Crit Care Resusc
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Randomized Controlled Trial
Effects of saline or albumin resuscitation on standard coagulation tests.
To explore whether fluid resuscitation with normal saline or 4% albumin is associated with differential changes in routine clinical coagulation tests. ⋯ Administration of albumin or of larger fluid volumes is associated with a prolongation of APTT. In ICU patients, the choice and amount of resuscitation fluid may affect a routinely used coagulation test.
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The concept of relative adrenal insufficiency in patients with severe sepsis continues to be controversial. This arises in part from the lack of an accepted "gold standard" for the diagnosis of adrenal insufficiency in the critically ill. Historically, assessment of adrenal function in this population has relied on measurement of plasma total cortisol level, in a blood sample taken either at random or as part of a corticotropin stimulation test. ⋯ We review the mechanisms known to affect tissue glucocorticoid activity and examine how they may be modified by critical illness. These include both free and interstitial cortisol concentrations, intracellular cortisol generation, and glucocorticoid-receptor activity and density. Changes in these factors are not reflected in plasma total cortisol concentrations, and more sophisticated techniques, including genetic transcriptional surveys, may be required to reveal the role of glucocorticoid insufficiency in critical illness.
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Multicenter Study
Withholding and withdrawal of life-sustaining therapies in intensive care: an Australian experience.
Withholding and withdrawal of treatment in intensive care is currently widely accepted, but little has been published about Australian practice. ⋯ In this population of critically ill patients, most deaths occurred after discussion of end-of-life decisions and withholding or withdrawal of treatment.
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To assess and describe postoperative complications of single dilator percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in a large series of critically ill patients. ⋯ In a large heterogeneous group of critically ill patients, single dilator PDT was safe and had few postoperative complications. Although ST was used in higher-risk patients, those who underwent PDT were more likely to receive a larger-sized tracheostomy tube; they were also less likely to experience obstruction or displacement of the postoperative tracheostomy tube. These differences are probably related to a combination of patient selection, smaller, shorter tracheostomy tubes, and larger tissue incision size with ST.
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To evaluate the effect of the introduction of automated external defibrillators (AEDs) on survival after inhospital cardiac arrest. ⋯ ROSC and survival to hospital discharge did not change significantly after deployment of AEDs. The existence of a timely and robust resuscitation response with relatively good baseline outcomes, and the low proportion of initial shockable arrest rhythms may have limited the capacity of AEDs to improve survival.