Clinics in chest medicine
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The exact prevalence of obesity among critically ill patients is not known, but some evidence suggests that in the United States one in four patients in the intensive care unit is obese. The authors review the physiologic alterations in obesity that are relevant in critical illness and highlight some common diseases associated with obesity. Various practical challenges in the care of the critically ill obese patient, including drug dosing, are also reviewed.
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Airway management is a major factor underlying morbidity and mortality in the obese population. The validity of anthropomorphic prediction model in assessing a difficult airway is less accurate compared with lean subjects. ⋯ Application of noninvasive positive airway pressure can prevent atelectasis and improve oxygenation during the anesthetic induction as well during the postoperative period and after liberation from mechanical ventilation. When performed by trained operators, bedside percutaneous dilatation tracheostomy in obese patients has a safety profile comparable to surgical tracheostomy but provides advantages including ease of performance and lesser cost, and obviates transporting a critically ill patient outside the intensive care unit.
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Clinics in chest medicine · Jun 2009
ReviewFungal infections in hematopoietic stem cell transplantation and solid-organ transplantation--focus on aspergillosis.
Invasive fungal infections (IFIs) represent a major complication in recipients of hematopoietic stem cell transplantation and solid-organ transplantation. The incidence of IFIs in transplant recipients has increased over the past 20 years, and these infections continue to be associated with high morbidity and mortality. This article reviews the important concepts guiding the management of IFIs in transplant recipients, including epidemiologic trends, new risk factors, and a timetable of infections, pathogens, therapy, and prevention of these infections. An emphasis is given to invasive aspergillosis.
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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.