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Search Results: 1 - 10 of 190126 matches for " Lui G Forni "
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Recently published papers: Heavyweight problems in the intensive care unit?
Lui G Forni
Critical Care , 2008, DOI: 10.1186/cc7138
Abstract: Thou seest I have more flesh than another man, and therefore more frailty.(William Shakespeare)The imbalance between the haves and the have nots is no more striking than when one considers nutrition. Obesity is an increasing problem in most of the western world with approaching 300 million people being classified as obese, whereas starvation affects almost one-half of the global population. Indeed, the obesity epidemic is highlighted here in the United Kingdom, where over the period between 1980 and 1997 the obesity rates in adults trebled [1]. As a consequence we are often faced with the management of such patients in our intensive care units (ICUs) and their inherent problems. Obese patients are viewed as more complex to manage for a variety of reasons: they are difficult to intubate, difficult to ventilate, difficult to wean, difficult to move – the list goes on. And on. But are these generalisations justified in the majority of cases? Two studies reported recently in Intensive Care Medicine add more weight to the arguments against such views [2,3].In the study by Sakr and colleagues, the European observational Sepsis Occurrence in Acutely Ill Patients study database was interrogated to examine the effect of body mass index (BMI) on morbidity and mortality outcomes [2]. Patients were stratified as underweight (BMI < 18.5), normal weight (BMI 18.5 to 24.9), overweight (BMI 25 to 29.9), obese (BMI 30 to 39.9) and very obese (BMI ≥ 40). BMI data were available from 91% of the cohort, with 53.9% being classed as overweight or greater and 2.8% classed as very obese. The results make interesting reading. There was no association between increased mortality and obesity. There was, however, an increase in morbidity with a trend towards longer length of stay, both in the ICU and in the hospital, between the normal weight groups and the very obese patients. Similarly, those patients with higher BMI showed an increase in ICU-acquired infections. The authors do point out the
Recently published papers: Delivery, volume and outcome – what is best for our patient?
Lui G Forni
Critical Care , 2007, DOI: 10.1186/cc6082
Abstract: "Nothing is permanent but change"Heraclitus, circa 500 BCFor those of us practicing in the United Kingdom, the National Health Service is approaching its 60th birthday and, far from being pensioned off, there is much political will to change the way healthcare is being delivered in a radical fashion. This reinvention of the National Health Service is being applied across the board, including the critical care arena, and an often-used phrase is that of 'reconfiguration' of services. This will probably lead, in time, to fewer critical care units in England and to more patients being transferred between hospitals.Two papers published in Critical Care Medicine therefore make interesting reading for those of us swept up in this maelstrom. Golestanian and colleagues performed a cohort observational study examining the effects of interhospital transfers on resource utilisation and outcomes at a tertiary care referral centre in the USA [1]. They compared patients transferred from other hospitals with those admitted 'in-house' from the A&E department or the wards. The patients transferred had higher Acute Physiology and Chronic Health Evaluation III scores (60.5 versus 49.7), higher intensive care unit (ICU) mortality (14% versus 8%) and higher hospital mortality (22% versus 14%). The length of stay was also longer in terms of both ICU bed days and hospital bed days. These results are in keeping with several other studies [2,3]. When stratified by disease severity using the Acute Physiology and Chronic Health Evaluation III model, however, the crude mortality differences were less striking, with no statistical differences observed. What did remain significantly different was the cost of treatment. On average, a patient transferred to the ICU from outside the institution cost about $10,000 more per admission. Somewhat surprisingly, this difference was principally confined to the group with the lowest predicted mortality – the reasons for which remain unclear. Does this mean t
Recently published papers: changing practices in the modern intensive care unit
Lui G Forni
Critical Care , 2002, DOI: 10.1186/cc2169
Abstract: Sir Francis Bacon, 1561–1626One always reviews the journals in January with some trepidation. Wading through the instructions for authors (a problem not encountered with the electronic press!), one is worried that the scientific literature may need resuscitating from the post-holiday somnolence. Fortunately, 2003 has been greeted with a fanfare of important papers in the critical care press, not least in the shape of some well conducted observational studies. Those involved in the intensive care arena often find themselves making difficult decisions, including that of cessation of therapy or, indeed, whether to admit a particular patient to the intensive care unit (ICU). The latter dilemma often causes much debate between clinicians. Two studies were published in Critical Care Medicine that may help