Journal of critical care
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Journal of critical care · Sep 1993
Acute renal failure in the critically ill: management by continuous veno-venous hemodiafiltration.
The consequences of newer techniques of continuous renal replacement therapy in critically ill patients are not yet fully known. The clinical and biochemical impact of continuous veno-venous hemodiafiltration (CVVHD) was, therefore, prospectively studied in 60 critically ill patients with acute renal failure. Prospective clinical, biochemical, and hematological data were collected from patients receiving CVVHD. ⋯ Continuous veno-venous hemodiafiltration offers superior azotemia control and a safe approach to renal replacement therapy in critically ill patients. Its use is associated with a comparatively favorable outcome. CVVHD may be regarded as the treatment of choice in such patients.
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Journal of critical care · Sep 1993
Deciding to terminate treatment: a practical guide for physicians.
Providing house officers and practicing physicians with annotated, concise, practical guidelines for decisions to terminate treatment is the objective of this report. The study selection and data extraction focused on statutes, regulations, court decisions, medicolegal analyses, clinical studies, and position papers addressing termination-of-treatment issues. To foster a systematic approach, we developed a laminated, pocket-sized card containing a series of questions to be asked by any physician confronted with termination-of-treatment decisions. Systematic identification and deliberate assessment of (1) brain death; (2) the nature, extent, cause, prognosis, and reversibility of impairment; (3) the type of treatment to be withheld or withdrawn; (4) the futility of any proposed intervention; (5) the capacity of the patient for health care decision-making; (6) the evidence of patient's wishes; (7) the proper roles of family members, surrogate decision makers, and other health professionals (eg, ethics committees); and (8) applicable policies, ethics, laws, and potential conflicts of interest will enhance efficiency and add value to the decision-making process at the end of life.
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Journal of critical care · Sep 1993
Prevalence and prediction of multiple organ system failure and mortality in acute pancreatitis.
We studied the prevalence of multiple organ system failure (MOSF), the relations between age, pre-existing chronic conditions, local complications, systemic infection, organ system failure, and mortality in patients with acute pancreatitis. During the study period, 267 consecutive patients were admitted to a tertiary hospital with acute pancreatitis. Multivariate analyses were used to identify factors predictive of MOSF occurrence and mortality. ⋯ In multiple logistic regression, advanced age, chronic disease, local complications, failure of the cardiovascular, renal, hepatic, gastrointestinal, and neurological systems independently contributed to mortality prediction. Advanced age and prior chronic disease may reflect diminished physiological reserve and predispose to local complications, systemic infection, and MOSF. Although local complications and systemic infection are important predisposing factors for MOSF, a host-dependent response to unknown specific or nonspecific factors may have a role in the pathogenesis of the syndrome in 25% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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Emphasis in medical training is laid on therapeutic approaches that prolong life at all costs. This training is reinforced by current medical practices in the United States and by an ever-expanding medical technology, such that it becomes difficult, if not impossible, to "let the patient go." In response, individuals promote the "right-to-die" and euthanasia, so that patients may maintain their human dignity during the dying process. A more rational and nonpolarized approach to this issue would be to strive for the preservation of human function, not physiological function alone. ⋯ On this basis, therapies can be withheld and withdrawn when they no longer reflect these goals. Caution regarding potential abuses of this approach need to be raised, however, when considering care for the very vulnerable of society. In that regard, therapeutic goals directed at maintaining human function need to be developed in parallel with global societal values regarding quality of life issues.
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Journal of critical care · Sep 1993
Postreperfusion syndrome: hypotension after reperfusion of the transplanted liver.
Sixty-nine patients undergoing liver transplantation were evaluated to elucidate the relationship between hypotension and physiological changes seen on reperfusion of the grafted liver. Measured variables included hemodynamic profiles, core temperature, serum potassium, ionized calcium levels, arterial blood-gas tensions, and acid-base state. Measurements were taken 60 minutes after skin incision (baseline), 5 minutes before reperfusion, and 30 seconds and 5 minutes after reperfusion. ⋯ Collectively in both groups, there was no correlation between MAP and physiological variables; however, there was a poor correlation with SVR (r = .32, P < .01). Reperfusion hypotension seen in group 2 patients correlated only with a decrease in systemic vascular resistance (r = .5, P < .05). Acute hyperkalemia, hypothermia, and acidosis do not appear to be major causes of reperfusion hypotension.