Critical care clinics
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Today's intensivists are provided with more information than ever before, yet current monitors present data from multiple sources in a relatively raw form with virtually no intelligent data integration and processing. In the next century, technological advances in miniaturization, biosensors and computer processing, coupled with an improved understanding of critical illnesses at the molecular level, will lead to the development of a new generation of monitors. ⋯ Nanotechnology will permit monitoring of critical changes in the intracellular environment or the by-products of cellular metabolism and signal messaging. This article discusses monitoring technologies that hold promise for further development in the next century and point out techniques likely to be abandoned.
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With rapidly increasing processing power, networks, and bandwidth, we have ever more powerful tools for ICU computing. The challenge is to use these tools to build on the work of the Innovators and Early Adopters, who pioneered the first three generations of systems, and extend computing to the Majority, who still rely on paper. ⋯ When these preconditions are met, the promise of computing will be realized, perhaps with the upcoming fourth-generation systems. ICU computing can then finally cross the chasm and become the standard of care.
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The transport environment presents challenges not faced in the hospital arena. Both ground and air ambulance transport vehicles are hampered by space limitations, lack of universally available power, and physical forces of no importance in the stationary hospital environment. ⋯ Prior planning and understanding the limitations of the transport arena are the keys to successful transport. The future will likely see improvements in technology and integration of hospital delivery systems and patient management systems, expanding our ability to provide critical care outside the traditional ICU environment.
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Critical care clinics · Jul 2000
ReviewAirway management and direct laryngoscopy. A review and update.
Direct laryngoscopy is the direct visualization of the larynx while using a rigid laryngoscope to distract the structures of the upper airway. This article reviews the anatomy relevant to laryngoscopy and then presents a stepwise approach to the procedure. Alternative intubation techniques, positioning, laryngoscopy blades, and stylets are then covered. Pharmacologic adjuncts are discussed briefly as they relate to the difficult airway and incorporation into overall airway management.
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Critical care clinics · Jul 2000
ReviewEmergent management of the airway. New pharmacology and the control of comorbidities in cardiac disease, ischemia, and valvular heart disease.
Once it is decided that the patient in distress requires tracheal intubation, the primary goal is to secure the airway as quickly and safely as possible to assure adequate oxygenation and ventilation. The clinician should quickly review the patient's history, physical examination findings, and laboratory data to determine the presence of cardiovascular disease, assess intravascular volume status, and formulate a plan for induction of anesthesia. The stresses of hypoxia, hypercarbia, acidosis, and extreme fatigue result in near-maximal sympathetic outflow that is manifest as tachycardia, labile blood pressure, and increased myocardial contractility. ⋯ Most clinical studies have been performed in hemodynamically stable patients, so the routine dosages of sedative hypnotics should be reduced substantially and titrated to effect. An additional strategy is to treat significant hemodynamic perturbations with vasopressors, vasodilators, short-acting selective beta-1 blockers, and inotropic agents. The choice of vasoactive agent depends on the magnitude of the hemodynamic response and the presence of specific underlying cardiovascular pathology.