Recently published papers: out with the old and in with the new ... then something new for the old!

New therapies are challenging older, established practices. One recently published report shows us that we may be able to avoid endotracheal intubation in patients with a reduced level of consciousness. Recombinant activated factor VII is proving to be useful in many coagulation disorders, and intracerebral haemorrhage can be added to this list. Homeopathy, in the form of potassium dichromate, shows promise as a new treatment for excessive tracheal secretions. Rotation protocols for antibiotics have been evaluated with respect to their ability to prevent the development of new resistant micro-organisms in our hospitals and units. Finally, glucocorticoids may be of benefit to septic patients outside the intensive care unit (ICU) and may prevent their deterioration and admission to the ICU.

Artifact-free computed tomography of the chest and abdomen in the severely ill patient.

A method is described for obtaining consistently high-quality images during nonneurologic computed tomography of the severely ill and uncooperative patient using a neuromuscular blocker to induce apnea. Careful control of respiration during data acquisition eliminates motion artifacts.

National survey of the use of sedating drugs, neuromuscular blocking agents, and reversal agents in the intensive care unit.

The objectives of this study were to describe the sedative, neuromuscular blocking agents (NMBA) and reversal agents utilized in adult intensive care units across the United States and determine the adherence to American College of Critical Care Medicine and Society of Critical Care Medicine (SCCM) guidelines. In addition, the authors assessed the use of written protocols, criteria used for selecting these agents, and monitoring practices. Questionnaires were mailed to attending physician members of SCCM in the spring of 1998. A cover letter was enclosed that explained the purpose of the survey asking the respondent to forward the questionnaire to a colleague if unable to complete. Four-hundred fifty-seven questionnaires were returned representing 393 different institutions for a response rate of 50.4% (393/780). Respondents were physicians (91.2%) practicing in a community (49.7%) or university teaching hospital (38.3%). The sedative agents used most often were opioids and benzodiazepines for >72 hours, and NMBA utilized were vecuronium and pancuronium for >24 hours. The most often cited indications for sedatives were agitation, anxiety/fear, and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 32.6% used written protocols for sedatives and 46.8% for NMBA. Decisions regarding agent selection were based on clinician preference and experience and agent duration of action. Seventy-eight percent monitored sedative use primarily with the Glasgow Coma Scale and the modified Ramsay score. Monitoring of NMBA was used more frequently (91.3%) with peripheral nerve stimulation. The most common reversal agents used were naloxone and flumazenil for adverse drug effects. While many of the respondents indicated they used morphine and lorazepam for long-term sedation, the majority utilized midazolam and propofol for >24 hours despite the recommendation of SCCM. Vecuronium was prescribed more routinely than pancuronium. The number of institutions utilizing protocols for any of these agents was low; instead, decisions were based on clinician preference.

Comparación de los efectos renales de la dobutamina y la dopamina en pacientes en estado crítico / Comparison of renal effects of dobutamine and dopamine in critically ill patients

Introducción. La dopamina se ha usado a dosis bajas para minimizar la falla renal de pacientes graves, sobre bases poco firmes. Objetivo. Comparar los efectos de la infusión a dosis bajas de dobutamina vs dopamina en la optimización de la función renal en pacientes graves estables. Pacientes y métodos. Estudiamos 52 pacientes de la UCI (17 mujeres, 35 hombres, edad media 49.4 ñ 18.2 años) con riesgo de disfunción renal: 29 (grupo A) se trató con dobutamina 5 µg/kg/min y 23 (grupo B) con dopamina 3 µg/kg/min, durante 72 horas. Se efectuaron pruebas de función renal basales antes de iniciar la infusión de los fármacos, que se repitieron a las 24 y 72 horas. Resultados: Se observó aumento de la diuresis (77.3 ñ 24.5 mL/h) y FeNa (0.72 ñ 0.36 por ciento) a las 72 h con dobutamina comparado con los datos basales (45.7 ñ 16.7 mL/min, 0.48 ñ 0.32 por ciento, respectivamente), p< 0.001; la dopamina sólo incrementó la diuresis a las 24 h (78.3 ñ 25.4 mL/min, 0.72 ñ 0.35 por ciento) en relación a los datos iniciales (45.7 ñ 16.7 mL/min, 0.59 ñ 0.53 por ciento), p= 0.049. El resto de las pruebas de función renal no mostró cambios. Conclusión. En pacientes estable graves, la dobutamina aumenta la FeNa y la diuresis; la dopamina sólo incrementa esta última