Organ support during critical illness requires considering many factors: 1) when to start support and how much is needed, 2) safety, costs and technology considerations, 3) appropriate monitoring, and 4) determining when to discontinue support. Essential measures like checklists, early goal-directed therapy, and focusing on basic supportive interventions can help optimize outcomes for critically ill patients.
A talk by Pratik Pandharipande at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include:
Analysis of best available data
Use of best available judgement
Gathering of different opinions
An understanding that you won’t always make the right decision
To document the 'crap' out of it!
And to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases).
Touching on the processes designed to prevent missed injuries such as;
Territory Trauma Survey
Roles of clinical decision rules
To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
Matt Anstey is an intensivist from Sir Charles Gardiner hospital in Perth, Australia.
He gave this talk on outcomes after intensive care at an ICN WA meeting in Perth last year.
A talk by Pratik Pandharipande at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include:
Analysis of best available data
Use of best available judgement
Gathering of different opinions
An understanding that you won’t always make the right decision
To document the 'crap' out of it!
And to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases).
Touching on the processes designed to prevent missed injuries such as;
Territory Trauma Survey
Roles of clinical decision rules
To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
Matt Anstey is an intensivist from Sir Charles Gardiner hospital in Perth, Australia.
He gave this talk on outcomes after intensive care at an ICN WA meeting in Perth last year.
Hello members...this powerpoint deals with A journal presentation, that aims at highlighting the "Efficacy & safety of Lacosamide in painful diabetic neuropathy patients".
This also elucidates a model of "Journal club presentation" for interested students.
Happy reading!!
:)
Imogen Mitchell - Morphing the Recalcitrant ClinicianSMACC Conference
Imogen Mitchell’s SMACC Chicago talk 'Morphing the Recalcitrant Clinician’ talks us through the steps to engage the reluctant physician when implementing change.
Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician.
1. Seek out a clinical champion
2. Establish a common purpose/vision
3. Standardise what is standardisable
4. Communication, communication, communication
5. Work out barriers and overcome them
6. Deal with the ‘Whats in it for me?’WIFM
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Watch the webinar recording: http://bit.ly/1hnf3Os
Objectives:
1.Understanding when delirium can and cannot be assessed, and how sedatives make an accurate assessment more complicated
2.Understanding why different genetics, administering more than one drug or duration of sedative drug administration can change therapeutic effect and why it matters in the critically ill
Managing DM and thyroid disease in shift workersNemencio Jr
This slide deck discusses the effects of shift work on physiology and behavior of thyroid axis and beta cell function and risk of diabetes, including glucose control among those with diabetes. Management strategies are also discussed
Hello members...this powerpoint deals with A journal presentation, that aims at highlighting the "Efficacy & safety of Lacosamide in painful diabetic neuropathy patients".
This also elucidates a model of "Journal club presentation" for interested students.
Happy reading!!
:)
Imogen Mitchell - Morphing the Recalcitrant ClinicianSMACC Conference
Imogen Mitchell’s SMACC Chicago talk 'Morphing the Recalcitrant Clinician’ talks us through the steps to engage the reluctant physician when implementing change.
Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician.
1. Seek out a clinical champion
2. Establish a common purpose/vision
3. Standardise what is standardisable
4. Communication, communication, communication
5. Work out barriers and overcome them
6. Deal with the ‘Whats in it for me?’WIFM
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Watch the webinar recording: http://bit.ly/1hnf3Os
Objectives:
1.Understanding when delirium can and cannot be assessed, and how sedatives make an accurate assessment more complicated
2.Understanding why different genetics, administering more than one drug or duration of sedative drug administration can change therapeutic effect and why it matters in the critically ill
Managing DM and thyroid disease in shift workersNemencio Jr
This slide deck discusses the effects of shift work on physiology and behavior of thyroid axis and beta cell function and risk of diabetes, including glucose control among those with diabetes. Management strategies are also discussed
A Study On Clinical Profile Of Sepsis Patients In Intensive Care Unit Of A Te...dbpublications
Background : Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection which is one of the most important cause of mortality & morbidity in critically ill patients. In this study clinical profiles of the sepsis patients admitted in ICU in this part of India have been evaluated. Methods & Materials: This prospective hospital based observational study was undertaken in the department of Emergency Medicine ICU of Gauhati Medical College & Hospital, over a period of one year from August 2014 to July 2015 after obtaining institutional ethical committee clearance.
