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Search Results: 1 - 10 of 203090 matches for " Daniel de Backer "
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Atlas of hemofiltration: a practical guide for beginners
Daniel De Backer
Critical Care , 2002, DOI: 10.1186/cc1505
Abstract: The first part explains the principles of blood purification and introduces the reader to the complex nomenclature. It also describes the principles of solute transport, allowing one to understand what exactly is being removed, to what degree and by means of which mechanism.In the second, richly illustrated part, the authors present nine haemofiltration devices. Although this section will soon be outdated because of the fast moving nature of the discipline, these brief reports form a vital aspect of the book. A few sentences are provided for each device regarding its performance and main characteristics, as is a list of major advantages and disadvantages. Hence, this part of the book is very useful for practitioners who wish to compare several devices in theory before actually testing them in their own units. It should be noted that some of the devices are not presented by the authors themselves but rather by contributors who are affiliated with the respective manufacturers; potential conflicts of interest are stated in all cases, however, and these chapters are of similar quality to those written by the authors themselves.The third part of the book explains some practical aspects of haemofiltration, including vascular access, anticoagulation, drug removal and use in paediatric patients. Again, these chapters are very nicely presented. Two of them deserve special mention. Chapter 15 uses a case presentation to describe the most commonly encountered problems in haemofiltration, and provides some useful tips for troubleshooting where appropriate. Chapter 17 addresses all of the important nursing issues associated with haemofiltration, again including a very interesting troubleshooting guide.Overall the book is well designed. One might regret that illustrations and figures are in black and white, but coloured illustrations would have raised the price considerably. The chapters are well organized and the index will help the reader to find all necessary information quick
Critical Care Medicine: The Essentials
Daniel De Backer
Critical Care , 2010, DOI: 10.1186/cc9204
Abstract: Why should we read The Essentials? All patients do not behave the same, therefore physicians have to decide patient management using clinical judgment based on clinical signs, on core physiology and on patient response to disease and interventions. Most of the attractiveness of this book comes from the fact that it is written by clinicians for clinicians. It describes a lot of clinical signs, (patho)physiological patterns, X-ray aspects, and other small tricks that guide the physician to rapidly diagnose at the bedside what the patient may present or to better set up ventilatory support.This book is separated into two parts: the first relates to techniques and methods, while the second relates to diseases. The separation is sometimes artifactual, as mechanical ventilation has to be discussed as a technique but also for the management of ventilatory failure. Nevertheless, this separation does not impede reading because there is no overlap and because this book is not a handbook. Chapters have to be read cautiously, taking time to understand the details of physiological principles or the interaction between disease processes and interventions.The book covers most aspects of intensive care practice, including a rapid description of the diseases that may be encountered in critically ill patients, the specificities of critically ill patients, and the therapeutic interventions and monitoring techniques that may be used. The quality of the different sections is quite heterogeneous. The cardiovascular sections are excellent and the respiratory sections are really astonishing. Even physicians with excellent knowledge in respiratory medicine will learn by reading these parts. The sections describe all types of respiratory failure and discuss their specific management. Respiratory patterns and ventilatory support are reported extensively.The section on hemodynamic monitoring is attractive - including a large part on the interpretation of pulmonary artery tracings (which is par
Oxford Handbook of Critical Care for PDAs, 2nd edition
Daniel De Backer
Critical Care , 2007, DOI: 10.1186/cc5152
Abstract: What is gained from presentation in a personal digital assistant (PDA)? Information is easily accessed at the bedside, at any time of the day. However, users should not expect to have all the information that is usually provided in textbooks presented in this PDA version. Indeed, chapters are succinct and concise; even if these present all the essential information, details cannot be provided. The information is easily accessible either directly from the index and table of contents, or through easy links. These links are well organized and are of course the essential gain from the PDA format. Users can easily find their way through the different chapters. Another important advantage of the PDA is that the facility for making annotations is offered.Most areas of intensive care medicine are covered, including the classical pathophysiological disorders (shock and organ failure), monitoring techniques, organ support technologies, and intoxication management.Organization and management of the intensive care unit is also covered. This includes smoke and fire management. Although at a first glance it might not seem useful to have fire management dealt with on PDAs, one can imagine that this might be helpful for the physician confronted with such a stressful and difficult experience. Indeed, PDAs are always in physicians' pockets, and thus a rapid reminder of essential information is easily available when one does not have the time to search for information in an office. However, some other parts of this chapter might seem less useful, such as descriptions of audits or staffing. Scoring systems are also briefly described; one might nevertheless regret that there is no integrated automatic calculator.The most interesting aspect of this guide is probably the use of drug recommendations. For each pathology, therapeutic options are discussed and, when applicable, drug dosages are proposed.Some chapters and assumptions are occasionally surprising. The maximal dose for dopamine i
Can passive leg raising be used to guide fluid administration?
