Clinics in chest medicine
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Despite the key role of nutrition in health and the almost universal use of supplemental feeding in the ICU, there is a lack of high-quality evidence to guide clinical practice. Enteral nutrition is superior to TPN in almost all circumstances and most patients in the ICU can be fed successfully by this route. There is little evidence to support the use of special feeds and the role of immunonutrients remains unproven. Nutritional support cannot completely prevent the adverse effects of catabolic illness and overfeeding should be avoided.
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Clinics in chest medicine · Dec 2003
ReviewCritical issues in hematology: anemia, thrombocytopenia, coagulopathy, and blood product transfusions in critically ill patients.
Systematic evaluations of anemia, thrombocytopenia, and coagulopathy are essential to identifying and managing their causes successfully. In all cases, clinicians should evaluate RBC measurements alongside WBC and platelet counts and WBC differentials. Multiple competing factors may coexist; certain factors affect RBCs independent of those that affect WBCs or platelets. ⋯ In severe sepsis, levels of protein C decrease, as do fibrinogen and platelet levels. Because of its anticoagulant effect, however, drotrecogin alfa may induce bleeding. Guidelines for drotrecogin alfa use must take into account bleeding risks.
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Clinics in chest medicine · Dec 2003
ReviewImproving care for patients dying in the intensive care unit.
It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. ⋯ Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.
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Although the effective evaluation and management of agitated patients often receives less attention than other aspects of critical illness, it is among the most important and rewarding challenges that face critical care physicians. Key features of effective management include a thorough, organized search for potentially dangerous and correctable causes; a sound understanding of the pharmacology of analgesics and sedatives; and keeping a steady eye on appropriate management goals. In turn, the reward for excellent care will be shorter lengths of stay, more rapid liberation from mechanical ventilation, improved cognition, cost savings, and, perhaps, improved survival.
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Endocrine emergencies are commonly encountered in the ICU. This article focuses on several important endocrine emergencies, including diabetic hyperglycemic states, adrenal insufficiency, myxedema coma, thyroid storm, and pituitary apoplexy. Other endocrine issues that are related to intensive care, such as intensive insulin therapy, relative adrenal insufficiency, and thyroid function test abnormalities are also covered in detail.