Critical care clinics
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The delivery of critical care in the emergency department is a growing challenge that faces emergency physicians and intensivists. As emergency departments and intensive care units become increasingly crowded, critically ill patients will remain in the emergency department for longer periods of time. The care provided for critically ill patients during the emergency department stay significantly decreases the progression of organ failure and mortality. ⋯ As critical care requires significant resources including time from physicians and nurses, as well as physical resources including space, monitoring equipment, and medications, improving the quality of critical care delivery in the emergency department is not without obstacles. Resources are not limitless and the true goal is finding the point where delivering the best patient care possible occurs within the available resources of the emergency department and the hospital. This article describes the current status of critical care in the emergency department and discusses possible strategies for improvement.
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The management of patients for end-stage liver disease in the ICU mandates a multidisciplinary approach and intense monitoring. Orthotopic liver transplantation still remains the only definitive therapy. ⋯ In recent years, considerable progress has been made in developing specific and supportive medical measures. Future research should target a better understanding of mechanisms responsible for liver cell death and liver regeneration, as well as developments in xenotransplantation, hepatocyte transplantation, and liver-directed gene therapy.
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Although much has been accomplished in HTx and LTx in the past few decades, much remains to be conquered. It is an ever-changing, always fascinating field. Though science and technology know no limits, the primary limitation of HTx and LTx continues to be the availability of donor organs. One can only hope that further advances in educating the public will help close the large gap between the list of those waiting and the organs available for transplantation.
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Renal failure commonly occurs in an ICU as part of the evolution of an underlying disease process. Appropriate and rapid resuscitation and treatment prevents or reverses prerenal insults. Patients usually make a complete recovery if the disease process is reversible and the renal injury mild or moderate. ⋯ Continuous forms of RRT are gaining favor as they are associated with less hemodynamic instability, though current evidence does not demonstrate any clear outcome benefit. Mortality is high when the severe form of ARF is established. ARF may have some attributable mortality, but the poor outcome is usually related more to the underlying medical problems and concurrent multisystem derangements.
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A bioterrorist attack of any kind has the potential to overwhelm a community and, indeed, in the case of smallpox, an entire nation. During such an attack the number of patients requiring hospitalization and specifically critical care is likely to be enormous. Intensivists will be at the forefront of this war and will play an important role in dealing with mass casualties in an attempt to heal the community. ⋯ A biologic weapons attack, however, is likely to push this multidimensional nature of the intensivist to the maximum, because such an attack is likely to result in a more homogeneous critically ill population where the number of critical care staff and supplies to treat the victims may be limited. One hopes that such an event will not occur. Sadly, however the events of September 11, 2001, have only heightened the awareness of such a possibility.