One of the characteristics of acute lung injury is noncardiogenic pulmonary edema. Arguments have been made for the management of acute lung injury with either a liberal or conservative approach to ...fluid administration. In this trial, neither approach offered a mortality benefit; there were clinical and physiological benefits to conservative fluid management.
Arguments have been made for the management of acute lung injury with either a liberal or conservative approach to fluid administration. In this trial, neither approach offered a mortality benefit; there were clinical and physiological benefits to conservative fluid management.
Pulmonary edema resulting from increased capillary permeability, a hallmark of acute lung injury, worsens as intravascular hydrostatic pressure rises and oncotic pressure falls.
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Although lung failure alone can be lethal, death in patients with acute lung injury is usually due to the failure of nonpulmonary organs.
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The optimal fluid management of acute lung injury is not settled.
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The usual practice is wide-ranging, and many practitioners weigh the risks and benefits of strategies of conservative as compared with liberal fluid management. In the conservative approach, fluid intake is restricted and urinary output is increased in an attempt to . . .
Hemodynamic monitoring is a common physiological intervention in patients with acute lung injury. In this randomized, controlled trial in which patient care was dictated by a specific hemodynamic ...protocol, there was no significant difference in 60-day mortality whether monitoring was performed with a pulmonary-artery catheter or a central venous catheter.
Hemodynamic monitoring is a common physiological intervention in patients with acute lung injury. In this trial there was no significant difference in 60-day mortality whether monitoring was performed with a pulmonary-artery catheter or a central venous catheter.
The pulmonary-artery catheter (PAC) provides unique hemodynamic data, including the cardiac index and pulmonary-artery–occlusion pressure. People who advocate the use of the PAC note that the clinician's ability to predict intravascular pressure with the use of this catheter is poor
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; central venous pressure, as obtained by means of the PAC, correlates imperfectly with pulmonary-artery–occlusion pressure
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; and the insertion of a PAC often changes therapy.
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Although many critically ill patients receive PACs,
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no clear clinical benefit has been associated with their use.
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Practitioners often misinterpret the information obtained by means of a PAC or act . . .
Beyond mortality: future clinical research in acute lung injury Spragg, Roger G; Bernard, Gordon R; Checkley, William ...
American journal of respiratory and critical care medicine,
05/2010, Letnik:
181, Številka:
10
Journal Article, Conference Proceeding
Recenzirano
Odprti dostop
Mortality in National Heart, Lung and Blood Institute-sponsored clinical trials of treatments for acute lung injury (ALI) has decreased dramatically during the past two decades. As a consequence, ...design of such trials based on a mortality outcome requires ever-increasing numbers of patients. Recognizing that advances in clinical trial design might be applicable to these trials and might allow trials with fewer patients, the National Heart, Lung and Blood Institute convened a workshop of extramural experts from several disciplines. The workshop assessed the current state of clinical research addressing ALI, identified research needs, and recommended: (1) continued performance of trials evaluating treatments of patients with ALI; (2) development of strategies to perform ALI prevention trials; (3) observational studies of patients without ALI undergoing prolonged mechanical ventilation; and (4) development of a standardized format for reporting methods, endpoints, and results of ALI trials.
Acute lung injury (ALI) and its more severe form, the acute respiratory distress syndrome (ARDS), are syndromes of acute respiratory failure that result from acute pulmonary edema and inflammation. ...The development of ALI/ARDS is associated with several clinical disorders including direct pulmonary injury from pneumonia and aspiration as well as indirect pulmonary injury from trauma, sepsis, and other disorders such as acute pancreatitis and drug overdose. Although mortality from ALI/ARDS has decreased in the last decade, it remains high. Despite two major advances in treatment, low VT ventilation for ALI/ARDS and activated protein C for severe sepsis (the leading cause of ALI/ARDS), additional research is needed to develop specific treatments and improve understanding of the pathogenesis of these syndromes. The NHLBI convened a working group to develop specific recommendations for future ALI/ARDS research. Improved understanding of disease heterogeneity through use of evolving biologic, genomic, and genetic approaches should provide major new insights into pathogenesis of ALI. Cellular and molecular methods combined with animal and clinical studies should lead to further progress in the detection and treatment of this complex disease.
This report provides a brief overview of some relevant ongoing research on critical care and how research priorities are determined by the National Heart, Lung, and Blood Institute. Long-term and ...patient-centered outcomes have become more prominent research questions for clinical studies in patients who are critically ill. Rehabilitation research would be appropriate in this context, and funding is most likely received through investigator-initiated R01 applications. National Institutes of Health program staff are available for discussion and advice and encourage contact from extramural investigators.
Fibrin turnover in lung inflammation and neoplasia IDELL, Steven; MAZAR, Andrew P; BITTERMAN, Peter ...
