was published in the October issue of Intensive Care Medicine (2007) 33:1732-1739
End of life decisions are an integral part of Intensive Care Medicine which are strongly influenced by the religious or cultural background of the respective health care system. In the same medical circumstance decisions might be completely different for different cultures and religions. This dilemma was addressed by the Ethicus study group published by Sprung et al. and chosen as the article of the month October. The group analyzed data on end of life decisions from 37 ICU´s in 17 different European countries. The magnitude of the problem can be assessed when reading that out of almost 32000 patients being admitted during the study period around 10 % had limitations in treatment with a majority of patients not being mentally able to communicate their attitude nor having clearly documented patients wishes. Considerable differences were found between the religious affiliations of the physicians involved which was evident for the time to take decisions, the frequency these decisions were discussed with the patients family, the frequency of efforts to assess the patients wishes, as well as for the content of the decisions themselves. Withholding and withdrawal of therapy and evidently active shortening of the dying process were found to be different between religions but also between the geographical regions high lightening the importance of cultural and legal issues fro physicians. Interestingly, there were considerable differences between different regions even for physicians of the same religion. The paper helps to understand how complex the issue of end of life decision is and how much the Intensive Care Community has to learn about it.
was published in the September issue of Intensive Care Medicine (2007) 33:1563-1570
The best mode of renal replacement therapy remains an issue of debate between Intensives and Nephrologists when applied fro the treatment of acute renal failure (ARF) in the Intensive Care Unit. Continuous versus intermittent, high versus low volume, early versus late, which anticoagulation should be used in patients with relevant bleeding or coagulation disorders… all those questions are addressed every day in Intensive Care Units around the word. However, it might be true that exactly this variation in clinical practice is one of the reasons fro the relatively poor outcome in patients suffering from ARF during their stay in the Intensive Care Unit. Therefore, the worldwide survey published by Uchimo and colleagues was chosen as the Article of the Month September. These authors published data from a worldwide survey on more than 100 patients on the use of continuous renal replacement therapy (CRRT) in Intensive Care medicine. It becomes obvious from their results that ARF might have an in hospital mortality around 64 % although no significant impact of the modes employed was found. However, although recent data suggest benefits for a high volume strategy only 12 % received such high doses of CRRT. Anticoagulation was carried out mostly with heparin or without any anticoagulant which might be the reason for the relatively low incidence of bleeding complications. Citrate – which has been found to positively affect bleeding episodes and filter life in recent studies – was used only in 10 % of cases. The study shows clearly that a large variability exists when using CRRT in the ICU and that clinical practice does not necessarily reflect best evidence from published data – as it is the case fro many interventions…
were published in the July issue of Intensive Care Medicine (2007) , DOI10.1007/s00134-007-0630-2 &
DOI 10.1007/s00134-007-0659-2
The comparison of different ventilator modes is not so trivial since we clinicians try to accomplish several goals with a given mode: we want to unload the respiratory system while achieving a sufficient gas exchange without causing harm due to over-inflation or alveolar collapse at end expiration. Further to this we aim to make the mode as comfortable as possible and yield the best patient ventilator synchrony. However, all these variables describe the respiratory condition of the patient without taking the many secondary effects of respiratory distress or comfort into account. A whole body of literature has addressed the question of hemodynamical consequences of different ventilator modes and some physiological observations on organ function have been reported. The observation that the quality of sleep might be a effected by ventilator management seems obvious but has not been addressed in great detail so far. Therefore, we chose two articles on this subject as articles of the month July. The first paper by Dr. Alexopoulou describes the effects of proportional assist ventilation in comparison to pressure support on sleep quality and the second paper by Dr. Toublanc addresses the comparison of assist control ventilation versus pressure support.
The papers show us that we should be aware of the respiratory settings at night since a poor sleep quality is something we definitively want to prevent in our patients taking into account the sleep deprivation and poor sleep quality is very common in the ICU and might contribute to many adverse events such as the development of delirium, weaning failure or others.
The abdominal compartment syndrome has gained increasing interest in the intensive care community over the last years. The condition is meanwhile known to be frequent in critically ill patients and to affect several organ systems and functions. The World Society of Abdominal Pressure has released an initial statement of an expert panel to clarify the definitions and measurement issues when assessing abdominal pressure. Based on this the second part of this expert panel statement on treatment recommendations is published in the June issue of ICM.
It has been chosen the article of the month since it offers a most comprehensive review of the relevant literature within this clinically interesting field to our members.
The April article 2007
The March article 2007
The February article 2007
The January article 2007
was published in the January issue of Intensive Care Medicine (2007) 33:66-73
Delirium in critically ill patients is a newly recognized entity with important prognostic implications. Two main scoring systems exist for diagnosing delirium and thus for defining the importance of this problem. These scores mostly differ by the evaluation of consciousness under sedation. In this large prospective survey in one Canadian ICU, the authors used the Intensive Care Delirium Screening Checklist, a validated scale already described in Intensive Care Medicine. They found that delirium occurred in 31.8% of 764 patients. Delirium was associated with a history of hypertension and alcoholism, higher APACHE II score, and with clinical effects of sedative and analgesic drugs when used to induce coma. These findings may help to design better prevention of this severe side effect of ICU stay.
