Critical care clinics
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Meeting the challenges of allocating critical care resources in the fairest way possible depends upon the development of a standardized strategy for apportioning ICU services in times of limited supply. Two main approaches are emerging to handle these challenges. ⋯ The second approach involves improving the efficiencies of the care giving system itself. Either approach requires the establishment of a standard of care that reduces the potential for personal biases into the decision making process.
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Scoring systems used to predict clinical outcomes for critically ill patients have been refined in the past decade, yet even the most recently developed systems contain flaws that limit their application. In general, prediction rules are derived by defining an association between a number of clinical variables and a particular outcome in a reference patient population. By systematically examining the qualities of the independent variables and the size and scope of the derivation data set, potential sources of error and bias can be identified. Existing and future predictive systems must be validated on large groups of patients and continuously updated to keep pace with new approaches to the practice of critical care medicine.
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Proper anesthetic care begins with a thorough preoperative assessment. This can rarely be performed in the acute trauma victim. ⋯ Substance abuse is also discussed. A better understanding of the interactions between pre-existing disease and traumatic injury should result.
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Three areas of particular importance in dealing with critical complications of trauma are pharmacology, monitoring, and nutritional support. This article deals with each of these from the perspective of the doctor or nurse at the bedside. This survey stands as a sampler and guidebook to these subjects as they pertain to the critically ill multiple trauma patient.
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A great deal of progress has been made regarding improved prehospital transport, the quality of trauma care, and injury prevention research. The analysis of the four determinants of outcome in the trauma victim allowed for the discovery of subgroups who may benefit from a change in triage, resuscitation, or management. Our recent investigation into the effect of host factors on mortality resulted in the discovery that pre-existing illness predicts outcome independent of other determinants, including age and ISS. ⋯ The bottom line in care of any trauma victim is that all deviations from normal must be noted, but they should be evaluated properly with respect to the acute injuries. It is the authors' hope that this overview will guide the intensivist in focusing on the treatment of acute injuries without losing sight of the importance of both recognizing and managing chronic illnesses so their detrimental effect on patient outcome can be minimalized. A large multicenter investigation is needed to see whether these recommendations will, in fact, positively impact on trauma victim outcome.