Critical care clinics
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The PAC has allowed physicians to obtain information that was unavailable prior to its introduction into clinical medicine. There are numerous pitfalls, however, in obtaining and interpreting this information. ⋯ Can PA catheterization lead to an improved outcome in an individual patient? If the patient is chosen carefully, the catheter inserted successfully and safely, the data obtained meticulously and interpreted correctly, and this interpretation leads to a change in therapy to which the patient responds appropriately, then the patient will experience an improved outcome based on PAC use. Does this happen often enough in the millions of catheterizations that are performed each year to improve the outcome of the group significantly as a whole? Almost certainly not.
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In conclusion, dopamine has the unique ability, compared with other catecholamines, to improve renal blood flow, glomerular filtration rate, sodium excretion, and creatinine clearance, independent of its cardiac effects. In addition, low-dose dopamine can decrease renal and systemic vascular resistance, suppress aldosterone secretion, and interact with atrial natriuretic factor. Because of these clinically significant properties, dopamine has been used successfully to improve and treat acute oliguric renal failure in a variety of clinical situations as just described. ⋯ For those who are skeptical, we offer the following suggestion: "The obscure we see eventually, the obvious takes a little longer"--E. R. Murrow.
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This article argues that dopamine infused in low doses has not been shown to avert the onset of or ameliorate the course of acute renal failure in critically ill patients. The inotropic and diuretic effects of dopamine are discussed, and its adverse effects are described. An attempt is made to offer an evidence-based role for low-dose dopamine, namely as a diuretic in ventilated, euvolemic patients, resistant to conventional diuretic therapy.
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Critical care clinics · Jul 1996
ReviewDoes a full-time, 24-hour intensivist improve care and efficiency?
This article reviews the hypothesis that staffing with full-time intensive care physicians leads to improvements in the management of ICUs and in the outcome for ICU patients. Variations in the professional organization of critical care units in the United States are discussed. The advantages and disadvantages of open, closed, and transitional (comanagement) ICU organizational structures are presented.
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Critical care clinics · Jul 1996
ReviewHigh-inflation pressure and positive end-expiratory pressure. Injurious to the lung? No.
Survival rates in ARDS with conventional ventilation using high oxygen fractions and low PEEP levels have been reported to be less than 10%. In three prospective evaluations of ARDS in the 1980s, mortality rates remained greater than 60%. Early studies using high-level PEEP therapy in severe ARDS by Douglas, Downs, Kirby, and Civetta showed improved survival rates with ranges between 60% and 80%. ⋯ Currently available information indicates that increases in mean airway pressure (induced with PEEP or other modes of ventilatory support to restore losses in FRC that occur during ARDS) and limiting exposure to toxic concentrations of oxygen minimize ventilator-induced secondary lung injury and maximize chances for survival. Arbitrary limitations of peak inspiratory or end-expiratory airway pressure or mandatory tidal volume in patients with severe ARDS seem to be unfounded. Failure to achieve adequate physiologic end-points in these patients may increase morbidity and mortality rates.