Journal of intensive care medicine
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J Intensive Care Med · Sep 2011
ReviewDiagnosis and management of life-threatening pulmonary embolism.
Pulmonary embolus (PE) is estimated to cause 200 000 to 300 000 deaths annually. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. The diagnosis of PE in the critically ill is often challenging because the presentation is nonspecific. ⋯ Evidence suggests that sub-massive PE is a heterogeneous group with respect to risk. It is possible that those at highest risk may benefit from thrombolysis, but existing studies do not identify subgroups within the sub-massive category. The role of inferior vena cava (IVC) filters, catheter-based interventions, and surgical embolectomy in life-threatening PE has yet to be completely defined.
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J Intensive Care Med · Sep 2011
Massive aspiration past the tracheal tube cuff caused by closed tracheal suction system.
Aspiration past the tracheal tube cuff has been recognized to be a risk factor for the development of ventilator-associated pneumonia (VAP). This study investigated the effect of closed tracheal suctioning on aspiration of fluid past the tracheal tube cuff in an in vitro benchtop model. ⋯ Massive aspiration of fluid occurs along the tracheal tube cuff during suction with the closed tracheal suction system.
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J Intensive Care Med · Jul 2011
Comparative StudyFocused bedside echocardiography in the surgical intensive care unit: comparison of 3 methods to estimate cardiac index.
We sought to determine which of 3 methods used to evaluate cardiac index (CI) is the most accurate using focused bedside echocardiography (ECHO). We hypothesized that the fractional shortening (FS) method would provide a more accurate estimate of CI than the left ventricular outflow tract/velocity-time integral (LVOT/VTI) or Simpson's methods. This was a prospective observational cohort study conducted in the surgical ICU of an urban level 1 trauma center utilizing all patients with a pulmonary artery catheter (PAC) in place. ⋯ Our data showed a significant association between the PAC estimate of CI and our estimate using the FS method. The other methods were difficult to obtain, subjective, and inaccurate. Fractional shortening was the method of choice to estimate CI for the BEAT exam performed by intensivists in SICU patients.
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J Intensive Care Med · Jul 2011
ReviewProtecting participants of clinical trials conducted in the intensive care unit.
Research in the intensive care unit (ICU) raises a number of scientific and ethical challenges. Potential participants in critical care studies are likely to be considered particularly vulnerable-they may lack sufficient capacity to make informed decisions about trial participation, their health care proxies may lack legal authority to enroll them in research trials or may not know their true intent, and the life-threatening nature of the illness may make them or their surrogates more susceptible to therapeutic misconception. ⋯ In this article, we review the key literature addressing the various scientific and ethical issues raised by critical care research, including questions of equipoise and the selection of control groups, informed consent, therapeutic misconception, conflict of interest, and quality improvement projects. We also describe the current status of key policy or regulatory initiatives designed to address these issues, particularly in light of recent controversies involving critical care studies like the ARDSNet trial.