***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To evaluate the effects of short-term , high-volume hemofiltration ( STHVH ) on hemodynamic and metabolic status and 28-day survival in patients with refractory septic shock . Design Prospect i ve , interventional . Setting Intensive care unit ( ICU ) , tertiary institution . Patients Twenty patients with intractable cardiocirculatory failure complicating septic shock , who had failed to respond to conventional therapy . Interventions STHVH , followed by conventional continuous venovenous hemofiltration . STHVH consisted of a 4-hr period during which 35 L of ultrafiltrate is removed and neutral fluid balance is maintained . Subsequent conventional continuous venovenous hemofiltration continued for at least 4 days . Measurements and Main Results Cardiac index , systemic vascular resistance , pulmonary vascular resistance , oxygen delivery , mixed venous oxygen saturation , arterial pH , and lactate were measured serially . Fluid and inotropic support were managed by protocol . Therapeutic endpoints were as follows during STHVH : a ) by 2 hrs , a ≥50 % increase in cardiac index ; b ) by 2 hrs , a ≥25 % increase in mixed venous saturation ; c ) by 4 hrs , an increase in arterial pH to > 7.3 ; d ) by 4 hrs , a ≥50 % reduction in epinephrine dose . Patients who attained all four goals ( 11 of 20 ) were considered hemodynamic “ responders ” ; patients who did not ( 9 of 20 ) were considered hemodynamic “ nonresponders . ” There were no differences in baseline hemodynamic , metabolic , and Acute Physiology and Chronic Health Evaluation and Simplified Acute Physiology Scores between responders and nonresponders . Survival to 28 days was better among responders ( 9 of 11 patients ) than among nonresponders ( 0 of 9 ) . Factors associated with survival were hemodynamic-metabolic response status , time interval from ICU admission to initiation of STHVH , and body weight . Conclusions These data suggest that STHVH may be of major therapeutic value in the treatment of intractable cardiocirculatory failure complicating septic shock . Early initiation of therapy and adequate dose may improve hemodynamic and metabolic responses and 28-day survival STUDY OBJECTIVE To determine whether correction of acidemia using bicarbonate improves hemodynamics in patients who have lactic acidosis . DESIGN Prospect i ve , r and omized , blinded , crossover study . Each patient sequentially received sodium bicarbonate and equimolar sodium chloride . The order of the infusions was r and omized . SETTING Intensive care unit of a tertiary care hospital . PATIENTS Fourteen patients who had metabolic acidosis ( bicarbonate less than 17 mmol/L and base excess less than -10 ) and increased arterial lactate ( mean , 7.8 mmol/L ) . All had pulmonary artery catheters and 13 were receiving catecholamines .  MEASUREMENTS AND MAIN RESULTS Sodium bicarbonate ( 2 mmol/kg body weight over 15 minutes ) increased arterial pH ( 7.22 to 7.36 , P less than 0.001 ) , serum bicarbonate ( 12 to 18 mmol/L , P less than 0.001 ) , and partial pressure of CO2 in arterial blood ( PaCO2 ) ( 35 to 40 mm Hg , P less than 0.001 ) and decreased plasma ionized calcium ( 0.95 to 0.87 mmol/L , P less than 0.001 ) . Sodium bicarbonate and sodium chloride both transiently increased pulmonary capillary wedge pressure ( 15 to 17 mm Hg , and 14 to 17 mm Hg , P less than 0.001 ) and cardiac output ( 18 % and 16 % , P less than 0.01 ) . The mean arterial pressure was unchanged . Hemodynamic responses to sodium bicarbonate and sodium chloride were the same . These data have more than 90 % power of detecting a 0.5 L/min ( 7 % ) change in mean cardiac output after administration of sodium bicarbonate compared with that after sodium chloride . Even the 7 most acidemic patients ( mean pH , 7.13 ; range , 6.90 to 7.20 ) had no significant hemodynamic changes after either infusion . CONCLUSIONS Correction of acidemia using sodium bicarbonate does not improve hemodynamics in critically ill patients who have metabolic acidosis and increased blood lactate or the cardiovascular response to infused catecholamines in these patients . Sodium bicarbonate decreases plasma ionized calcium and increases PaCO2 BACKGROUND Acute renal failure ( ARF ) requiring dialysis in critically ill patients is associated with an in-hospital mortality rate of 