Publications

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The role of hypertonic saline in sepsis remains unclear because clinical data are limited and the balance between beneficial and adverse effects is not well defined. In this systematic literature review, we searched PubMed and Embase to identify all randomized controlled trials up until January 31, 2018 in which hypertonic saline solutions of any concentration were used in patients of all ages with sepsis and compared to a cohort of patients receiving an isotonic fluid. We identified 8 randomized controlled trials with 381 patients who had received hypertonic saline. Lower volumes of hypertonic saline than of isotonic solutions were needed to achieve the desired hemodynamic goals (standardized mean difference, -0.702; 95% CI, -1.066 to -0.337; P < .001; moderate-quality evidence). Hypertonic saline administration was associated with a transient increase in sodium and chloride concentrations without adverse effects on renal function (moderate-quality evidence). Some data suggested a beneficial effect of hypertonic saline solutions on some hemodynamic parameters and the immunomodulatory profile (very low-quality evidence). Mortality rates were not significantly different with hypertonic saline than with other fluids (odds ratio, 0.946; 95% CI, 0.688-1.301; P = .733; low-quality evidence). In conclusion, in our meta-analysis of studies in patients with sepsis, hypertonic saline reduced the volume of fluid needed to achieve the same hemodynamic targets but did not affect survival.

Severe sepsis is common and increasing in incidence. Mortality rates remain high. Discovery of the link between the coagulation system and the inflammatory response to sepsis led to the development of drotrecogin alpha (activated). This recombinant form of the natural anticoagulant, activated protein C, was shown to reduce 28-day mortality from severe sepsis in a large, randomised, placebo-controlled, multi-centre Phase III study. Although subsequent studies have demonstrated that drotrecogin alpha (activated) is not of benefit to all patients with severe sepsis, it does reduce mortality rates in patients at a high risk of death. Drotrecogin alpha (activated) is associated with an increased risk of bleeding. Recent studies have shed light on its mode of action, which is primarily attributed today to cytoprotective effects especially on the endothelium with improved microcirculation. Ongoing studies will help define which patients are most likely to benefit, perhaps with the help of biochemical markers.

info:eu-repo/semantics/published

<h3>Background</h3> The majority of ICU deaths are preceded by an end-of-life decision. <h3>Aim</h3> To discuss the challenges of end-of-life care and use of ACPs in critically ill patients. <h3>Methods</h3> Review of relevant literature and personal experience. <h3>Results</h3> ACPs apply more to patients with chronic conditions (eg. advanced cancer or progressively debilitating diseases) and are rarely relevant in the ICU setting. <h3>Discussion</h3> The more acute the disease, the more difficult it is to determine how an individual would wish to be treated, as he/she is no longer in a position to make decisions. There are many different types of acute, unexpected events and many different processes, and it is not possible to cover every eventuality in one document, whatever its length. Moreover, it is often difficult to predict the likelihood of recovery in these patients. Hence, ACPs do not make sense in the acute setting. One could argue that ACPs may prevent futile therapy, but disproportionate care (a preferred term nowadays) should anyway be avoided in all cases, and there is no need for a document to confirm this. Many consider it preferable to identify a proxy, who will be able to express the patient's wishes as reliably as possible. <h3>Conclusion</h3> End-of-life decisions are complex and influenced by religious and cultural background. They must be guided by the four key ethical principles: beneficence, non-maleficence, patient autonomy, and distributive justice. ACPs are rarely relevant in the ICU. Every attempt must be made to facilitate an end-of-life with dignity and without suffering.

on Intensive Care and Emergency Medicine seal is maintained by gentle pressure on the TT keeping the cuff pressing on the vocal cords. During percutaneous tracheostomy the bougie remains in the trachea. When ventilation through the tracheostomy tube (cuff inflated) is confirmed, the TT and bougie are withdrawn. Throughout the procedure, if ventilation difficulties occur, the TT can be easily re-inserted using the bougie as a guide.

Sepsis remains a leading cause of death in the intensive care unit. With no specific sepsis therapies available, management currently relies on infection control and hemodynamic stabilization. Rapid diag-nosis enabling early initiation of appropri-ate therapy is essential to maximize sur-vival rates. Effective antimicrobial therapy should be started as soon as possible after diagnosis, with empirical choices based on likely pathogens, local microbiologi-cal patterns, and any recent antimicrobial therapy. At the same time, fluids and va-sopressor agents should be commenced to restore and maintain hemodynamic stability and adequate tissue perfusion. No effective immunomodulatory therapies are available, but some candidates are un-dergoing clinical trials. Better techniques for characterization of the degree of sepsis response in individual patients are needed to help target such agents more appropri-ately as some patients may benefit from immunosuppressive agents while others may require an immune stimulating in-tervention. The management of patients with septic shock is often complex and the development of sepsis teams should be encouraged so that the multiple compo-nents of treatment, e.g., insertion of intra-vascular lines, blood sampling for culture and biochemistry, positioning of required monitoring devices, fluid, antibiotic and vasoactive drug administration, etc, can be carried out simultaneously.&nbsp;&nbsp;