Ann Acad Med Singap
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Septic shock is a major cause of death among patients in intensive care units. It has a mortality rate of 20% to 80%. The clinical syndrome of septic shock is characterised by hypotension, hyporesponsiveness to vasoconstrictors and volume depletion which will then lead to multiorgan dysfunction and death. ⋯ Inhibition of NO synthase, the enzyme responsible for NO production, has been proposed as a new therapy for septic shock. However, experimental reports have provided conflicting results, demonstrating both beneficial and detrimental effects. A brief review of the role of NO in septic shock and the possible use of NO synthase inhibitors as potential therapeutic agents is presented here.
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Ann Acad Med Singap · May 1998
Randomized Controlled Trial Comparative Study Clinical TrialCaudal morphine in paediatric patients: a comparison of two different doses in children after major urogenital surgery.
We compared the duration of postoperative analgesia and the occurrence of side-effects of two different doses of caudal morphine in children undergoing major urogenital surgery. Fifty-two children aged between 1 and 12 years were randomly selected to receive caudal morphine, either 25 micrograms.kg-1 (Group A) or 50 micrograms.kg-1 (Group B) with 0.5 ml kg-1 of 0.25% plain bupivacaine immediately before surgery. They were monitored for 24 hours in a high dependency area for known complications of epidural morphine. ⋯ The occurrence of vomiting and pruritus was similar in both groups. Urinary retention was not recorded as all children had an indwelling catheter as required by the surgical procedure. We concluded that 25 micrograms.kg-1 of caudal morphine is as effective as 50 micrograms.kg-1 for providing postoperative analgesia in children undergoing urogenital surgery.
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In recent years, several factors have led to increasing focus on the meaning of appropriateness of care and clinical performance in the intensive care unit (ICU). The emergence of new and expensive treatment modalities, a deeper reflection on what constitutes a desirable outcome, increasing financial pressure from cost containment efforts, and new attitudes regarding end-of-life decisions are reshaping the delivery of intensive care worldwide. ⋯ Their application has broadened to include ICU performance assessment, individual patient decision-making, and pre- and post-hoc risk stratification in randomised trials. In this paper, we review the popular scoring systems currently in use; design issues in the development and evaluation of new scoring systems; current applications of scoring systems; and future directions.
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Ann Acad Med Singap · May 1998
ReviewContinuous renal replacement therapy: continuous blood purification in the intensive care unit.
Severe acute renal failure (SARF) occurs when renal dysfunction is such that haemodialysis or haemofiltration becomes necessary to maintain homeostasis. SARF is increasingly seen in association with multiorgan failure and has become a predominantly Intensive Care Unit disorder. Because of this change in epidemiology, the treatment of SARF has evolved from being exclusively nephrologist and intermittent haemodialysis-based to being mostly intensivist and continuous haemofiltration-based, particularly in European countries with a strong ICU tradition and in Australia. ⋯ Such studies have also shown that increasing the intensity of fluid exchange may offer further beneficial effects in the setting of sepsis. In the light of these findings, CRRT is moving into the area of adjuvant treatment of sepsis, and pilot randomized controlled trials are being conducted to test the hypothesis that CRRT, either in standard or high fluid exchange volumes, attenuates the inflammatory effects of sepsis in humans. In the future, the use of CRRT may extend beyond its initial scope into the area of adjuvant management of sepsis and continuous blood purification may become part of a complex multifaceted approach to multiorgan dysfunction.
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Ann Acad Med Singap · May 1998
ReviewControlled observations in critical care medicine: the therapeutic trial.
The practice of critical care medicine revolves around the monitoring of patients to identify acute physiologic deterioration and the titration of therapies aimed at supporting internal homeostasis. Central to this practice is the evaluation of therapies or stresses designed to assess homeostatic reserve and to uncover pathologic processes. Both the cardiovascular and respiratory systems have received particular attention because of the ease with which specific haemodynamic and respiratory parameters can be measured, the ability to modulate their status with therapies, and the intimacy of both cardiovascular and respiratory status to overall homeostasis. ⋯ Clinical trials form much of the basis for titration of therapy, wherein a specific therapy is adjusted so as to optimise its effectiveness in an individual. Titration is typically done once a diagnosis has already been made or a treatment identified, such as with the titration of antihypertensive therapy in either hospital or outpatient setting. This review will focus on the exploratory aspect of clinical trials wherein a specific manoeuvre is performed to determine either the aetiology or severity of a pathophysiologic problem.