AACN advanced critical care
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Procalcitonin is a promising biomarker for antibiotic therapy because its levels rise and fall quickly with bacterial infections. A multidatabase literature search was reviewed with 3 primary prospective randomized control trials used in further analysis. ⋯ Short-term studies did not show a difference in the intensive care unit length of stay, infection relapse rate, superinfection rate, or multidrug-resistant bacteria rate between the procalcitonin-protocol and control group. Because procalcitonin-guided antibiotic therapy has been shown to reduce the duration of treatment with antibiotics in critically ill patients without worsening the mortality rate or other outcomes, the implementation of a procalcitonin-guided antibiotic therapy should be considered for patients with proven or highly suspected bacterial infections in the intensive care unit.
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Critically ill patients receiving palliative care at the end of life are at high risk for experiencing pain, dyspnea, and death rattle. Nearly all these patients are at risk for the development of delirium. Patients who are alert may experience anxiety. ⋯ Evidence-based interventions are offered for both prevention and treatment of pain, dyspnea, anxiety, and delirium. Death rattle does not produce patient distress, and current pharmacological treatment lacks an evidence base. Pain management has a robust evidence base compared to management of dyspnea, anxiety, and delirium among this population; well-designed, adequately powered studies are needed.
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Because of technological advancements and encouraging experiences during the 2009 influenza A (H1N1) epidemic, many critical care clinicians consider extracorporeal membrane oxygenation (ECMO) a reasonable strategy for managing patients with refractory hypoxemia when standardized therapies have failed. Although the literature remains unclear as to whether it should be considered a routine or a rescue strategy in the management of patients with severe acute respiratory distress syndrome, experts agree that ECMO therapy is most likely to result in positive outcomes and fewer complications when provided at regional ECMO centers. Some institutions have developed the expertise and resources required to provide this sophisticated therapy, but significantly more facilities may choose to send their patients to a tertiary ECMO center when they do not respond to usual care. ⋯ The clinical indications for, and the use of, ECMO therapy in the management of refractory hypoxemia is briefly reviewed, followed by a description of how ECMO works to provide gas exchange and tissue perfusion. The primary considerations for circuit management, hemodynamic support, and pulmonary care are described, and significant complications of the therapy are identified. The remainder of the article focuses on the patient care and preparatory activities that occur before and during ECMO initiation, so that health care teams, patients, and their families can be confident of an efficient, safe, and highly skilled transfer of care between institutions.
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Depending on the causative agent, the differential diagnosis for acute nontraumatic weakness presentation can range from life threatening to trivial. Practitioners' comfort and experience with the rapid identification and evaluation of presenting neurological deficits vary widely. Given this fact and the reality that neurological presentation of weakness is common, the potential for missed diagnosis increases. To enhance knowledge of potentially life-threatening or morbidity-inducing complications, this article provides a systematic framework for physical and diagnostic evaluation of the most common differentials for acute causes of nontraumatic weakness.
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Acute abdominal pain represents the cardinal symptom of a large number of intra-abdominal pathologies. Because of multiple organ systems, varied pathology from life threatening to benign, and differences in presentation related to sex and age, identifying a final diagnosis is a challenge. ⋯ By developing a systematic approach to evaluating patients with abdominal pain, clinicians can generate a differential diagnosis to ensure appropriate treatment and improved patient outcomes. The purpose of this article is to provide clinicians with a framework for evaluating the complaint of acute abdominal pain and recognizing patients who require expedited evaluation.