Publications

A learning curve appeared to be present within the PROWESS trial such that the ability to demonstrate efficacy improved with increasing site experience. This potential learning curve may have implications for design of future trials. Investigational sites may need to require a minimum level of protocol-specific experience to appropriately implement a given trial. This experience should be an important consideration in designing trials and analysis plans. Diligence by coordinating centers, site investigators, study coordinators, and sponsors is necessary to ensure that the protocol is executed as designed such that a treatment benefit, if present, will be evident.

Background: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

Mongkolpun, Wasineenart; Cortez, Diego Orbegozo; Franco, Cláudio; Vincent, Jean-Louis; Creteur, Jacques

A systematic literature search provided no conclusive evidence of any pharmacologic intervention that has consistently reduced mortality in critically ill patients. Strategies associated with improved or noninvasive mechanical ventilation were associated with reduced mortality.

Early alterations of red blood cell rheology are common in intensive care unit patients, especially in those with sepsis. Comorbidities (other than hematologic diseases) do not significantly influence these abnormalities. These alterations could contribute to the microcirculatory alterations observed in critically ill patients.

SOCIETY OF CRITICAL CARE MEDICINE 34TH CRITICAL CARE CONGRESS PHOENIX, ARIZONA, USA JANUARY 15-19, 2005: Poster Presentation: Clinical Science: Therapeutics II

This study shows that there exists a subset of patients discharged from the ICU who may benefit from care in an step-down unit relative to that in the ward. We found that step-down unit care was associated with statistically significant improvements in patient outcomes especially for high-risk patients. Our results suggest that step-down units can provide effective transitional care for ICU patients.

Our data suggest that the use of warm blood cardioplegia, rather than cold crystalloid cardioplegia, may reduce the inflammatory response to CPB. This observation warrants future randomized investigation to determine its clinical relevance.

Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient's physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.