Daniel De Backer
Critical Care , 2006, DOI: 10.1186/cc5081
Abstract: In many instances, hemodynamic optimization requires the use of fluids. However, the response to fluids may be quite variable and cannot be adequately predicted from the measurements of intravascular pressures (central venous pressure or pulmonary artery pressure) [1] or volumes. Indeed, the relationship between stroke volume and preload varies considerably between the patients. Accordingly, extreme values only can predict fluid responsiveness. Dynamic indices reflecting respiratory-induced variations in stroke volume have been developed [2], but these cannot be used in patients with cardiac arrhythmias or in patients with spontaneous respiratory movements [3] or ventilated with a low tidal volume [4]. Recently, the so-called passive leg raising (PLR) test has been proposed. This test is based on the principle that PLR induces an abrupt increase in preload due to autotransfusion of blood contained in capacitance veins of the legs. This abrupt increase in preload leads to an increase in cardiac output in preload-dependent patients but not in other patients. However, the test requires the determination of cardiac output with a fast-response device, because the hemodynamic changes may be transient. In a previous issue of Critical Care, Lafanechère and colleagues [1] used esophageal Doppler to monitor cardiac output and reported that a PLR-induced increase in cardiac output higher than 8% can predict fluid responsiveness in critically ill patients. The predictive value of the PLR test was similar to that of respiratory-induced variations in pulse pressure. Although this study basically confirms the results of Monnet and colleagues [5], it brings some new pieces of information to the field, but also raises important questions.Indeed, the 22 patients investigated by Lafanechère and colleagues [1] were all in acute circulatory failure and treated with high doses of epinephrine or norepinephrine. However, the use of vasopressor agents may be of paramount importance in deter
A useful tool for trainees in intensive care
Daniel De Backer
Critical Care , 2005, DOI: 10.1186/cc3032
Abstract: This manual is already in its 5th edition. This 1200-page intensive care manual covers most of the field of intensive care practice, including organizational aspects and pediatric intensive care. Most of the contributors originate from Australia, the UK, and Hong Kong, and have a large experience in clinical practice, research, and teaching in intensive care. This manual lies somewhere between a handbook and a textbook, with the size of a textbook and the practical presentation and conciseness of a handbook. This format is somewhat regrettable because on the one hand the book is clearly too large to be stored in the pocket but on the other hand it is not exhaustive either. Given the information presented, this book is clearly intended for physicians in training in intensive care; a more experienced audience would rather read a more in-depth intensive care medicine textbook. The principal merit of the book is that young physicians can rapidly find up-to-date practical information.The book covers most aspects of intensive care practice, including a rapid description of the diseases that may be encountered in critically ill patients, the specifics of critically ill patients, and the therapeutic interventions and monitoring techniques that may be used. The quality of the different sections is quite heterogeneous. For example, the cardiovascular section covers the various etiologies and therapies of shock, hemodynamic monitoring, and multiple organ dysfunction. The chapter on hemodynamic monitoring is really outstanding. The information presented is not limited to the pulmonary artery catheter but also covers all the newer technologies. Transpulmonary thermodilution and its derived volumetric indices are discussed, as well as lithium dilution, esophageal Doppler and echocardiography. The limitations and advantages of each of these techniques are discussed and some decision trees are presented. Similarly, the chapter on monitoring oxygenation is very attractive. The physi
Optimal management of the high risk surgical patient: beta stimulation or beta blockade?
