Crit Care Resusc
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Acute respiratory distress syndrome (ARDS) is common in intensive care, with high mortality and morbidity. Preclinical studies suggest that corticosteroids reduce lung inflammation in ARDS. Early clinical trials using short courses of high-dose corticosteroids in patients at high risk of ARDS and with early ARDS showed increased mortality despite reduced lung inflammation, although more recent experience with lower doses over more prolonged periods is encouraging. ⋯ Inhalation maximises lung effects while minimising systemic absorption. Inhaled corticosteroids have been used successfully in a variety of animal models of lung injury. There is currently sufficient evidence to support a preliminary clinical trial of inhaled corticosteroids in patients at high risk of ARDS as well as with early and/or late ARDS, using markers of inflammation as a surrogate end-point.
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Paediatric cardiac surgery is now a mature specialty, yielding good results for those born with congenital heart disease (CHD). The current status of this surgery is considered, highlighting progress in genetic studies, improvements in intensive care management, and contemporary management of the low cardiac output syndrome. Emerging issues include the neurodevelopmental status of patients undergoing cardiac surgery, and known issues with the Fontan circulation. ⋯ Some patients classed as the "successes" of paediatric cardiac programs, as well as those with known persisting problems, need close follow-up in adult facilities. There is every indication that significant numbers of patients with complex disease are now entering a phase of life when late complications may present. Some overlap in experience between paediatric and adult care settings is invaluable in providing optimal care.
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Levosimendan is a novel calcium-sensitising agent that has been proposed as a potentially valuable inotrope for the treatment of acute or decompensated severe heart failure. Early clinical trials described some improvements in surrogate haemodynamic parameters, and suggested a possible survival benefit. However, before concluding that there is a place for routine use of levosimendan in the intensive care unit, a careful appraisal of all available evidence is needed. ⋯ The best available evidence comes from the two large clinical trials, REVIVE and SURVIVE. These studies suggest that levosimendan does not improve survival for patients with acute severe heart failure. Until their results can be fully scrutinised, and placed in the context of all available evidence, we should conclude that there is no place for levosimendan in the ICU.
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Historical Article
History of mouth-to-mouth ventilation. Part 3: the 19th to mid-20th centuries and "rediscovery".
The start of the 19th century saw the enthusiasm of the previous one for mouth-to-mouth ventilation (MMV) dissipated. To inflate the lungs of the asphyxiated, the Royal Humane Society in the United Kingdom had recommended bellows since 1782. Principal determinants for change were aesthetic distaste for mouth-to-mouth contact and the perceived danger of using expired air, although MMV survived in the practice of some midwives. ⋯ Ready adoption of MMV in the US was followed by worldwide spread, especially after endorsement from the 1962 international symposium at Stavanger in Norway. However, already there were occasional rumblings of reluctance to perform MMV. In this article, I consider MMV also in the context of other ventilatory modes for resuscitation.
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Over the past 12 years, the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group and the broader intensive care community in Australia and New Zealand have established a track record for conducting high quality, investigator-initiated clinical research in critically ill patients. This is highlighted by the publication of the SAFE (Saline Albumin Fluid Evaluation) study in the New England Journal of Medicine and the MERIT (Medical Early Response Intervention and Therapy) study in the Lancet. Here, we discuss potential impediments to the further advancement of intensive care research in Australia and New Zealand, and suggest strategies to address them. ⋯ We contend that the best chance of improving outcomes in many disease states requires studies to commence before patients enter the ICU, which will depend on collaboration with established and emerging craft groups, such as ambulance services, emergency medicine and anaesthesia. We also emphasise the need to study system factors affecting patient outcomes, as well as the translation of research findings into clinical practice. Finally, we describe the establishment and objectives of the Australian and New Zealand Intensive Care Research Centre (ANZIC-RC) and outline the Centre's current projects in the context of an integrated research framework.