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Society of Critical Care Medicine, Jan. 31-Feb. 4, 2009

Society of Critical Care Medicine's 38th Annual Critical Care Congress

The Society of Critical Care Medicine's 38th Annual Critical Care Congress took place Jan. 31-Feb. 4 in Nashville and attracted 4,915 attendees, including 3,742 nurses, pharmacists, physicians, respiratory therapists, students, veterinarians, and other providers from around the world.

Program co-chair Heidi L. Frankel, M.D., of the University of Texas Southwestern Medical Center in Dallas, said that highlights included the Presidential Address by Mitchell M. Levy, M.D., who commented on the success of the "Surviving Sepsis" campaign and the importance of balancing intellect and compassion in the practice of bedside care, and the William C. Shoemaker Honorary Lecture by Peter Buerhaus, R.N., Ph.D., of Vanderbilt University, who spoke on the future of the nation's nursing workforce.

"Dr. Buerhaus is a fascinating individual and a world-renowned economist on workforce shortages," Frankel said. "He told us that the current economy is going to be a boon to the nursing shortage because nursing is going to be a very attractive profession to students."

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During a plenary session entitled Haldane, Hot Dogs and Halitosis: The Emerging Biology of the Nitrate Anion in Physiology and Therapeutics, Mark Gladwin, M.D., of the Hemostasis and Vascular Biology Research Institute at University of Pittsburgh, presented a broad overview of nitrite biology and showed how nitrite is converted to nitric oxide as red cells deoxygenate from artery to vein.

"(This) is likely to be an important physiologic biology of hypoxic signaling and perhaps important therapeutically in diseases associated with ischemia and reperfusion," Gladwin said.

As an example, Gladwin discussed an animal study he conducted to test the possibility of using inhaled nitrite for persistent pulmonary hypertension of the newborn. "We just took simple nitrite, mixed it in saline and put it in a plastic albuterol nebulizer," he said. "The animals were subjected to 30 minutes of hypoxia and developed pulmonary hypertension. Then we gave them inhaled nitrite for 20 minutes. Remarkably, we saw an immediate drop in pulmonary pressures, and we saw a slight further drop in systemic pressures. The interaction of nitrite in the host also generated nitric oxide gas in the expired breath."

Gladwin also presented data showing that nitrite is converted in the acidic stomach to nitric oxide, where it regulates the mucosal blood flow, mucus production and has important bacterial killing effects. "It's very clear that nitrite is a potent cytoprotective agent," he said. "In forming nitric oxide, it inhibits inflammation, and a lot of data suggests it prevents the reperfusion burst of reactive oxygen species that activate mitochondrial-dependent apoptosis."

Although nitrite may be a potential therapy for a wide range of conditions -- from myocardial infarction to sickle cell disease -- he said further clinical work is needed to address its safety and efficacy for the treatment of specific human diseases.

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"Another key theme we promoted was the 'I Am SCCM' theme where we emphasized that each of our 14,000 members is important to the organization and important in the bedside care of every ICU patient," Frankel said. "Even though what we do is a team sport, individuals still really matter in terms of research and the care of patients."

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Another highlight "was a late-breaker session that included a major trial showing the efficacy of a specific sedation strategy for ICU patients that resulted in less time on the ventilator and less delirium," said Frankel.

During that study, Richard R. Riker, M.D., of the University of Vermont College of Medicine and Maine Medical Center in Portland, Maine, and colleagues randomly assigned critically ill patients who had expected mechanical ventilation of more than 24 hours to receive either sedation with dexmedetomodine or a traditional benzodiazepine: midazolam. Although there were no group differences in the percentage of time within the target sedation range, they found that dexmedetomodine was associated with a significant reduction in the rate of delirium and number of days until extubation.

"To our knowledge, this is the first study to show that even when the elements of best sedation practice (including daily arousal, a consistent light-to-moderate sedation level, and delirium monitoring) are used for all patients, the choice of dexmedetomidine as the foundation for patient sedation further improves these important outcomes," Riker and colleagues wrote. "Dexmedetomidine appears to be the first drug to both reduce the development of delirium and to improve the resolution of delirium if it develops in the ICU."

"With the demonstration of the safety of dexmedetomidine at higher doses and for longer periods, clinicians now have a widened choice of sedatives and should always consider not only the need for sedation but also the possible clinical implications of the choice of sedative," said Hannah Wunsch, M.D., of Columbia University and John Kress, M.D., of the University of Chicago, in an accompanying editorial.

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Sedatives Effective for Critically Ill on Ventilation

MONDAY, Feb. 2 (HealthDay News) -- Dexmedetomidine is similar to midazolam in effectively sedating critically ill patients on mechanical ventilation for prolonged periods, but with less delirium and shorter time to extubation, according to research published online Feb. 2 in the Journal of the American Medical Association, released early to coincide with the Society of Critical Care Medicine's annual meeting in Nashville.

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