Daniel De Backer
Critical Care , 2005, DOI: 10.1186/cc3930
Abstract: The peri-operative care of high-risk surgical patients remains a challenge. Despite improvement in surgical and anesthesiological procedures, the mortality of high-risk surgical procedures remains above 10%. In these patients, peri- and post-operative alterations in oxygen transport are closely related to the development of organ failure and death [1,2]. This led to the concept that increasing deliberately oxygen delivery (DO2) may prevent the development of organ failure. Several studies have reported that peri-operative hemodynamic optimization (goal directed therapy (GDT)) guided by the pulmonary artery catheter may decrease morbidity and mortality [3-7]. GDT is usually based on generous fluid administration and, if needed, beta-adrenergic agents, including dobutamine [3,6] and dopexamine [4,5]. Several questions remain unanswered, however, and limit the wide application of GDT in patients submitted to high-risk surgery.One major limitation of GDT is that it was usually initiated in the operating room or even sometimes before the intervention. This is usually difficult to apply, either because of bed shortage or because the assessment of peri-operative risk of death is sometimes difficult before the surgical intervention. Some surgical interventions may indeed be much easier than predicted, and the patients would then have been submitted to useless or even deleterious GDT, while other interventions are sometimes unexpectedly complicated and GDT is not provided to these patients. In this issue of Critical Care, Pearse et al. [8] elegantly avoided these problems. They investigated the effects of GDT applied only when the patient is admitted to the intensive care unit (ICU), when peri-operative risk of death may be more easily determined. They used fluids and dopexamine to increase DO2 (to a target of 600 mL/min.m2) for 8 h. The DO2 target was achieved in 80% of the GDT group and in 45% of the control group. Fewer patients developed complications in the GDT group th
The cuff-leak test: what are we measuring?
Daniel De Backer
Critical Care , 2004, DOI: 10.1186/cc3031
Abstract: Tracheal extubation of patients is still a major challenge, with the possibility of post-extubation stridor and then re-intubation if the patient is unable to sustain the increase in respiratory work. Stridor is responsible for 15–38% of extubation failures [1-3] and for close to 38% of early extubation failures [3]. Recognition of stridor is important because these patients can benefit from close monitoring and from specific therapies including non-invasive respiratory assistance, aerosolized adrenaline (epinephrine), and steroids (even though the efficacy of steroids remains under debate). Ideally, patients at risk of developing laryngeal edema should be identified as early as possible, and the cuff-leak test has been proposed for this purpose. The principle of this test is quite simple and is based on the fact that the air leak around a tracheal tube with a cuff deflated will be inversely related to the degree of laryngeal obstruction generated by laryngeal edema.The cuff-leak test was developed initially in children with croup [4]; extubation was likely to be successful if an air leak could be heard when the baby coughed during positive pressure ventilation. The test was further refined to allow quantitative measurements, using the difference between the expired tidal volume with the cuff inflated and with the cuff deflated: the higher the leak, the lower the likelihood that post-extubation stridor will occur. The discrimination power of the test is highly variable (Table 1), depending on the population investigated, the incidence of post-extubation stridor (ranging from to 4% to 38%), the method of determination of cuff leak (absolute value versus value relative to tidal volume measured with an inflated cuff, number of measurements of tidal volumes averaged, and so on). But perhaps more importantly, the cut-off value should be adapted to the situation; the cut-off that is usually given in most studies assumes an equivalent impact of false positive and false neg
Abdominal compartment syndrome
Daniel De Backer
Critical Care , 1999, DOI: 10.1186/cc373
Abstract: Various systems are involved in this syndrome. First, the increased intra-abdominal pressure is transmitted to the pleural space so that lung compliance decreases. Hypoventilation and alteration of ventilation/perfusion distribution lead to hypoxemia and hypercapnia. When mechanical ventilation is applied, very high inspiratory pressures are often required to deliver tidal volume. Second, the combined increase in abdominal pressure and pleural pressure leads to a decrease in venous return, direct compression of the heart, and increased afterload (especially in the right ventricle). Third, perfusion to the intra-abdominal organs can be critically reduced by the combined effects of the decreased cardiac output, increased interstitial pressure, and increased outflow pressure. This can lead to oliguria and renal failure. Splanchnic ischemia can also occur as reflected by a decreased mucosal pH [1,2], decreased liver metabolism [3], and bacterial translocation [4]. In addition, perfusion of the abdominal wall may be decreased, so that wound