Critical care clinics
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The intensivist should be aware of the upper airway manifestations of the common rheumatologic disorders which may lead to ICU admission or which may potentially pose a problem during airway management. Information should be obtained from the patient, the patient's family, and the patient's primary physician, if possible. One should be fully prepared with various options in case a problem arises with an airway. ⋯ One should make a concentrated and serious effort to be as gentle as possible and to avoid even minimal trauma to the mucosa in these patients, because they are at risk for mucosal edema and subsequent postextubation stridor. In cases of stridor, helium-oxygen mixtures may be of help and may eliminate the need for reintubation. When difficulty in establishing an airway is anticipated, it is prudent to attempt airway control in the operating room with surgical assistance standing by should cervical tracheotomy is required.
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Rheumatoid arthritis (RA) is a systemic, debilitating disease characterized by chronic polyarticular inflammation that leads to erosion of joint and bones and to significant extra-articular, systemic, and cardiopulmonary manifestations. RA affects the patient's psychologic and social well-being as well as physical activity. ⋯ This article discusses the basic pathophysiology and clinical manifestations of RA and the extra-articular disorders that bring these patients to an ICU. The management of these patients in ICU is discussed, with emphasis on airway management and outcome.
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All chronically critically ill patients are at high risk for development and progression of pressure ulcers. Constant surveillance including daily examination of the skin must be part of the care protocol. ⋯ We believe that early intervention and appropriate treatment, guided by the paradigm we have described, can retard progression and promote healing [49]. Treatment decisions should be made within the context of the patient's overall care goals.
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CCI patients are patients who have suffered acute illness or injury and require life support or care in an ICU setting for periods of weeks or months. These patients account for between 5% and 10% of ICU admissions, and they appear to be increasing in number. Over half of the patients are over age 65. ⋯ Specialized units have been evolving to manage these patients at lower costs than in acute ICUs, and with similar outcomes. Further refinement of the definition of CCI is an important objective, and should pave the way to better design of outcomes studies. Efforts should continue to learn how to identify patients at high risk for CCI and poor outcome so that expensive resources can be managed effectively, and patient-provider decision making can be better informed.
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Evidence is accumulating that distressing physical and emotional symptoms are prevalent among patients with critical illness, including those requiring prolonged mechanical ventilation, and that suffering is underestimated and undertreated by caregivers. Although patients and their families rank communication as a preeminent concern, it remains deficient in process and content, even when the illness requires weeks of critical care. Strategies are available to improve symptom management and communication about appropriate goals of care. For the CCI, whose risks of death, disability, and suffering are so high, it is essential that excellent palliative care be provided along with restorative treatment in an integrated way.