Clinics in chest medicine
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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.
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Clinics in chest medicine · Dec 2003
ReviewPrognostication and intensive care unit outcome: the evolving role of scoring systems.
Prognostic scoring systems remain important in clinical practice. They enable us to characterize our patient populations with robust measures for predicted mortality. This allows us to audit our own experience in the context of institutional quality control measures and facilitates, albeit imperfectly, comparisons across units and patient populations. ⋯ These measures may also be used for research to better characterize the natural history and course of a certain disease group or population. Also, they may be used in innovative ways to predict ICU mortality and post-ICU long-term morbidity. These current and developing applications will help us to further understand the link between ICU severity of illness and long-term morbidity as we move beyond survival as the sole measure of ICU outcome.
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Tracheotomy is one of the most commonly performed surgical procedures among critically ill patients. In the past, tracheotomy was delayed as long as possible in ventilator-dependent patients because of concerns regarding injury to the airway from the surgical procedure. Greater recognition of the benefits of tracheotomy in terms of greater patient comfort and mobility has promoted its earlier performance. ⋯ The decision to convert a patient from translaryngeal intubation to a tracheostomy requires anticipation of the duration of expected mechanical ventilation and the weighing of the expected benefits and risks of the procedure. The convenience of percutaneous tracheotomy performed in the ICU by critical care specialists without formal surgical training has further promoted the adoption of tracheotomy for ventilator-dependent patients. Regardless of the method for performing tracheotomy, meticulous surgical technique and careful postoperative management are necessary to maintain the excellent safety record of tracheotomy for critically ill patients.