Critical care clinics
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Critical care clinics · Jul 2002
ReviewInfection in the chronically critically ill: unique risk profile in a newly defined population.
Although CCI is defined as prolonged ventilatory failure with tracheotomy stemming from preceding critical illness, the contention that multisystem debilities impact on most CCI patients' care and recovery is a central thesis of this volume. Perhaps reflecting the combined debilities inherent in CCI, infectious complications take their toll in morbidity, mortality, and persistent ventilatory insufficiency. ⋯ Strategies to improve outcome in CCI-related infection include standard measures of support especially nutrition, reducing environmental inoculum through pulmonary hygiene measures, skin care, and limiting barrier breaches, and appropriate antimicrobials directed at likely pathogens. Future stratification of patient risk on the basis of immune phenotype or genotype and potential immunomodulatory prophylaxis may be around the corner, as new prospects in the pharmaceutical armamentarium are presently undergoing testing.
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The provision of care to the CCI patient is complex, challenging, and unique. The advanced practice nursing model at Mount Sinai Hospital is one successful care delivery model that fills the needs of both CCI patients and the nurses who work with them. The following transferable aspects of the RCU add to the unit's successful outcomes: (1) an interdisciplinary approach assures that all aspects of care are included in the clinical plan; (2) clinical care pathways, algorithms, and standard protocols based on physician, NP, and clinical nurse collaboration are successful management strategies; (3) formal discharge planning meetings with participation of patients, families, NPs, and social workers provide a forum for discharge planning and an avenue to address ethical issues such as advance directives, resuscitation status, and patient self-determination decisions; (4) full participation by nurses in all aspects of the unit's activities is a cost-effective strategy for maximizing positive outcomes for patients and their families. ⋯ As we reflect on our experience, we hope to heighten the reader's awareness of CCI patients as thinking, feeling, and unique human beings. As Benner [31] suggested, we hope this paper will facilitate seeing the person beyond the disease. As limited financial resources increasingly affect health care, providing high-quality, cost-effective care to the CCI patient remains one of the greatest challenges for nurses and physicians in the United States.
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Critical care clinics · Jul 2002
ReviewEndocrine and metabolic issues in the management of the chronically critically ill patient.
The metabolic syndrome of chronic critical illness (CCI) consists of multisystem organ dysfunction resulting from the initial acute injury and chronic immune-neuroendocrine axis activation, adult kwashiorkor-like malnutrition, and prolonged immobilization with suppression of the PTH-vitamin D axis and hyper-resorptive metabolic bone disease. CCI patients can also present unique challenges in the management of diabetes mellitus, thyroid and adrenal diseases, electrolyte abnormalities and hypogonadism.
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CINMAs occur commonly in acutely critically ill inflamed patients, and can prolong respiratory failure, lead to ventilator dependency, and contribute to the development of chronic critical illness. The etiology of NMDs are diverse and overlap, and distinguishing different disease entities by clinical exam and electrophysiologic studies can be difficult. CIP, which has been the most widely studied CINMA, represents the peripheral nervous system manifestation of the MODS. ⋯ Although there are no definitive treatments, diagnosing a CINMA may provide helpful prognostic information. Future preventative measures may include immunoglobulin, nerve growth factors, or strict glycemic control, although in the CCI phase general supportive care is given, including prevention of iatrogenic complications, nutritional support, psychosocial support, and physical therapy. The early recognition of CINMAs and prevention of associated complications are important to enabling CCI patients with CINMAs to recover and return home with an acceptable functional level and quality of life.
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Critical care clinics · Jul 2002
Multidisciplinary care of the obese patient with chronic critical illness after surgery.
The surgical patient with prolonged critical illness usually has a higher severity of illness on ICU admission, and is destined for greater morbidity, debilitation, and poorer hospital and long-term survival. Care of those with obesity is particularly difficult. Only with meticulous attention to detail and refined, dedicated, multidisciplinary processes of care, preferably assisted by protocolization, can these patients sustain any hope of recovery to acceptable functionality.