http://ccforum.com/ The latest research articles published by Critical Care 2013-06-18T00:00:00Z H7N9 influenza is a new emerging infection in 2013 and has higher mortality. Both chest radiography and CT had some limitations in assessing such patients. We perform daily lung ultrasound in a patient with H7N9 influenza. The characters of lung ultrasound and lung ultrasound score showed high consistency with CT and the progression of pneumonia. Ultrasound can be adjutant to chest radiography and CT in caring patients with H7N9 influenza. http://ccforum.com/content/17/3/438 Peng Shen Youming Zong Jing Shu Yunchao Shi Wenjun Zhu Huijiang Qian Maoxian Yang Mao Zhang Critical Care 2013, null:438 2013-06-18T00:00:00Z doi:10.1186/cc12751 /content/figures/cc12751-toc.gif Critical Care 1364-8535 ${item.volume} 438 2013-06-18T00:00:00Z PDF Patient-ventilator trigger asynchronies are common with the use of assisted forms of mechanical ventilatory support, including non-invasive mechanical ventilatory support (NIV). Future system designs need to address this in order to improve the effectiveness of NIV http://ccforum.com/content/17/3/157 Neil MacIntyre Critical Care 2013, null:157 2013-06-18T00:00:00Z doi:10.1186/cc12729 /content/figures/cc12729-toc.gif Critical Care 1364-8535 ${item.volume} 157 2013-06-18T00:00:00Z PDF Traumatic cardiac arrest resuscitation is considered a heroic and futile endeavor. However, newer articles have more promising statistics and divide between prehospital ground and helicopter transport. Here we discuss why there might be a difference in the survivability of this subset of trauma patients. http://ccforum.com/content/17/3/156 Kelly Klein Critical Care 2013, null:156 2013-06-17T00:00:00Z doi:10.1186/cc12720 /content/figures/cc12720-toc.gif Critical Care 1364-8535 ${item.volume} 156 2013-06-17T00:00:00Z XML New oral anticoagulants including dabigatran, rivaroxaban and apixaban have been recently approved for primary and secondary prophylaxis of thromboembolic conditions. However, no clear strategy exists for managing and reversing their anticoagulant effects. We aimed to summarize the available evidence for clinical management and reversal of bleeding associated with new oral anticoagulants. Using a systematic review approach we aimed to identify studies describing reversal strategies for dabigatran, rivaroxaban and dabigatran. The search was conducted using Medline, EMBASE, HealthSTAR, and grey literature. We included laboratory and human studies. Out of 106 potentially relevant references, we included 23 studies reported in 37 references. Four studies were conducted in humans and the rest were in vitro and in vivo studies. The majority of the studies evaluated the use of prothrombinase complex concentrate (PCC) either activated or inactivated, and recombinant activated factor VII (rFVIIa). Other interventions were also identified. Laboratory studies suggest than hemostatic parameters and bleeding might be partially or completely corrected by PCC for rivaroxaban better than dabigatran. Studies in humans suggest that PCC might reverse the effects of rivaroxaban better than dabigatran assessed by hemostatic tests. We were not able to locate studies evaluating the clinical efficacy of these agents. Best available evidence suggests that PCC (activated or inactivated) might be the best option for reversing new anticoagulants. Evidence for rFVIIa is less compelling. There might be differences in the efficacy of reversing agents for different anticoagulants. Studies assessing clinical efficacy of these reversal agents are needed. http://ccforum.com/content/17/3/230 Alejandro Lazo-Langner Eddy Lang James Douketis Critical Care 2013, null:230 2013-06-17T00:00:00Z doi:10.1186/cc12592 /content/figures/cc12592-toc.gif Critical Care 1364-8535 ${item.volume} 230 2013-06-17T00:00:00Z PDF IntroductionEstimation of kidney function in critically ill patients with acute kidney injury (AKI), is important for appropriate dosing of drugs and adjustment of therapeutic strategies, but challenging due to fluctuations in kidney function, creatinine metabolism and fluid balance. Data on the agreement between estimating and gold standard methods to assess glomerular filtration rate (GFR) in early AKI are lacking. We evaluated the agreement of urinary creatinine clearance (CrCl) and three commonly used estimating equations, the Cockcroft Gault (CG), the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, in comparison to GFR measured by the