American journal of respiratory and critical care medicine,
02/2001, Letnik:
163, Številka:
2
Journal Article
BACKGROUND:Many subjects enrolled in research studies have a limited understanding of the research to which they consented.
OBJECTIVE:To develop recommendations to enhance comprehensiveness and ...understanding of informed consent forms used in critical care clinical trials.
DESIGN:Consensus process.
RECOMMENDATIONS:We provide recommendations regarding the U.S. federally required basic and additional elements of informed consent as applied to critical care clinical trials. We also identify issues that investigators need to address, if relevant, in the informed consent forms of critical care clinical trials. These include the description, in understandable language, of complex and detailed experimental protocols that are the focus of the clinical trial, disclosure of death as a risk factor if mortality is an outcome variable, and the identification of who can legally serve as the prospective subject’s surrogate. We also offer suggestions to enhance subjects’ understanding of informed consent forms.
CONCLUSIONS:The literature on informed consent forms suggest that shorter informed consent forms written at a lower reading level, when read carefully, might provide better subject understanding. Prospective evaluation is needed to determine whether our recommendations enhance the informed consent process.
The National Heart, Lung, and Blood Institute, along with the Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases, convened a panel to develop ...recommendations for treatment, prevention, and research for respiratory failure from severe acute respiratory syndrome (SARS) and other newly emerging infections. The clinical and pathological features of acute lung injury (ALI) from SARS appear indistinguishable from ALI from other causes. The mainstay of treatments for ALI remains supportive. Patients with ALI from SARS who require mechanical ventilation should receive a lung protective, low tidal volume strategy. Adjuvant treatments recommended include prevention of venous thromboembolism, stress ulcer prophylaxis, and semirecumbent positioning during ventilation. Based on previous experience in Canada, infection control resources and protocols were recommended. Leadership structure, communication, training, and morale are an essential aspect of SARS management. A multicenter, placebo-controlled trial of corticosteroids for late SARS is justified because of widespread clinical use and uncertainties about relative risks and benefits. Studies of combined pathophysiologic endpoints were recommended, with mortality as a secondary endpoint. The group recommended preparation for studies, including protocols, ethical considerations, Web-based registries, and data entry systems.
Objective To evaluate whether race or ethnicity was independently associated with parental refusal of consent for their child's participation in a multisite pediatric critical care clinical trial. ...Study design We performed a secondary analyses of data from Randomized Evaluation of Sedation Titration for Respiratory Failur e (RESTORE), a 31-center cluster randomized trial of sedation management in critically ill children with acute respiratory failure supported on mechanical ventilation. Multivariable logistic regression modeling estimated associations between patient race and ethnicity and parental refusal of study consent. Result Among the 3438 children meeting enrollment criteria and approached for consent, 2954 had documented race/ethnicity of non-Hispanic White (White), non-Hispanic Black (Black), or Hispanic of any race. Inability to approach for consent was more common for parents of Black (19.5%) compared with White (11.7%) or Hispanic children (13.2%). Among those offered consent, parents of Black (29.5%) and Hispanic children (25.9%) more frequently refused consent than parents of White children (18.2%, P < .0167 for each). Compared with parents of White children, parents of Black (OR 2.15, 95% CI 1.56-2.95, P < .001) and Hispanic (OR 1.44, 95% CI 1.10-1.88, P = .01) children were more likely to refuse consent. Parents of children offered participation in the intervention arm were more likely to refuse consent than parents in the control arm (OR 2.15, 95% CI 1.37-3.36, P < .001). Conclusions Parents of Black and Hispanic children were less likely to be approached for, and more frequently declined consent for, their child's participation in a multisite critical care clinical trial. Ameliorating this racial disparity may improve the validity and generalizability of study findings. Trial registration ClinicalTrials.gov : NCT00814099.
Little is known about how nursing care at the end of a child's life impacts long-term parental bereavement. We aimed to explain, contextualize, and examine comparisons between quantitative trends in ...children's end-of-life care and parents' qualitative perceptions. We used a mixed methods design, combining quantitative data from the RESTORE clinical trial with qualitative interviews with bereaved parents. Patients who died during RESTORE were included in quantitative analyses. A subset of their parents was interviewed 7 to 11 years later. The quantitative analyses included 104 children. Eight parents were interviewed; 4 had a child die after cancer, and 4 had a child die after a complex chronic illness. Quantitatively, patients' pain and sedation scores were generally comfortable. Children died with multiple invasive devices in place. Parents' descriptions of their child's comfort and critical care requirements differed by illness trajectory (cancer, complex chronic illness). Parents' memories of their child's suffering aligned with peaks in clinical scores, rather than averages. Invasive devices and equipment altered parents' ability to make meaningful final memories with the dying child. Pediatric intensive care clinicians may need to broaden how they attend to dying children's pain and corresponding parental distress, as parents' memories of their dying child's suffering persist for years.
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