RESULTS: Clinical profiles of 50sepsis patients, with male preponderance (56%) & mortality rate 36% were studied. Mean age was 48.36 years (SD ±17.16). fever & tachycardia were present in all patients. 30 patients (60%) required ventilatory support, 28 patients (56%) required inotropic support, 10 patients (20%) required dialysis. Gram negative bacteria were found to be the predominant pathogens associated with sepsis(73.4%) where most common organism responsible was Klebsiella (36.8%). Conclusion : assessment of clinical signs & initial serological & radiological investigations are of utmost importance to detect more critically ill patients as early as possible to intervene earlier for saving the life of the sepsis patients.
The good news in resuscitation is that there have not been any new advances that mandate a change in practice since the 2016 ANZCOR Guidelines. The bad news is that despite our best intent, the ever-increasing research appears unable to demonstrate improved outcomes with any particular approach. Two of the most exciting areas (eCPR and post-resuscitation care) are being covered in detail at separate talks at this meeting. This presentation will focus on updating the audience on the more continuous approach to evidence evaluation, and the key recent publications that have made us at least re-evaluate our practices in BLS (including ventilation), ALS (including anti-arrhythmics) and peri-resuscitation care.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
1. 11th Congress of the TSMSICM
What to Consider
during Organ Support?
Younsuck Koh, MD, PhD, FCCM
Dept. of Pulmonary & CCM
Asan Medical Center, Univ. of Ulsan
Seoul, Korea
3. Issues in Organ Support
1.Failed organ
2.When to start, How, How much
3.Safety & Cost
4.Technology support
5.Monitoring
6.When to quit
7.Chronically critically ill
8.Essential measures in our
daily practice
6. Normal: 0.5-1.5 mmol/L
If lactate > 4 mmol and pH is less than 7.30,
consider tissue hypoxia
7. Tissue oxygen debt as a determinant of lethal and nonlethal
postoperative organ failure
-100 consecutive high-risk surgical op. in 98 pts.
- the tissue O2 deficit = the measured VO2 – the estimated VO2 requirement
Net cumulative
VO2 deficit
Shoemaker WC, et al. Crit Care Med 1988; 16:1117
8. Multiorgan Failure
• The MOF in sepsis occurs due to a substantial
cumulative tissue oxygen debt, not always due
to inadequate DO2.
The effects of vasodilation with prostacyclin on oxygen delivery and
uptake in critically ill patients. N Engl J Med. 1987: 317(7):397-403.
Prostacyclin produced increase in oxygen delivery was associated with a
significantly greater increase in oxygen uptake in the patients who died as
compared with the survivors (median increase, 19 vs. 5 percent, P<0.001).
In the survivors, the oxygen extraction ratio fell (median change, -17
percent; range, -27 to -6 percent) and the mixed venous oxygen tension
increased. In the patients who died, the extraction ratio rose (median
change, 11 percent; range -24 to +40 percent) and the mixed venous oxygen
tension did not change.
13. How Much?
“If we could give every individual the right amount
of nourishment and exercise, not too little and not
too much, we would have found the safest way to
health.” Hippocrates (460?-377 BC)
17. Another Goal-Directed Tx
Rivers E, et al. N Engl J Med 2001;345:1368-77
Early Goal-Directed
Therapy in the Treatment of
Severe Sepsis and Septic
Shock:
Achievement of target
values
18. 49.2%
33.3%
28-day Mortality
60
50
40
30
20
10
0
Standard Therapy
n=133
EGDT
n=130
P = 0.01*
*Key difference was in sudden CV collapse, not MODS
Rivers E. N Engl J Med 2001;345:1368-77.
23. DO2(ml/min)
= CO x (1.39 x Hb x SaO2 + 0.0031 x PaO2)
RBC Transfusion
Euvolemic & critically ill.
