Critical care clinics
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Critical care clinics · Jan 2002
ReviewEffects of prone position ventilation in ARDS. An evidence-based review of the literature.
In summary, the many studies done on PPV show that the technique improves oxygenation most of the time. The mechanisms behind this effect are probably numerous and have yet to be elucidated completely. ⋯ Despite the recent large, randomized, controlled trial showing no improvement in mortality rate or organ dysfunction overall, there is evidence suggesting that PPV may be of most benefit in more severely ill patients. Further studies will be useful.
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Critical care clinics · Jan 2002
ReviewMechanical ventilation in acute lung injury and ARDS. Tidal volume reduction.
Traditional mechanical ventilation practices used generous tidal volumes in patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS). This approach may have caused overdistention of aerated lung units, thus exacerbating lung injury in some patients. ⋯ This article reviews the rationale for tidal volume reduction in ALI/ARDS and the differences between the studies. Several different interpretations of the recent clinical trial results are addressed.
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Critical care clinics · Jan 2002
ReviewOptimal peep in ARDS. Changing concepts and current controversies.
From many recently performed studies, it is clear that a criterion standard for determining the optimal positive end-expiratory pressure (PEEP) level in patients with acquired respiratory distress syndrome (ARDS) does not exist. What is evident and consistent, however, are several points such the optimal PEEP level ultimately represents a balance between regional areas of overstretching and regional derecruitment; higher levels of PEEP may be required early in ARDS, independent of oxygenation requirements; and the exact method for titrating PEEP in patients with ARDS remains to be determined. These points and others are delineated and discussed in this article.
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Critical care clinics · Oct 2001
ReviewCommentary. Balancing sedation and analgesia in the critically ill.
The authors have presented a template for a systematic approach to comforting critically ill patients that can be modified to suit institutional preferences. In this algorithm, the cause of patient discomfort is sought with the priority given to pain and then to anxiety. Special attention is directed to the identification of correctable causes of pain and anxiety with application of nonpharmacologic techniques or medications to control patient discomfort. ⋯ Doing so can promote cost effectiveness, reduce side effects caused by drugs, and decrease morbidity and ICU stay. Any treatment protocol or algorithm is simply a guide to therapy and cannot address every clinical situation. The importance of individualized care and physician or care team judgment must be emphasized.
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Critical care clinics · Oct 2001
ReviewUsing protocols to improve the outcomes of mechanically ventilated patients. Focus on weaning and sedation.
The use of nonphysician-directed protocols and guidelines for the management of sedation and weaning has been shown to reduce the duration of mechanical ventilation for patients with acute respiratory failure when compared with conventional physician-directed practices. Practitioners in ICUs frequently are needed to perform multiple tasks and to evaluate numerous elements of clinical information in the care of the critically ill. In this complex environment, protocols and guidelines are one strategy for ensuring that specific tasks are carried out in a timely manner. ⋯ The results of studies evaluating the use of protocols and guidelines have important implications for general critical care practices, because many ICUs do not have physicians who are constantly at the patient's bedside. The need for effective communication from the bedside caregiver (e.g., nurse, respiratory therapist, pharmacist, technician) to the physician, so that treatment orders can be changed appropriately, usually results in some delay in the implementation of treatment changes. Protocols are one method for potentially reducing those delays and ensuring that medical care is administered in a more standardized and efficient manner.