Crit Care Resusc
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There is now significant evidence that initial use of the correct antibiotic saves more lives than virtually all other intensive care therapy. This means covering all possible causative organisms with the initial empirical choice. For nosocomial sepsis, broad-spectrum antibiotics must be started as soon as the relevant samples have been taken for culture, with de-escalation of therapy targeted to the causative organisms when results and susceptibilities are available. ⋯ We have shown that some patients with normal serum creatinine levels have very high creatinine clearance rates; in ICU patients with sepsis, blood pressure and tissue perfusion are maintained with large fluid loads and inotropic agents, thereby raising creatinine clearance. High clearances produce low trough concentrations of antibiotic, with important implications for underdosing and the development of antibiotic resistance. The new paradigm for treating sepsis, particularly nosocomial sepsis, is: get it right the first time, hit hard up front, and use large doses of broad-spectrum antibiotics for a short period.
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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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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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Comparative Study
Methods and preliminary results for a data linkage project to determine long-term survival after intensive care unit admission.
To describe a local data linkage project to match hospital data with the Australian Institute of Health and Welfare (AIHW) National Death Index (NDI) to assess long-term outcomes of intensive care unit patients. ⋯ ICU-based linkage projects are feasible to determine long-term outcomes of ICU patients.