Clinics in chest medicine
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Clinics in chest medicine · Mar 2009
ReviewMeasurement of quality and assurance of safety in the critically ill.
The global health care community has worked tirelessly for nearly a decade to make medical care safer for patients, but it still has limited ability to evaluate whether safety has improved. While there is a universal push to measure safety outcomes, the main barrier has been poor investment in the basic science of patient safety. ⋯ This article describes several dilemmas in measuring patient safety, outlines a conceptual model and presents a framework for measuring patient safety, and offers future directions. Future research should seek to create a scientifically sound and feasible safety scorecard and improve performance.
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Clinics in chest medicine · Mar 2009
ReviewShort- and long-term cognitive outcomes in intensive care unit survivors.
Evidence increasingly suggests that cognitive impairment is common in intensive care unit survivors, although the nature, severity, and natural history remain unclear. Although the cognitive impairments improve over time in some individuals, they often fail to completely abate. ⋯ The potential etiologies of cognitive impairments in intensive care unit survivors are not fully understood and are likely heterogeneous and vary widely across patients. The contributions of these many factors may be particularly significant in patients with pre-existing vulnerabilities for the development of cognitive impairments, such as mild cognitive impairment, dementia, prior traumatic brain injury, or other comorbid disorders, as well as predisposing genetic factors.
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Clinics in chest medicine · Mar 2009
ReviewCritical care management of subarachnoid hemorrhage and ischemic stroke.
This article addresses current critical care management strategies for patients with aneurysmal subarachnoid hemorrhage (SAH) and ischemic stroke. The chronology of typical SAH care is discussed, with an emphasis on the treatment of poor-grade SAH and on current monitoring techniques. Acute diagnosis and treatment of the life-threatening ischemic strokes is reviewed, emphasizing the care of patients with acute basilar artery occlusion and the malignant middle cerebral artery syndrome. Up-to-date estimates of the long-term outcomes of these syndromes are reviewed.
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Acute kidney injury (AKI) is common among critically ill patients and results in increased mortality in this population. This review focuses on the diagnosis and management of AKI. ⋯ The authors also explore the available data on choice of dialysis modality and dialysis dose for the treatment of AKI, as well as the breakthrough development of the bioartificial kidney. Last, the authors review co-interventions that may have relevance to prognosis of AKI, such as intensive insulin therapy and the use of erythropoietin.
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During disease states, the endocrine axes exhibit different levels of activity according to the severity of illness. These various alterations have been widely investigated. Indeed, evidence indicates that the anterior pituitary is dysfunctional in these states, especially when multiple organ dysfunction syndrome is present, impacting both adrenal and thyroid glands, but also secretion of estrogen, growth hormone, insulin-like growth factor-1, and prolactin. ⋯ Others, such as vasopressin and apelin, are newly ascribed. Therapeutic issues in critically ill patients still remain controversial and are ardently debated, especially with regard to the needs and practical use of corticosteroids in septic shock. This article focuses on actual knowledge, mechanisms, definitions, and therapeutic recommendations, as well as on areas of uncertainty relative to adrenal gland insufficiency in septic shock.