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The choice of which intravenous solution to prescribe remains a matter of considerable debate in intensive care units around the world. Trends have been moving away from using hydroxyethyl starch solutions following concerns about safety. But are the available data sufficient to clearly assess the risk-benefit balance for all patients, and is there enough evidence of harm to justify removing these drugs completely from our hospitals?
The effects of hydrochloric acid (HCl) administration were studied in 15 critically ill patients whose metabolic alkalosis caused a significant alkalemia (pH 7.50 to 7.58) unresponsive to sodium and potassium chloride administration. Arterial pH and bicarbonate and chloride concentrations normalized after a 6- to 12-h mean infusion of 200 +/- 54 mmol of .25 N HCl. There were no deleterious vascular, hematologic, or metabolic side-effects. HCl administration was associated with an increase in mean PaO2 from 94 +/- 21 to 121 +/- 31 torr (p less than .001). This increase was comparable in patients breathing spontaneously and those treated with controlled mechanical ventilation, and was attributed at least in part to a decrease in pulmonary shunt. These results indicate that .25 N HCl, infused at the rate of 100 ml/h into the superior vena cava, can correct metabolic alkalosis safely and rapidly. The persistence of the beneficial effects of this treatment on arterial oxygenation remains to be confirmed.
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IntroductionTrans-nasal cooling started during cardiopulmonary resuscitation (CPR) has shown to improve the return to spontaneous circulation (ROSC) and survival rate in an experimental prolonged cardiac arrest model. A multicenter randomized trial (PRINCE) has also suggested an improved neurological outcome in patients receiving trans-nasal cooling during CPR in the prehospital setting when compared with those treated by conventional hypothermia on hospital arrival, provided a delay between collapse and CPR of less than 10 minutes. MethodsPatients with witnessed cardiac arrest and a downtime less than 20 minutes were randomized to prehospital intra-arrest cooling versus standard ACLS care. Trans-nasal cooling (RhinoChill, BeneChill Inc., CA, USA) was initiated using a mixture of volatile coolant fluid with oxygen delivered into the nasopharynx for rapid evaporative heat transfer. Cooling was continued during CPR and, for patients who achieved ROSC, until initiation of systemic cooling at hospital. Resuscitation was continued for at least 30 minutes. All patients were then cooled at the hospital. ResultsTwenty-four patients were included, but one in the treatment group was excluded from the per-protocol analysis because of DNR orders. Patients randomized to treatment group (n = 9) or standard care (n = 14) had similar demographics, initial rhythm, time from collapse to CPR and ALS arrival. Median time from collapse to cooling initiation was 19 minutes. In total, 6/9 (66%) treated and 6/14 (42%) control patients achieved ROSC. Three patients (33%) in the treatment group survived to hospital discharge with CPC 1 to 2, while only one (7%) of the control group patients had good neurological outcome. No serious adverse events occurred in treated patients. ConclusionsTrans-nasal cooling seems to be safe and feasible in a prehospital setting. These single-center data confirm that trans-nasal cooling may improve the ROSC rate as well as good neurological outcome if started in patients with a short delay between collapse and CPR.
The present review showed a slight reduction in mortality from septic shock over the years, although this result should be approached with caution. The heterogeneity of the articles and absence of a severity score for most of the studies limited our analysis. Furthermore, there was an increasing prevalence of Gram-positive causative organisms, and a change of the predominant origin of sepsis from the abdomen to the chest.