in determining patient selection.The study by Benoit and coworkers [1] attempted to assess outcome and early prognostic indicators in a global population of patients with haematological malignancies following admission to intensive care. This is a group of patients in which resistance among intensivists to admission is often encountered, despite the undoubted improvements in treatment of both solid tumours and haematological malignancies. This study from Belgium examined 124 consecutive critically ill patients admitted to the ICU over a 3.5-year period. The overall ICU mortality rate was 42%. The in-hospital mortality rate was 54% and the 6-month mortality rate was 66%. This somewhat flies in the face of other studies, which have suggested mortality rates of 75–85% in patients with haematological malignancies who require mechanical ventilation.The usual statistical models of multivariable logistic regression analysis were applied to the data and four variables were independently associated with outcome. It is worth noting that no patient with oliguria survived, but oliguria was not included in the multivariable analysis. Leukopenia, use of vasopressors and an elevated ur
Clinical review: Timing of renal replacement therapy
Michael Joannidis, Lui G Forni
Critical Care , 2011, DOI: 10.1186/cc10109
Abstract: The primary goal of renal replacement therapy (RRT) is to compensate for, in part, the loss of renal function and associated sequelae. These include the accumulation of nitrogenous waste products, uraemic toxins, electrolyte disturbances, metabolic acidosis and volume overload. Organ support is much beloved by intensivists and, to an extent, defines us, but despite the introduction of convective therapies, RRT has changed little in the past 50 years. Furthermore, the use of current extracorporeal circuits does not compensate for other endocrinological and metabolic functions of the kidney.The cause of the acute kidney injury (AKI) necessitating RRT is also relevant. The unconditional acceptance of terms such as AKI must be considered together with the underlying aetiology in order to understand the basic pathological processes associated with kidney injury. Without an underlying cause, AKI tells us nothing save an observed disturbance in conventionally measured 'markers' of function coupled with reduced urine production. Clearly, the outcome from AKI in a young patient secondary to an interstitial nephritis is very different from that of an elderly diabetic developing AKI following systemic infection from a ruptured viscus. It may be that the aetiology of the underlying condition is also of great import with regard to timing of treatment. In many ways this highlights the differences between single organ 'AKI' and 'multiorgan AKI' in that timing of RRT on a renal unit may differ significantly from our patients on the ICU in terms of both dose delivered and duration of treatment.In ICU patients AKI is often encountered at an early stage before traditional measures of renal function are deranged. Therefore, symptoms may not be as pronounced compared to a patient developing renal failure prior to ICU admission. Furthermore, AKI may be regarded as a systemic disease, rather than organ failure in isolation characterised by a systemic inflammatory response with concomitant
Recently published papers: Sepsis – guidelines, treatment and novel approaches
Navneet Kalsi, Lui G Forni
Critical Care , 2008, DOI: 10.1186/cc6836
Abstract: "Man is a creature composed of countless millions of cells: a microbe is composed of only one, yet throughout the ages the two have been in ceaseless conflict"AB ChristieSeptic shock remains a common cause of death in intensive care units worldwide and presents the clinician with a variety of management problems. The Surviving Sepsis Campaign has gone far in collating the considerable wealth of information currently available about this devastating condition and provides excellent guidelines, which are essential reading for consultant and trainee alike [1]. However, new insights into the management of these patients continue to accumulate, and the last few months have been no exception. One of the basic tenets of treating septic shock is the provision of cardiovascular support through the use of catecholamines, although there is much interest in other agents as addressed in the study by Russell and colleagues in The New England Journal of Medicine [2]. They examined the use of the pituitary-derived peptide hormone vasopressin in patients with septic shock through a multi-centred, randomised trial involving 778 patients given low-dose vasopressin (0.01 to 0.03 U/min) in addition to noradrenaline (norepinephrine) compared with noradrenaline alone. No overall differences were found between the two groups in terms of either the primary endpoint of 28-day mortality or the various secondary endpoints. Interestingly, the vasopressin-treated group had a 28-day mortality of 35% compared with 39% of the group treated with noradrenaline alone, which is clearly much less than one would expect. The authors do suggest that this may reflect an improvement in the overall care of patients with septic shock, but equally it could reflect the selection criteria used: 6,229 patients were assessed for eligibility but more than 5,000 patients were not enrolled, a significant proportion of whom had cardiac disease. The authors themselves do concede that the baseline mean arterial pressures
