Purpose Systemic levels of soluble urokinase-type plasminogen activator receptor (suPAR) positively correlate with the activation level of the immune system. We reviewed the usefulness of systemic levels of suPAR in the care of critically ill patients with sepsis, SIRS, and bacteremia, focusing on its diagnostic and prognostic value. Methods A PubMed search on suPAR was conducted, including manual cross-referencing. The list of papers was narrowed to original studies of critically ill patients. Ten papers on original studies of critically ill patients were identified that report on suPAR in sepsis, SIRS, or bacteremia. Results Systematic levels of suPAR have little diagnostic value in critically ill patients with sepsis, SIRS, or bacteremia. Systemic levels of suPAR, however, have superior prognostic power over other commonly used biological markers in these patients. Mortality prediction by other biological markers or severity-of-disease classification system scores improves when combining them with suPAR. Systemic levels of suPAR correlate positively with markers of organ dysfunction and severity-of-disease classification system scores. Finally, systemic levels of suPAR remain elevated for prolonged periods after admission and only tend to decline after several weeks. Notably, the type of assay used to measure suPAR as well as the age of the patients and underlying disease affect systemic levels of suPAR. Conclusions The diagnostic value of suPAR is low in patients with sepsis. Systemic levels of suPAR have prognostic value, and may add to prognostication of patients with sepsis or SIRS complementing severity-of-disease classification systems and other biological markers.

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Summary Key wordsTotal intravenous unaesthesia. Anaesthetics, intravenous; propofol, ketamine.Ketamine is a powerful analgesic, even in doses insufficient to induce anaesthesia.' It has many of the attributes of the 'ideal' analgesic agent for longer routine operations: a very high margin of safety, no irritation of the veins and no negative influence on ventilation or circulation. Its main disadvantages are that it produces hypertension and precipitates psychomimetic emergence phenomena. These effects can be mitigated by judicious medication, particularly by administering benzodiazepines. The combination of midazolam with ketamine has been recommended previously ror total intravenous anaesthesia in military surgery, general civilian practice and cardiac s~r g e r y .~-~ In this study, the combination of propofol/ketamine was compared to the combination propofol/fentanyl in a double-blind, prospective trial in patients undergolng general anaesthesia for elective surgery. Haemodynamic variables, the time to recovery and patient acceptability were compared. MethodsA prospective study of 18 patients who underwent noncardiac surgery was performed. Patients gave informed consent to a protocol approved by the medical ethics committee of our hospital. All patients were ASA grade 1 or 2 and scheduled for operations longer than 15 minutes (Table I). Patients received oral oxazepam (0.25-0.3 mg/kg) as premedication 2 hours before surgery and were allocated randomly to one of two groups to receive propofol with ketamine (n = 9) or propofol with fentanyl (n = 9) for total intravenous anaesthesia.Standard lead I1 of the electrocardiogram was monitored and an intravenous cannula inserted on arrival of the patient in the operating theatre. Heart rate was detected by electrocardiogram and calculated electronically on a beatto-beat basis. The pulse rate was timed for at least 30 seconds. One person recorded all arterial pressure measurements by auscultation (diastolic reading as Korotkoff phase V) using an anaeroid sphygomanometer previously calibrated at zero and 150 mmHg against a mercury column. Anaesthesia was induced with propofol (2 mg/kg) and either fentanyl (3 pg/kg) or ketamine (I mg/kg). Vecuronium (0.15 mg/kg) was administered. Anaesthesia was maintained with propofol 12 mg/kg/hour during the first 30 minutes, followed by 9 mg/kg/hour for 30 minutes and then 6 mg/kg/hour combined with fentanyf 1.5 pg/kg/hour or with ketamine 2 mg/kg hour. The patient's lungs were ventilated with oxygen-enriched air with an no2 of 0.35.The postinduction arterial pressure and heart rate were recorded one minute after induction, and direct laryngoscopy with a curved blade was initiated 2 minutes after induction. None of the patients received topical or intravenous lignocaine before laryngoscopy, and tracheal intubation was always accomplished within 20 seconds.

Only 28% of the interventional studies were RCTs. Over half of the 275 interventional studies were single group interventions, pointing to the need for studies of improved methodological quality into ABI rehabilitation.