New horizons (Baltimore, Md.)
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The requirements for nutrient substrates are altered in patients with infection and critical illness. Parenteral and enteral nutritional support are indicated in septic patients to preserve lean body mass and support metabolic processes while appropriate anti-infective therapy is administered. In general, such patients require greater amounts of protein and fewer calories than normal patients. ⋯ The salutary effect of enteral nutrition on the gastrointestinal tract has been shown to enable severely injured patients to have a lower frequency of infectious complications than similar patients fed parenterally. A new enteral formula fortified with arginine, nucleotides, and fish oil has been demonstrated to reduce hospital stay and to reduce complications in patients who are fed for > or = 7 days when compared with conventional formula. The increased use of early enteral nutrition and special nutrient formulas has the potential to reduce hospital length of stay, complications, and the cost of care if used appropriately.
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Disseminated intravascular coagulation is a frequent finding in critically ill patients, and may be diagnosed in the majority of patients with Gram-negative sepsis. Tissue damage may result from intravascular thrombosis, and disseminated intravascular coagulation is an underestimated causal factor in the pathogenesis of organ failure in sepsis. The diagnosis of disseminated intravascular coagulation is difficult, as the initial coagulation process that leads to thrombosis is counteracted by fibrinolytic responses, that in the context of ongoing consumption of clotting factors may result in an overwhelming bleeding tendency. ⋯ No well-designed, controlled clinical trials exist that form a basis for rational treatment decisions. Treatment frequently needs to be individualized, and rapid adjustments may be necessitated by the course of the disease. Nonetheless, we believe that recent insights in the pathophysiology of disseminated intravascular coagulation, in particular concerning the role of the extrinsic coagulation pathway, provide ground for some optimism concerning future therapeutic options.
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Aminoglycosides have historically been the mainstay of antibiotic therapy in the ICU. Despite the availability of numerous less toxic antibiotics, the clinical and microbiologic attributes of these agents have ensured their continued use in the management of infections in the critically ill patient. Innovative dosing regimens may replace traditional dosing methods if they are shown to provide improved clinical response with less toxicity potential.
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Infection of vascular catheters is one of the leading causes of nosocomial bacteremia in the critically ill patient. Most catheter-associated infections result from exogenous microbial contamination of the catheter at the time of insertion or during use and are endemic. ⋯ The diagnosis of catheter infections is difficult, as there are few signs or symptoms that are specific for an infected catheter. Catheter infection should be suspected in patients who develop fever, chills, and leukocytosis with no other apparent site of infection.
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In the 25 yrs since the original description of adult respiratory distress syndrome, much has been learned concerning the pathology and pathophysiology of the syndrome. Investigations into the humoral mediator of the syndrome are proceeding. Despite these advances and the advances in intensive care medicine, adult respiratory distress syndrome remains a considerable clinical challenge, especially when associated with sepsis.