50 to 80 % . The worldwide st and ard for renal replacement therapy is intermittent hemodialysis ( IHD ) . Continuous hemodialysis and hemofiltration techniques have recently emerged as alternative modalities . These two therapies have not been directly compared . METHODS A multicenter , r and omized , controlled trial was conducted comparing two dialysis modalities ( IHD vs. continuous hemodiafiltration ) for the treatment of ARF in the intensive care unit ( ICU ) . One hundred sixty-six patients were r and omized . Principal outcome measures were ICU and hospital mortality , length of stay , and recovery of renal function . RESULTS Using intention-to-treat analysis , the overall ICU and in-hospital mortalities were 50.6 and 56.6 % , respectively . Continuous therapy was associated with an increase in ICU ( 59.5 vs. 41.5 % , P < 0.02 ) and in-hospital ( 65.5 vs. 47.6 % , P < 0.02 ) mortality relative to intermittent dialysis .  Median ICU length of stay from the time of nephrology consultation was 16.5 days , and complete recovery of renal function was observed in 34.9 % of patients , with no significant group differences . Despite r and omization , there were significant differences between the groups in several covariates independently associated with mortality , including gender , hepatic failure , APACHE II and III scores , and the number of failed organ systems , in each instance biased in favor of the intermittent dialysis group . Using logistic regression to adjust for the imbalances in group assignment , the odds of death associated with continuous therapy was 1.3 ( 95 % CI , 0.6 to 2.7 , P = NS ) . A detailed investigation of the r and omization process failed to explain the marked differences in patient assignment . CONCLUSIONS A r and omized controlled trial of alternative dialysis modalities in ARF is feasible . Despite the potential advantages of continuous techniques , this study provides no evidence of a survival benefit of continuous hemodiafiltration compared with IHD . This study did not control for other major clinical decisions or other supportive management strategies that are widely variable ( for example , nutrition support , hemodynamic support , timing of initiation , and dose of dialysis ) and might material ly influence outcomes in ARF . St and ardization of several aspects of care or extremely large sample sizes will be required to answer optimally the questions originally posed by this investigation Objectives Maintenance of normoglycemia with insulin reduces mortality and morbidity of critically ill patients . Here we report the factors determining insulin requirements and the impact of insulin dose vs. blood glucose control on the observed outcome benefits . Design A prospect i ve , r and omized , controlled trial . Setting A 56-bed predominantly surgical intensive care unit in a tertiary teaching hospital Patients and InterventionA total of 1,548 patients were r and omly assigned to either strict normalization of blood glucose ( 80–110 mg/dL ) with insulin infusion or the conventional approach , in which insulin is only given to maintain blood glucose levels at 180–200 mg/dL. Measurements and Main Results It was feasible and safe to achieve and maintain blood glucose levels at < 110 mg/dL by using a titration algorithm . Stepwise linear regression analysis identified body mass index , history of diabetes , reason for intensive care unit admission , at-admission hyperglycemia , caloric intake , and time in intensive care unit as independent determinants of insulin requirements , together explaining 36 % of its variation . With nutritional intake increasing from a mean of 550 to 1600 calories/day during the first 7 days of intensive care , normoglycemia was reached within 24 hrs , with a mean daily insulin dose of 77 IU and maintained with 94 IU on day 7 .  