infusion clearance of 51Cr-EDTA, in critically ill patients with early AKI after complicated cardiac surgery. Methods: Thirty patients with early AKI were studied in the intensive care unit, 2 to 12 days after complicated cardiac surgery. Infusion clearance for Chromium-ethylenediaminetetraacetic acid (51Cr-EDTA) was obtained as a measure of GFR (GFR51Cr-EDTA) calculated from the formula; GFR (mL/min/1.73m2) = (51Cr-EDTA infusion rate x 1.73) / (arterial 51Cr-EDTA x BSA) and compared with the urinary CrCl and the estimated GFR (eGFR) from the three estimating equations. Urine was collected in two 30 min periods to measure urine flow and urine creatinine. Urinary CrCl was calculated from the formula; CrCl (mL/min/1.73m2) = (urine volume x urine creatinine x 1.73) / (serum creatinine x 30min x BSA). Results: The within-group error was lower for GFR51Cr-EDTA than the urinary CrCl method, 7.2 %. vs. 55.0 %. The between-method bias was 2.6, 11.6, 11.1 and 7.39 ml/min, for eGFRCrCl, eGFRMDRD , eGFRCKD-EPI and eGFRCG , respectively, when compared to GFR51Cr-EDTA. The error was 103, 68.7, 67.7 and 68.0 % for eGFRCrCl, eGFRMDRD, eGFRCKD-EPI and eGFRCG, respectively when compared to GFR51Cr-EDTA. Conclusions: The study demonstrated a poor precision of the commonly utilized urinary CrCl method for assessment of GFR in critically ill patients with early AKI and should not be used as a reference method when validating new methods for assessing kidney function in this patient population. The commonly used estimating equations perform poorly, when estimating GFR, with high biases and unacceptably high errors. http://ccforum.com/content/17/3/R108 Gudrun Bragadottir Bengt Redfors Sven-Erik Ricksten Critical Care 2013, null:R108 2013-06-15T00:00:00Z doi:10.1186/cc12777 /content/figures/cc12777-toc.gif Critical Care 1364-8535 ${item.volume} R108 2013-06-15T00:00:00Z PDF Clinical trials over time have used a variety of approaches for both measuring tight glycemic control and reporting results. The review by Finfer and colleagues in this issue of Critical Care is a step toward consensus within the research community to standardize the way blood glucose is measured and reported in clinical trials. The authors propose using specific measures of central tendency and dispersion for reporting glucose, advocate the use of blood gas analyzers and elimination of point-of-care glucose monitors in the intensive care unit, and comment on performance of continuous glucose monitors. As we await the release of updated rules from the International Standards Organization and process the new rules from the Clinical Laboratory and Standards Institute to regulate glucose monitoring, these recommendations should trigger many more conversations within the field as we strive for uniformity. However, we need to be cautious in prematurely proposing and adopting standards of care that fail to account for newer technology and data in this rapidly growing area of research. http://ccforum.com/content/17/3/155 Carmen Soto-Rivera Michael Agus Critical Care 2013, null:155 2013-06-14T00:00:00Z doi:10.1186/cc12599 /content/figures/cc12599-toc.gif Critical Care 1364-8535 ${item.volume} 155 2013-06-14T00:00:00Z XML The management reporting and assessment of glycemic control lacks standardization. The use of different methods to measure the blood glucose concentration and to report the performance of insulin treatment yields major disparities and complicates the interpretation and comparison of clinical trials. We convened a meeting of 16 experts plus invited observers from industry to discuss and where possible reach consensus on the most appropriate methods to measure and monitor blood glucose in critically ill patients and on how glycemic control should be assessed and reported. Where consensus could not be reached, recommendations on further research and data needed to reach consensus in the future were suggested. Recognizing their clear conflict of interest, industry observers played no role in developing the consensus or recommendations from the meeting. Consensus recommendations were agreed for the measurement and reporting of glycemic control in clinical trials and for the measurement of blood glucose in clinical practice. Recommendations covered the following areas: How should we measure and report glucose control when intermittent blood glucose measurements are used? What are the appropriate performance standards for intermittent blood glucose monitors in the ICU? Continuous