Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Jun 2006
ReviewInfection control and the prevention of nosocomial infections in the intensive care unit.
Nosocomial infections continue to be significant causes of morbidity, mortality, and added costs in the health care setting. Half of all life-threatening nosocomial bloodstream infections and pneumonias occur in intensive care units (ICUs), despite ICUs representing only 15 to 20% of all hospital beds. Thus an efficient focus for prevention and control of life-threatening health care-associated infections should be in ICUs. ⋯ Strict adherence to evidence-based catheter insertion and maintenance policies reduces nosocomial bloodstream infections. Evidence-based prevention strategies for ventilator-associated pneumonia, including management of respiratory equipment according to published guidelines and maintaining backrest elevation at 30 to 45 degrees, are effective. For greatest risk reduction, multifaceted programs ensuring maximal adherence with evidence-based infection control guidelines are needed.
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Semin Respir Crit Care Med · Jun 2006
ReviewStress hyperglycemia and adrenal insufficiency in the critically ill.
Critical illness evoked by trauma, extensive surgery, or severe medical illnesses is the ultimate example of acute severe physical stress. The endocrine response in a critically injured and stressed patient is varied and complex. ⋯ In addition, patients may have preexisting endocrine diseases, either previously diagnosed or unknown, and hence endocrine evaluation in a critically ill patient poses a major challenge to the health care provider. This review provides a novel insight into the dynamic endocrine alterations that occur during evolution of stress hyperglycemia and adrenal insufficiency in the critically ill patient and the available evidence for the therapy of these disorders.
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A substantial number of patients with liver failure are admitted to the intensive care unit; thus a thorough understanding of the prevention and treatment of complications in such patients is imperative. The management of liver failure is demanding and often involves the combined efforts of many specialists. ⋯ The initial assessment and management of acute liver failure are reviewed with an emphasis on the prevention and treatment of brain edema in the pretransplant setting. The current treatment of complications resulting from decompensated chronic liver disease such as portal hypertensive bleeding; infection, renal failure, and hepatic encephalopathy are then discussed.
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Shock is one of the most frequent situations encountered in the intensive care unit (ICU). Important new concepts have emerged for shock management in recent years. The concept of early goal-directed therapy has evolved from the basic management concepts for septic shock delivered in a structured fashion. ⋯ Prediction of responsiveness to fluid administration is a key component of the management of shock, as is assessing cardiovascular performance. The intensive care physician has several options to evaluate and treat shock. Further research should yield additional important advances.
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Semin Respir Crit Care Med · Jun 2006
ReviewDelirium and cognitive dysfunction in the intensive care unit.
Delirium remains a non recognized, but highly prevalent, form of organ dysfunction in the intensive care unit (ICU). Intensive care physicians have begun to benefit from elucidation of risk factors for delirium in the ICU, some of which are modifiable, whereas others are not. In the last 5 years, a new tool for use in detecting delirium among critically ill patients has been adapted, validated, and found objectively reliable for use at the bedside by nonpsychiatrists. ⋯ Although prevention and treatment options exist, little data guide current pharmacological approaches to delirium, and nonpharmacological approaches have yet to be fully adopted by ICUs. Ongoing trials will address some of these limitations, but large cohort studies within the ICU are needed to further clarify risk factors and to identify targets to modify the occurrence and course of delirium. Furthermore, consideration of a continuum may better elucidate the true magnitude of acute brain dysfunction in the ICU.