. ⋯ The pharmacodynamics of quetiapine and the literature on overdose are reviewed. We present these cases to broaden the knowledge of physicians treating quetiapine overdose and to publicise the potential deleterious interaction with adrenaline. We recommend use of noradrenaline in preference to adrenaline in pharmacological management of shock in these patients.