Recently published papers: Sugar, soap and statins – an unlikely recipe for the critically ill
David Bacon, Lui G Forni
Critical Care , 2006, DOI: 10.1186/cc4900
Abstract: "Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing"Francois-Marie Arouet VoltaireSome nonphysicians may argue that little has changed since the 18th century. However, the advent of the clinical trial and multicentre studies may have helped to shed some light on practice. To this end the results of the SOAP (Sepsis Occurrence in Acutely ill Patients) study [1], published recently in Critical Care Medicine, will cause a stir. That prospective study of 3147 patients took place in early May 2002 and joins the ranks of other such epidemiological work on the subject. The study was endorsed by the European Society of Intensive Care Medicine, and 24 European countries were involved, encompassing almost 200 intensive care units (ICUs). Patients were followed for up to 60 days, or until discharge or death if this occurred before 60 days. The volume of data collected is impressive, and further insight into outcomes from sepsis, as defined by the classical consensus conference criteria, can be gleaned.The incidence of sepsis approached 40% (37.4%), with the lung being the commonest site of infection [1]. Unsurprisingly, Staphylococcus aureus was the most frequent organism, but rather worryingly 14% of isolates were methicillin resistant. There was a marked difference in the frequency of sepsis between countries, and higher frequencies of sepsis were mirrored by higher ICU mortality rates. It is difficult to correlate this finding with any one factor but it may well reflect regional differences in ICU resources as well as variations in case-mix and thresholds for ICU admission. The multivariate analysis applied to the data provides few surprises. Patients with sepsis had a longer length of stay both in the ICU and in hospital, and they had more severe organ dysfunction and higher mortality rates. The prognostic variables for ICU mortality included the usual suspects. Age, cancer,
Initiation of renal replacement therapy: is timing everything?
Catherine SC Bouman, Lui G Forni
Critical Care , 2010, DOI: 10.1186/cc8188
Abstract: Acute kidney injury (AKI) remains a commonly encountered medical problem, often finding its way to the intensive care unit (ICU). Treatment involves normalisation of the circulation, and, failing that, renal replacement therapy (RRT) of whatever type.The interesting paper by Ostermann and Chang describes the correlation between parameters at initiation of RRT and outcome in critically ill patients who underwent RRT [1]. Although the study is retrospective, it is however multicentred and includes a large number of patients. ICU survivors (55.9%) were significantly younger, and less sick with less pre-existing chronic illnesses. In a multivariate analysis, mechanical ventilation and associated neurological failure on the day of RRT were the strongest independent risk factors for mortality, followed by hepatic, gastrointestinal and haematological failure, and pre-existing health problems. A higher serum pH was independently associated with a better outcome. A raised urea and a low creatinine concentration at initiation of RRT were independent risk factors for dying. Similar risk factors for death from AKI have been identified in the past, albeit at a single centre and including fewer patients [2,3]. Moreover, the data share similarities with several subsequent scoring systems for AKI - namely, age, need for ventilation, oligo-anuria, liver dysfunction and acidosis [4,5].What should be borne in mind is that the data analysed are somewhat old, and that over this period there have been several changes in the ICU practice for RRT: not least in the choice of replacement fluid and the dosing of RRT. Bicarbonate-buffered haemofiltration was not described until 1991 and was not commercially available until the late 1990s. In addition, dosing of RRT has gradually increased during the past decade, and it is likely in the present study that the dose may have been inadequate, particularly in the patients receiving continuous arteriovenous techniques. Using the current buffering te
Recently published papers: Acute kidney injury – diagnosis and treatment
Jasmine BL Lee, Lui G Forni
Critical Care , 2009, DOI: 10.1186/cc7778
Abstract: 'Where observation is concerned, chance favours only the prepared mind'(Louis Pasteur, 1822–1895)A renal flavour this month, for which we make no apologies! As we all know, acute renal failure is no more: we now deal in acute kidney injury (AKI)! We are still plagued by the lack of a useful early indicator for kidney injury, however, and the search for this holy grail continues.This prize may be getting closer, as a report by Haase-Fielitz and colleagues in Critical Care Medicine examines the role of serum biomarkers in predicting AKI in a cohort of patients following cardiac surgery [1]. They employed neutrophil gelatinase-associated lipocalin (a marker of tubular cell injury) and cystatin C (a marker of glomerular filtration rate) measured in serum together with conventional markers of renal function. The end points were development of AKI (defined as an increase in serum creatinine >50%), the need for renal replacement therapy and hospital