Early hemodynamic resuscitation in septic shock:understanding and modifying oxygen delivery

In a previous issue of Critical Care, researchers have focused on the venous-to-arterial carbon dioxide difference (Pv-aCO(2)) as a surrogate marker for systemic perfusion in patients with septic shock. Although the complex mechanisms responsible for an increased Pv-aCO(2) in septic shock need to be further unraveled, the potential prognostic value of Pv-aCO(2) seems clinically relevant and useful in daily practice in view of its easy availability

Clinical review: Strict or loose glycemic control in critically ill patients - implementing best available evidence from randomized controlled trials

Glycemic control aiming at normoglycemia, frequently referred to as 'strict glycemic control' (SGC), decreased mortality and morbidity of adult critically ill patients in two randomized controlled trials (RCTs). Five successive RCTs, however, failed to show benefit of SGC with one trial even reporting an unexpected higher mortality. Consequently, enthusiasm for the implementation of SGC has declined, hampering translation of SGC into daily ICU practice. In this manuscript we attempt to explain the variances in outcomes of the RCTs of SGC, and point out other limitations of the current literature on glycemic control in ICU patients. There are several alternative explanations for why the five negative RCTs showed no beneficial effects of SGC, apart from the possibility that SGC may indeed not benefit ICU patients. These include, but are not restricted to, variability in the performance of SGC, differences among trial designs, changes in standard of care, differences in timing (that is, initiation) of SGC, and the convergence between the intervention groups and control groups with respect to achieved blood glucose levels in the successive RCTs. Additional factors that may hamper translation of SGC into daily ICU practice include the feared risk of severe hypoglycemia, additional labor associated with SGC, and uncertainties about who the primarily responsible caregiver should be for the implementation of SGC

Bench-to-bedside review: Sepsis is a disease of the microcirculation

Microcirculatory perfusion is disturbed in sepsis. Recent research has shown that maintaining systemic blood pressure is associated with inadequate perfusion of the microcirculation in sepsis. Microcirculatory perfusion is regulated by an intricate interplay of many neuroendocrine and paracrine pathways, which makes blood flow though this microvascular network a heterogeneous process. Owing to an increased microcirculatory resistance, a maldistribution of blood flow occurs with a decreased systemic vascular resistance due to shunting phenomena. Therapy in shock is aimed at the optimization of cardiac function, arterial hemoglobin saturation and tissue perfusion. This will mean the correction of hypovolemia and the restoration of an evenly distributed microcirculatory flow and adequate oxygen transport. A practical clinical score for the definition of shock is proposed and a novel technique for bedside visualization of the capillary network is discussed, including its possible implications for the treatment of septic shock patients with vasodilators to open the microcirculation

Tight glycaemic control: intelligent technology or a nurse-wise strategy?

Despite disappointing findings with the computerized decision-supported tight glycaemic control (TGC) protocol, Shulman and colleagues [1] argue that one reason to proceed with computerized TGC protocols is that complex protocols remain mandatory for TGC. Indeed, most intensivists think of TGC as difficult and complex. In The Netherlands as many as 46 different protocols are in use, including protocols with flowcharts, sliding scales, calculators and conversion tables as well as computerized decisionsupport protocols (survey, de Graaff MJ, Royakkers AANM, Kieft H, Spronk PE, van der Sluijs HP, Schultz MJ, unpublished data); they all are exceptionally complex and frequently difficult to follow. We recently had the opportunity to visit the Leuven hospital and were surprised to see their protocol, which is remarkably concise, far from complex, an

Year in review 2006: Critical Care – resource management

As health care resources become increasingly constrained, it is imperative that intensive care unit resources be optimized. In the years to come, a number of challenges to intensive care medicine will need to be addressed as society changes. Last year's Critical Care papers provided us with a number of interesting and highly accessed original papers dealing with health care resources. The information yielded by these studies can help us to deal with issues such as prognostication, early detection and treatment of delirium, prevention of medical errors and use of radiology resources in critically ill patients. Finally, several aspects of scientific research in critically ill patients were investigated, focusing on the possibility of obtaining informed consent and recall of having given informed consent

Quality of life before intensive care unit admission is a predictor of survival

Introduction: Predicting whether a critically ill patient will survive intensive care treatment remains difficult. The advantages of a validated strategy to identify those patients who will not benefit from intensive care unit (ICU) treatment are evident. Providing critical care treatment to patients who will ultimately die in the ICU is accompanied by an enormous emotional and physical burden for both patients and their relatives. The purpose of the present study was to examine whether health-related quality of life (HRQOL) before admission to the ICU can be used as a predictor of mortality. Methods: We conducted a prospective cohort study in a university-affiliated teaching hospital. Patients admitted to the ICU for longer than 48 hours were included. Close relatives completed the Short-form 36 (SF-36) within the first 48 hours o