Crit Care Resusc
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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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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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Randomized Controlled Trial
Effect of midazolam versus propofol sedation on markers of neurological injury and outcome after isolated severe head injury: a pilot study.
Midazolam and propofol are sedative agents commonly administered to patients with brain injury. We compared plasma concentrations of glial cell S100beta protein and nitric oxide (NO) between patients who received midazolam and those who received propofol sedation after severe brain injury, and investigated the association between S100beta and NO concentrations and neurological outcome. ⋯ Plasma concentrations of markers of neurological injury in patients with severe head injury were similar in those who received midazolam sedation and those who received propofol. Patients who had a poor neurological outcome at 3 months had consistently higher serum S100beta concentrations during the initial 4 days after injury than patients who had a good outcome.
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To assess the characteristics of patients who died in a teaching hospital and the role of the medical emergency team (MET) in their end-of-life care. ⋯ Most patients who died in our hospital were designated NFR at the time of death. A third of these patients were seen by the MET before death. In about 10% of cases, the MET participated in the decision to designate the patient NFR.