Clinics in chest medicine
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The recent movement toward standardization of critical care practice is associated with a growth in the use of guidelines and protocols. Although complex, the process of guideline development, implementation, evaluation, and maintenance can be systematic. Guideline implementation can improve the processes and outcomes of care; however, guideline adherence represents a major challenge to their success. The quality of the growing number of practice guidelines in critical care is important to assess and several useful instruments are available for this purpose.
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Shock is an emergency that requires continuous bedside evaluation, resuscitation, and re-evaluation. The initial bedside examination allows the clinician to determine whether the patient exhibits a clinical picture that is consistent with hypovolemic, cardiogenic, or vasodilatory shock. The primary survey dictates urgent initial resuscitation that usually consists of intubation, ventilation, and volume support. ⋯ Early shock has a hemodynamic component, which is often easily reversed. Septic shock and prolonged shock from any cause has an inflammatory component, which is not easily reversed and leads to multiple-system organ failure (MSOF) and death. Success in treatment of shock depends on early recognition of shock and the rapid tempo of resuscitation of its hemodynamic component to prevent or minimize the inflammatory component.
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Hemodynamic monitoring is a diagnostic tool. Because hemodynamic monitoring often requires invasive procedures, it can be associated with an increased incidence of untoward events. ⋯ The diagnostic accuracy of preload responsiveness is markedly improved by the use of arterial pulse pressure or stroke volume variation, neither of which require pulmonary arterial catheterization. The field of hemodynamic monitoring is rapidly evolving and will probably continue to evolve at this rapid pace over the next 5 to 10 years as new technologies, information management systems, and our understanding of the pathophysiology of critical illness progresses.
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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.