August 2005 - Critical Care and Shock

From the Editor

Xavier Leverve 19/08/2005

Already one year ago the terribly sad news of Dr Iqbal Mustafa sudden death hurt us, a few days before the opening of the Bali

A 39-year old gentleman with pancreatitis sustained cardiorespiratory arrest due to tension pneumothorax after a Swan-Ganz catheter placement. Despite recovering cardio-respiratory function, he did not regain consciousness. Three months later, he seemed awake, but did not answer questions, follow commands, blink to threat or exhibit purposeful movements. He had spastic quadraparesis, decerebrate posturing in response to noxious stimuli, sustained ankle clonus and bilateral Babinski sign. The electroencephalogram showed burst-suppression.

Analysis of post coronary bypass surgery risk factors and scoring system with study of immunogenetic epidemiology

Tri Wahyu 02/08/2005

Coronary heart disease patients with 308 polymorphism (particularly heterozygote G-A polymorphism) have a higher circulating TNF a concentration compared to CHD patients without polymorphism. The post surgical clinical manifestations were not proven to be influenced by circulating TNF Ã¡ concentrations. It is thought that the increase was not enough to yield clinically manifestation.

Lactate is the ultimate oxidative energy substrate in brain and elsewhere

Avital Schurr 02/08/2005

Now-a-days, the focus on lactate is due to its being an oxidative substrate for energy metabolism in brain (and other tissues), rather than a useless end product of anaerobic glycolysis. Mounting evidence indicates that lactate does play a major role in aerobic energy metabolism in the brain, the heart, skeletal muscle and possibly in any other tissue and organ.

Spontaneous breathing during mechanical ventilation in ARDS

Ross Freebairn 02/08/2005

The objective of mechanical ventilation used in the management of Acute Respiratory Distress Syndrome (ARDS) is to ensure adequate tissue oxygenation and alveolar ventilation while limiting the patientsâ€™ work of breathing and preventing further damage to the lungs. Although the â€œpartial supportâ€ ventilation modes were initially developed to assist weaning or liberation from supported ventilation, they have gained increasing popularity as primary ventilation modes, even in patients in with severe acute pulmonary dysfunction.

Is there any need for higher PEEP levels in ARDS patients?

Jack J Haitsma 02/08/2005

Lung protective ventilation has been shown to reduce mortality in ARDS patients. Current guidelines are focussed on lowering tidal volumes and minimizing mean airway pressures. In this review we discuss possible future improvements to mechanical ventilation; especially the open lung maneuver. We discuss the rationale for the use of higher PEEP levels in ARDS patients, using data from animal and human studies. Finally, guidelines for future strategies and/ or investigations are presented.

Fluid resuscitation: the good, the bad and the ugly

AB Johan Groeneveld 02/08/2005

Fluid resuscitation is one of the most common therapeutic steps in the critically ill. In this brief overview, the goals and potential adverse effects of fluid resuscitation are addressed. The contention is that the value of many of the fluid resuscitation goals in hypovolemic patients has not been unequivocally established, that overhydration is a significant problem and that certain types of fluids can be associated with major adverse effects.

Pyrexia in the critically ill

N R Webster 02/08/2005

Temperature change is a conserved physiological response to infection. In animal studies cytokine responses associated with body temperature changes have been elucidated. In humans with sepsis, hypothermia appears to be associated with higher TNF-alpha concentrations and has a significantly higher mortality. However, the presence of pyrexia does not appear to influence outcome from infection.