N Engl J Med 1999; 340: 409-417
Less is More
24. Early versus Late Parenteral Nutrition in
Critically Ill Adults
Compared early initiation of PN (within 2 days) with late
initiation (early enteral + initiated PN on day 8) in adults in the
intensive care unit (ICU)
Patients in the late-initiation group had a relative increase of
6.3% in the likelihood of being discharged alive earlier from the
ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13;
P=0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to
1.13; P=0.04), without evidence of decreased functional status at
hospital discharge.
Casaer MP, et al. NEJM 2011;365:506-17
25. Side Effect
Pulmonary-artery versus central venous catheter to guide treatment of
acute lung injury. N Engl J Med. 2006 25;354(21):2213-24.
.. PAC-guided therapy did not improve survival or organ function but was
associated with more complications than CVC-guided therapy.
27. Organ interaction
Ischemic AKI induces pulmonary EC apoptosis in whole-lung tissue in rats.
Micrographs (40x), ischemia-reperfusion injury stained with TUBEL (green)
White LE, et al. Shock 2012;38:320-327
28. Target
120
100
80
60
40
20
0
1 2 3 4 5
No. of acute organ failure
No. of pat ient s
100
50
0
Hospital mor talit y(% )
dist ribut ion Mortalit y
29. Place to Perform
The impact of intensive care unit admissions following early
resuscitation on the outcome of patients with severe sepsis and
septic shock.
Surat T, Viarasilpa T, Permpikul C.
J Med Assoc Thai. 2014 Jan;97 Suppl 1:S69-76.
..There were trends toward a lower 28 day mortality (18% vs. 25.6%, p =
0.33) among the patients in the ICU group.
Apart from the early goal-directed therapy, early ICU admission
substantially improves the outcomes of septic shock patients.
34. Serum Lactate
Metabolic
Normal: 0.5-1.5 mmol/L
If lactate > 4 mmol and pH is less than 7.30,
consider tissue hypoxia
35.
36. Biomarker for the Prediction of All-Cause Mortality in Critically ill:
A systemic review and meta-analysis
Zhang Z & Xu X. Crit Care Med 2014
37. Chronically Critically ILL
defined as those who survive initial life-threatening,
possibly reversible organ
failure(s) but are unable to recover
rapidly to a point at which they are fully
independent of life support
Their mean lengths of stay in the ICU
and in the hospital: 42.9+/-36.4 and
83.9+/-100.5 days
ICU and six-month cumulative mortality
rates: 42.6% and 75.9%
The SOFA score on day 21 and
comorbidity in the ICU appears to be a
valuable prognostic indicators in
chronically critically ill patients.
Lee K, et al. Anaesth Intensive Care. 2008;36(4):528-34
38. Resource use in the ICU: short- vs. long-term
patients
..In this university-based, medical-surgical adult ICU,
11% of all patients stayed more than 7 days
in the unit and consumed
more than 50% of all resources.
Stricker K, et al. Acta Anaesthesiol Scand. 2003;47:508-15.
40. The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care
Huynh TN, et al. JAMA Intern Med 2013;173:1887-94
41. Essential Measures to be Performed
1. Patients’ bed head elevation > 30°
2. Stress ulcer prophylaxis
3. DVT prophylaxis
4. Low tidal volume ventilation
5. Early removal of central venous & Foley catheter
6. Early enteral feeding
43. Prompting Physicians to Address a Daily Checklist and
Process of Care and Clinical Outcomes
Prompted group patients had lower risk-adjusted ICU mortality compared
with the control group (odds ratio, 0.36; 95% confidence interval, 0.13–0.96;
P = 0.041) and lower hospital mortality compared with the control group
(10.0 vs. 20.8%; P = 0.014).
Weiss CH, et al. Am J Respir Crit Care Med. 2011; 184(6): 680–686
44. Conclusion
• Stick to Basic Essential Measures.
• The earlier, the better
• Consider organ interactions when to resuscitate.
• Frequently less is more.
• Should stop non-responding measures.
Cause of in-hospital death:
--Sudden Cardiovascular collapse
Standard Tx= 25/119 (21%) EGDT 12/117 (10.3%)
--MODS
Standard Tx 26/119(21.8%) EGDT 19/117 (16.2%)
P. 1374 in New England Journal of Medicine
I am here today
to invite all of you
to Korea in August, 2015.