mortality. This study demonstrated that the novel biomarkers predicted AKI approximately 48 hours before conventional measures, such as creatinine. In particular, biomarker levels 24 hours postoperatively proved particularly useful. The study has some limitations, as the authors point out, but it is the largest adult study reported thus far.Where does Haase-Fielitz and colleagues' study leave us? Clearly this field will continue to expand and no doubt many more papers will be produced on the role of novel biomarkers, but how will it change our practice? One hopes that early identification of patients that have undergone renal injury (in whatever guise) will lead to improved outcomes through augmented observations and avoidance of further renal insult. The acid test will be to demonstrate that early intervention improves outcome in these patients. Then the holy grail may well have been found.Following on from this, a novel report from Heemskerk and colleagues examines the role of an infusion of alkaline phosphatase on renal func
Recently published papers: putting fluids in and taking fluids out
Catriona JM Shaw, Lui G Forni
Critical Care , 2006, DOI: 10.1186/cc5106
Abstract: Men worry over the great number of diseases, while doctors worry over the scarcity of effective remedies.Pien Chi'ao, Chinese physician ca. 500 BCA recurring theme in treating the critically ill, and indeed in all of medicine, is the search for evidence-based practice. As we all know, however, application of such principles is somewhat curtailed by the paucity of data even when considering aspects of treatment that to the ill-informed would seem fundamental.The study by Dubois and colleagues in Critical Care Medicine addresses a fundamental question: the use of albumin in the critically ill [1]. One may think this is yet another study adding to the confusion regarding the use of albumin when compared with other colloids as resuscitative fluids. But no, this prospective, randomised controlled study on 100 patients in a mixed intensive care unit (ICU) setting crudely examined the effect of albumin on organ function in hypoalbuminaemic patients. All adult patients with serum albumin <30 g/l were eligible provided that they had an expected length of stay >72 hours, a life expectancy >3 months, needed full active treatment and had not undergone albumin administration in the previous 24 hours. Those patients with volume overload were excluded. The primary endpoint was the effect of albumin administration on the delta Sequential Organ Failure Assessment score from day 1 to day 7. Three hundred millilitres of 20% albumin was given on day 1, followed by 200 ml/day providing the serum albumin remained below 31 g/l. The control group received no albumin.Interestingly, nearly 2,000 consecutive patients were screened before an adequate cohort was achieved, with almost 50% of patients not being hypoalbuminaemic on admission or during admission. The results, in brief, showed a greater change in Sequential Organ Failure Assessment score between the two groups: 3.1 ± 1.0 in the albumin group compared with 1.4 ± 1.1 in those patients with no albumin administration [1]. The major effe
Recently published papers: Treating sepsis, measuring troponin and managing the obese
Nicholas D Mansfield, Lui G Forni
Critical Care , 2005, DOI: 10.1186/cc3947
Abstract: Medicine is the only profession that labours incessantly to destroy the reason for its own existence.James Bryce (1914)Sepsis and septic shock in the intensive care unit (ICU) still contribute significantly to our workload and, unfortunately, account for significant mortality. Consequently, they continue to provide much interest in the literature as our understanding of the processes involved become ever more complex. An interesting physiological short term study performed by Albanese and colleagues [1] addresses a far more basic aspect to the treatment of septic shock: that is, the choice of inotrope. In 20 patients, the vasopressors terlipressin and norepinephrine were compared. The aim of this study was to compare the two inotropes given the known undesirable effects of norepinephrine and the observed diminished vasoreactivity to catecholamines in sepsis [2]. Patients were recruited if they had a mean arterial pressure (MAP) <60 mmHg, two or more organ dysfunctions and fulfilled criteria for septic shock. Norepinephrine was given at a predetermined incremental rate whereas those randomised to terlipressin were given a bolus (1 mg). The main findings (well presented in the discussion) were that both agents effectively increased MAP and improved renal function. Terlipressin resulted in a decrease in heart rate and cardiac index but no change in stroke volume index. Oxygen delivery and consumption index were also decreased with terlipressin. This observation was probably a reflection of decreased chronotropic drive with terlipressin. Is this important? Given the small sample size, no firm conclusions can be made, although the lack of detrimental effect on oxygen delivery suggests not. One wonders if the use of terlipressin may soon become commonplace in this interesting but difficult group of patients. On the same theme, Levy and colleagues from France report an interesting and rather brave study in septic shock [3]. In this prospective study, 110 patients with sept
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