Critical care clinics
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Central venous catheters are widely used in children with critical illness and chronic disease. These devices are often essential in the delivery of medications and intravenous fluids and in hemodynamic monitoring. ⋯ This article reviews the background, pathophysiology, and incidence of catheter occlusion and catheter-related thrombosis. Diagnostic, preventive, and treatment strategies, along with future research directions, are addressed.
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The patient with single-ventricle physiology presents a significant challenge to the intensive care team at all stages of management. An integrated approach that applies a working knowledge of cardiac anatomy, cardiopulmonary physiology, and the basic principles of intensive care is essential to guide management for each individual patient. This management requires cooperative and constructive involvement of surgeons, cardiologists, and intensivists, as well as a nursing and respiratory care team experienced in the management of single-ventricle patients. The outcome of each stage of palliation for single-ventricle lesions should continue to improve as new ideas are developed and as older ideas are subjected to rigorous scientific analyses.
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Critical care clinics · Jul 2003
ReviewCoagulation dysfunction in sepsis and multiple organ system failure.
In patients diagnosed with sepsis, severe sepsis or septic shock, cytokine-mediated endothelial injury, and TF activation initiate a cascade of events that culminate in the development of coagulation dysfunction characterized as procoagulant and antifibrinolytic. This abnormal state predisposes the patient to develop microvascular thrombosis, tissue ischemia, and organ hypoperfusion. Multiple organ dysfunction syndrome may be a product of this pertubation in coagulation regulation. ⋯ Current data suggest that AT III replacement therapy has limited efficacy in adults with severe sepsis. In contrast, adult patients diagnosed with severe sepsis and organ failure and treated with aPC (drotrecogin alfa activate) have a significantly reduced risk of death when compared with placebo-treated patients. A phase III trial examining the efficacy of protein C replacement therapy in pediatric patients with severe sepsis and organ failure is underway.
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In the last 5 years, the understanding of the epidemiology and pathogenesis of pediatric sepsis, septic shock, and multiple organ failure has expanded greatly. There has also been a substantial increase in the number of successful randomized trials in which success has been measured as reduction in mortality in adults, children, and newborns. ⋯ Robert E. Cunnion and following the format of the 1997 article.
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Critical care clinics · Jul 2003
ReviewA practical approach to evidence-based medicine: lessons learned from developing ventilator management protocols.
Development of robust clinical protocols is a time-consuming process that requires allocation of sufficient time and resources. As outlined for the mechanical-ventilation protocol, the goals of the protocol must be clear before embarking on this journey. Critical appraisal of existing evidence is an essential first step to developing a draft protocol. ⋯ An effective, ongoing training program must be implemented to ensure protocol success. The final protocol should be carefully monitored in 50 to 100 patients to ensure that clinicians are complying with the protocol rules and that adverse events related to the protocol are not occurring. Finally, protocols must be tended to and updated when new evidence becomes available.