healing may be impaired. Finally, intracranial pressure may also be increased due to the decrease in cerebral venous return and increased venous pressure.The magnitude of this syndrome and the involvement of the various organs depend on the level of the intra-abdominal pressure. The normal intra-abdominal pressure ranges between 0 and 5 mmHg. When it is mildly increased to between 10 and 15 mmHg, cardiac index is usually maintained or even increased because abdominal viscera are mildly squeezed and venous return increases. Respiratory and renal symptoms are unlikely to occur. Hepatosplanchnic blood flow may decrease [5]. At this point, intravascular volume optimization will probably correct these alterations. When intra-abdominal pressure is moderately increased to between 15 and 25 mmHg the full syndrome may be observed, but usually responds to aggressive fluid resuscitation, and surgical decompression should be considered. At high p
Year in review 2010: Critical Care - cardiology
Daniel De Backer, Sabino Scolletta
Critical Care , 2011, DOI: 10.1186/cc10542
Abstract: Vasopressor agents are the cornerstone of therapy for patients with septic shock. However, the time at which vasopressor agents should be introduced is controversial. Hamzaoui and colleagues evaluated the hemodynamic effects of early administration of norepinephrine in 105 patients with septic shock with life-threatening hypotension [1]. These patients had already received a limited amount of fluids (1,000 ml saline). Norepinephrine significantly increased the mean arterial pressure. The cardiac index increased from 3.2 ± 1.0 to 3.6 ± 1.1 l/minute/m2, which can be related to the beta (increase in heart rate or in contractility) or alpha (increase in preload by venous constriction) adrenergic effects of norepinephrine. The heart rate remained unchanged but the stroke volume increased, as a result of an increase in preload (global end-diastolic volume (GEDV) index increased from 694 ± 148 to 742 ± 168 ml/m2) and in contractility (cardiac function index increased from 4.7 ± 1.5 to 5.0 ± 1.6/minute). This effect was also observed in patients with poor cardiac contractility.Another important issue covered is whether beta-blockers agents have some protective effects during critical diseases [2]. In this post hoc analysis of a large trial in 314 critically ill patients with acute respiratory failure, oral beta-blockers at admission were associated with a lower risk of in-hospital (hazard ratio 0.33 (0.14 to 0.74), P = 0.007) and 1-year mortality (hazard ratio 0.29 (0.16 to 0.51), P = 0.0003). The beneficial effect of oral beta-blockers at admission holds true in patients with acute renal failure related to cardiac or noncardiac causes. In addition, administration of oral beta-blockers before hospital discharge had additional beneficial effects on 1-year mortality. These results should be cautiously scrutinized. Information was only available on use of beta-blockers prior to admission and at hospital discharge, but not during the acute stage of the disease. The statement 'c
The 32nd Annual Congress of the Society of Critical Care Medicine, 28 January – 2 February 2003, San Antonio, USA
Daniel De Backer, Jacques Creteur
Critical Care , 2002, DOI: 10.1186/cc2173
Abstract: Michael B Yaffe (Cambridge, MA, USA)In his lecture, Michael Yaffe alluded to how fundamental science may help in the development of new therapeutic agents. In the past, the search for new drugs was based on random selection of drugs of natural sources, which were secondary tested in all possible models. When the drug was proven to have efficacy, its chemical structure was isolated and the drug was then synthesized. Using this method, unfortunately, the rate of drug discovery has decreased. A more rational approach would be to take into account our understanding of the mechanism of diseases in order to identify target signalling pathways. Use of genomics to identify gene expression of cells in different conditions is unlikely to be helpful because the responses to several stimuli are often similar. For example, gene expression in macrophages is similar following stimulation by Gram-negative bacteria, Gram-positive cocci and mycobacteria. Proteomics may be more helpful in identifying regulatory pathways. Proteomics covers thousand of proteins acting in a changing environment, and hence it is important to identify how and why several proteins are interrelated and interplay in regulatory and/or pathophysiological processes. This leads to the possibility of identifying critical nodes in models and definition of where drugs are likely to act.Thierry Calandra (Lausanne, Switzerland)Thierry Calandra reviewed the mechanisms involved in innate immunity, with a special emphasis on the Toll-like receptor. He also stressed the important role played by the pituitary axis in the modulation of inflammation. In this context, the macrophage inhibitory factor (MIF) appears to be crucial. MIF is high in patients surviving sepsis, and the administration of MIF increases survival in experimental models. Interestingly, MIF is implicated in the hypothalamic–pituitary–adrenal axis, being present in the adrenal cortex, whereas dexamethasone induces MIF secretion.Mervyn Singer (London, Englan
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