or automated intermittent glucose monitoring - methods and technology: can we use the same measures for assessment of glucose control with continuous and intermittent monitoring? What is acceptable performance for continuous glucose monitoring systems? If implemented, these recommendations have the potential to minimize the discrepancies in the conduct and reporting of clinical trials and to improve glucose control in clinical practice. Furthermore, to be fit for use, glucose meters and continuous monitoring systems must match their performance to fit the needs of patients and clinicians in the intensive care setting.See related commentary by Soto-Rivera and Agus, http://ccforum.com/content/17/3/155 http://ccforum.com/content/17/3/229 Simon Finfer Jan Wernerman Jean-Charles Preiser Tony Cass Thomas Desaive Roman Hovorka Jeff Joseph Mikhail Kosiborod James Krinsley Iain Mackenzie Dieter Mesotten Marcus Schulz Mitch Scott Robbert Slingerland Greet Van den Berghe Tom Van Herpe Critical Care 2013, null:229 2013-06-14T00:00:00Z doi:10.1186/cc12537 /content/figures/cc12537-toc.gif Critical Care 1364-8535 ${item.volume} 229 2013-06-14T00:00:00Z XML Respiratory failure in HIV infected patients is a relatively common presentation to Intensive Care Unit (ICU). The debate on ICU treatment of HIV infected patients goes on despite overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV infected patients and improved outcome from critical illness remain under-recognised. Also the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decision to provide ICU support to HIV infected patients, a review of literature was undertaken.It is notable that the frequency of respiratory illnesses that are not directly related to underlying HIV disease is now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of Pneumocystis jirovecii as a cause of respiratory failure has declined since AIDS epidemic and sepsis including bacterial pneumonia has emerged as frequent cause of hospital and ICU admission amongst HIV patients.The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion.As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time ICU admission, the clinicians should keep a low threshold for requesting HIV test for patients with recurrent pneumonia. http://ccforum.com/content/17/3/228 Putul Sarkar Husham Rasheed Critical Care 2013, null:228 2013-06-14T00:00:00Z doi:10.1186/cc12552 /content/figures/cc12552-toc.gif Critical Care 1364-8535 ${item.volume} 228 2013-06-14T00:00:00Z PDF Despite the universal prescription of sedative drugs in the intensive care unit (ICU), current practice is not guided by high-level evidence. Landmark sedation trials have made significant contributions to our understanding of the problems associated with ICU sedation and have promoted changes to current practice. We identified challenges and limitations of clinical trials which reduced the generalizability and the universal adoption of key interventions. We present an international perspective regarding current sedation practice and a blueprint for future research, which seeks to avoid known limitations and generate much-needed high-level evidence to better guide clinicians' management and therapeutic choices of sedative agents. http://ccforum.com/content/17/3/322 Yahya Shehabi Rinaldo Bellomo Sangeeta Mehta Richard Riker Jukka Takala Critical Care 2013, null:322 2013-06-13T00:00:00Z doi:10.1186/cc12679 /content/figures/cc12679-toc.gif Critical Care 1364-8535 ${item.volume} 322 2013-06-13T00:00:00Z XML Liver dysfunction is believed to contribute to the metabolic derangements of critical illness. The cellular basis of liver dysfunction is poorly understood and its consequences largely unknown. Recent work by Gonnert and colleagues sheds additional light. Using two imaging techniques to track the clearance of biotransformed dyes by the liver in a rat model of intra-abdominal infection, the authors show that the predominant defect in sepsis lies in the excretion of biotransformed molecules from the hepatocyte into the bile canaliculi. Their work both points to a new aspect of hepatic dysfunction through focus on a role in the metabolic derangements of sepsis and suggests a possible strategy to diagnose and monitor this process in critically ill patients. http://ccforum.com/content/17/3/153 John Marshall Critical Care 2013, null:153 2013-06-12T00:00:00Z doi:10.1186/cc12731 /content/figures/cc12731-toc.gif Critical Care 1364-8535 ${item.volume} 153 2013-06-12T00:00:00Z XML