Signa Vitae

Journal for Intensive Care and Emergency Medicine

Category: Articles (Page 1 of 67)

Evolving from Past to Future: Facilitating SMART research

Abstract

In clinical research, there has been an increasing need to titrate ethical, legal and insurance requirements to the type of study, so that higher-risk research receives necessary and appropriate detailed attention, while low-risk studies can proceed more rapidly.

Spontaneous Medically Advantageous Research Trials (SMART) are non-profit studies that carry minimal or no risk to patients. This type of investigation, however, is currently hampered by the fact that, in many hospitals and jurisdictions it has to undergo the same bureaucratic procedures and safety assessments as high-risk, for-profit studies. We strongly believe that such practice of scientific research assessment should be radically modified. We advocate a new, specific research category for SMART investigations that grants them a preferential route from conception to ethics assessment to execution. In addition, we argue that such low risk studies assessing common, often not evidence-based applied treatments or investigations should in fact be a mandatory component of modern medicine. All clinicians, scientists, patients, patient associations, politicians, scientific associations and common citizens should be involved in this process, as they all play a crucial role in its evolution and success.

We contend that modern medical research and entire health systems should transition to a novel model of healthcare system where SMART execution is embedded into daily practice, in order to minimize anecdotal practice and maximize evidence-based practice.

Key-words: no profit study, medical research, ethical committee, progress

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Current management of sepsis and septic shock

Abstract

Sepsis remains a leading cause of death in the intensive care unit. With no specific sepsis therapies available, management currently relies on infection control and hemodynamic stabilization. Rapid diagnosis enabling early initiation of appropriate therapy is essential to maximize survival rates. Effective antimicrobial therapy should be started as soon as possible after diagnosis, with empirical choices based on likely pathogens, local microbiological patterns, and any recent antimicrobial therapy. At the same time, fluids and vasopressor agents should be commenced to restore and maintain hemodynamic stability and adequate tissue perfusion. No effective immunomodulatory therapies are available, but some candidates are undergoing clinical trials. Better techniques for characterization of the degree of sepsis response in individual patients are needed to help target such agents more appropriately as some patients may benefit from immunosuppressive agents while others may require an immune stimulating intervention. The management of patients with septic shock is often complex and the development of sepsis teams should be encouraged so that the multiple components of treatment, e.g., insertion of intravascular lines, blood sampling for culture and biochemistry, positioning of required monitoring devices, fluid, antibiotic and vasoactive drug administration, etc, can be carried out simultaneously.

Key words: infection, fluid resuscitation, immunomodulation, organ dysfunction, sepsis team, vasopressors

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Fluid Therapy and Acute Kidney Injury: A Question of Balance?

Abstract

Fluid therapy remains one of the fundamental treatment options available for patients with acute kidney injury. However, there remains debate over several aspects of this treatment with many questions unanswered. Firstly, how do we prescribe fluid in this group of patients? Secondly, what is the role of fluid therapy in patients with or at risk of developing acute kidney injury and thirdly, what role does fluid balance play, if any, in the development of acute kidney injury. The following narrative review will attempt to tie some of the aspects of the treatment of this devastating syndrome together and formulate an overall hypothesis for fluid management in acute kidney injury.

Key words: Acute kidney injury, glomerular filtration rate, fluid overload

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Multimodal monitoring (MMM) in the perioperative period

Abstract

Routine anaesthesia monitoring until the mid-1980s often consisted of just a finger on the pulse, primitive ECG and intermittent blood pressure (MAP) measurement using a cuff and aneroid gauge or mechanical oscillotonometer. Then in quick succession an explosion of new monitors was introduced including pulse oximetry (SpO2), end tidal carbon dioxide (EtCO2) and anaesthetic agent monitoring as well as automated non-invasive blood pressure (NIBP) machines. These were all routinely in place in many hospitals by the late 1980’s, but then progress came to a halt with no advances in routine anaesthetic monitoring for over 25 years.

This paper concentrates on three classes of non- or minimally invasive monitors which have become additionally available in the last 10 to 15 years and if used in combination their potential impact on improving outcome following surgery in high risk patients:

  1. Monitors which calculate stroke volume (SV, and thus cardiac output, CO) from a standard radial arterial line (e.g. LiDCO, UK), oesophageal probe (Deltex, UK), ECG pads or even from the finger
  2. Monitors which assess the degree of cortical suppression (e.g. BIS, Medtronic, USA) produced by anaesthetics thus potentially allowing the administrator to “fine tune” anaesthesia for individual patients
  3. Monitors which assess tissue oxygenation, usually of the brain (e.g. Invos, Medtronic, USA)

If used together they provide complementary information which should improve perioperative haemodynamic management and outcome and form part of a multi-modal monitoring (MMM) strategy which is the subject of this article.

Key words: cardiac output, minimally invasive, tissue oxygenation, depth of anaesthesia, multi-modal monitoring

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Genetic determinants of survival

Abstract

The human genome comprises some 20,000 genes, or 3 billion base pairs. Variation in this genetic sequence is common- and some of these variants affect gene function or the protein transcribed from it. Human characteristics are determined by the interaction of the genome with environmental challenges- and differences between us thus result from variation in those challenges and in the genome itself. This is true of human susceptibility to disease, and survival from it. Genetic variation influences human behaviours which may predispose to health or disease; the risk of contracting an infectious disease, or of suffering diseases such as cancer or myocardial infarction; the development of complications; the response to any treatment administered; and thus the outcome of the disease state. Genetic studies can help shed light on the mechanisms which underpin disease processes, whilst perhaps suggesting ways in which treatment might be ‘personalised’, and novel therapeutic targets for drug development.

More sophisticated approaches to such endeavours are required, given the failure to identify the bulk of gene variants of influence using conventional strategies.

Key words: Gene, polymorphism, survival, genome

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