Insulin requirements were highest and most variable during the first 6 hrs of intensive care ( mean , 7 IU/hr ; 10 % of patients required > 20 IU/hr ) . Between day 7 and 12 ,  insulin requirements decreased by 40 % on stable caloric intake . Brief , clinical ly harmless hypoglycemia occurred in 5.2 % of intensive insulin-treated patients on median day 6 ( 2–14 ) vs. 0.8 % of conventionally treated patients on day 11 ( 2–10 ) . The outcome benefits of  intensive insulin therapy were equally present regardless of whether patients received enteral feeding . Multivariate logistic regression analysis indicated that the lowered blood glucose level rather than the insulin dose was related to reduced mortality ( p < .0001 ) , critical illness polyneuropathy ( p < .0001 ) , bacteremia ( p = .02 ) , and inflammation ( p = .0006 ) but not to prevention of acute renal failure , for which the insulin dose was an independent determinant ( p = .03 ) . As compared with normoglycemia , an intermediate blood glucose level ( 110–150 mg/dL ) was associated with worse outcome . Conclusion Normoglycemia was safely reached within 24 hrs and maintained during intensive care by using insulin titration guidelines . Metabolic control , as reflected by normoglycemia , rather than the infused insulin dose per se , was related to the beneficial effects of intensive insulin therapy BACKGROUND This study was design ed to determine the consequences of acute hyperglycemia on the immune function of peripheral neutrophils , peritoneal macrophages , and alveolar macrophages in nondiabetic rats . METHODS The animals were r and omly divided into nonsurgical ( normal ) and surgical groups . The postoperative rats were further divided into normoglycemic ( control ) and hyperglycemic ( glucose ) groups . The hyperglycemic condition was maintained by constant infusion of glucose to raise plasma glucose concentration to 300 mg/dL for 3 hours . The immune cells were then harvested to determine their phagocytic and oxidative capacities via flow cytometry . RESULTS The results showed that hyperglycemia significantly decreased the respiratory burst of alveolar macrophages ( p < .05 ) . In contrast , hyperglycemia enhanced phagocytosis in these cells ( p < .002 ) . There was a significant activation of the respiratory burst in peripheral neutrophils by surgery ( p < .002 ) , but no effect of hyperglycemia . CONCLUSIONS We conclude that hyperglycemia itself can influence immune function in some phagocytic cells , which may be an important factor in postsurgical infection Objective To study the effect of early and continuous venovenous hemofiltration ( CVVH ) on the plasma concentrations of several humoral mediators of inflammation and subsequent organ dysfunction in septic patients . Design R and omized , controlled trial . Setting Intensive care unit of a tertiary hospital . Patients Twenty-four patients with early septic shock or septic organ dysfunction . Interventions R and om allocation to receive 48 hrs of isovolemic CVVH at 2 L/hr of fluid exchange or no hemofiltration . Measurements and Main Results We measured the plasma concentrations of complement fractions C3a and C5a , interleukins 6 , 8 , and 10 , and tumor necrosis factor & agr ; at baseline and 2 , 24 , 26 , 48 , and 72 hrs . A multiple organ dysfunction score ( MODS ) was calculated daily for each patient until death or discharge from the intensive care unit . The concentrations of most mediators decreased between baseline and 72 hrs . Some significant falls in concentration could be identified between specific time points , but CVVH was not associated with an overall reduction in any plasma cytokine concentrations . There was also no difference between the mean cumulative MODS for control survivors ( 43.3 ± 19.7 ) and CVVH survivors ( 33.2 ± 19.0;p = .30 ) , and no difference between the average MODS calculated for all controls ( 4.1 ± 1.9 ) and all CVVH subjects ( 3.3 ± 1.7;p = .26 ) . CVVH did not improve oxygenation , lower the platelet count , or reduce the duration of vasopressor support and mechanical ventilation . Conclusions Early use of CVVH at 2 L/hr did not reduce the circulating concentrations of several cytokines and anaphylatoxins associated with septic shock , or the organ dysfunction that followed severe sepsis . CVVH using current technology can not be recommended as an adjunct to the treatment of sept 
    Output:
    
Glycemic control ( maintenance of glucose < 150 mg/dL ) is recommended .
The beneficial effect of glycemic control appears to be related control of glucose and not the administration of insulin .
Continuous hemofiltration offers easier management of fluid balance in hemodynamically unstable septic patients but in the absence of hemodynamic instability is equivalent to intermittent hemodialysis .
It is uncertain whether high-volume hemofiltration improves prognosis in sepsis .