Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2016
ReviewWho Should Be at the Bedside 24/7: Doctors, Families, Nurses?
Critical illness does not keep to regular, daytime business hours; we must provide high-quality care and support for intensive care unit (ICU) patients 24 hours per day, 7 days per week. Whether this mandates the presence of similar numbers and types of personnel throughout all hours of the day, however, has been the subject of much debate and substantial research. In this article, we review the available literature on the consequences of having three groups of care providers at a patient's bedside overnight: physicians, visitors, and nurses. ⋯ Uncertainties include whether outcomes are better when each nurse is assigned only one patient (or, more generally, the optimal patient:nurse ratio), who these nurses should be (e.g., registered nurses vs. other personnel), and what their roles should entail (e.g., managing ventilators). As such, we cannot yet identify the optimal overnight nurse staffing strategy. What is clear is that the critical care community needs more and better data to further define these aspects of the relationship between ICU structure and ICU outcomes.
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Semin Respir Crit Care Med · Feb 2016
ReviewImproving the Patient Handoff Process in the Intensive Care Unit: Keys to Reducing Errors and Improving Outcomes.
Patient handoffs are highly variable and error prone. They have been recognized as a major health care challenge. Patients in the intensive care unit are particularly vulnerable due to their complex clinical history and the critical nature of their condition. ⋯ In this review, we reflect on the importance of the handoff process, review common errors, identify barriers and challenges, and propose different methods to improving the handoff process. The purpose of this article is to examine the overall scope of the problem; provide the most up-to-date evidence on the handoff process; and identify ways to perform handoffs in an accurate, safe, and efficient manner to provide high-quality patient care. The direction of future research is also proposed.
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Semin Respir Crit Care Med · Feb 2016
ReviewHow Cool It Is: Targeted Temperature Management for Brain Protection Post-Cardiac Arrest.
Neurological recovery often determines outcome in patients resuscitated after cardiac arrest. Temperature control as a neuroprotective strategy has become standard of care. The first randomized trials showing improved neurological outcomes in patients treated with hypothermia with a target temperature of 33°C over a decade ago led to the inclusion of this intervention in practice guidelines and the broad adoption of hypothermia protocols across the world. ⋯ However, the optimal temperature target, timing of induction, duration of temperature control, and speed of rewarming are unclear. Similarly, the value of targeted temperature management in cases of in-hospital arrest and non-shockable rhythms is unknown. This article reviews the neuroprotective mechanisms of hypothermia, the evidence supporting targeted temperature management after cardiac resuscitation, areas of persistent uncertainty and controversy, and future research directions.
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Semin Respir Crit Care Med · Feb 2016
ReviewSweet Spot: Glucose Control in the Intensive Care Unit.
Hyperglycemia, hypoglycemia, and glycemic variability are all independently associated with morbidity and mortality of critically ill patients. A strategy aiming at normoglycemia (so-called tight glycemic control) could improve outcomes of critically ill patients, but results from randomized controlled trials of tight glycemic control are conflicting. Strict glycemic control is associated with an increased risk of hypoglycemia, which could offset the benefit of this intervention. ⋯ Second, continuous blood glucose monitoring has the potential to improve safety and efficacy. Until recently, blood glucose levels were monitored manually using point-of-care devices with significant inaccuracies. Various continuous monitoring systems have been developed, but studies testing their accuracies and usefulness in an intensive care unit setting are highly needed.
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Semin Respir Crit Care Med · Feb 2016
ReviewTools of the Trade: Point-of-Care Ultrasonography as a Stethoscope.
Since the advent of portable ultrasonography machines, many providers, including intensivists and pulmonologists, have been trained in point-of-care ultrasonography. When point-of-care ultrasonography is performed with focused clinical question and goal in mind, it serves as a valuable adjunct to physical examination and facilitates patient care and disease management. Its clinical application is now wider than that of a stethoscope in the intensive care unit where the noise level is high. ⋯ In addition, recent studies on the use of multiorgan system point-of-care ultrasonography in diagnoses and management of acutely ill patients are described. As new clinical applications have been identified, a conventional approach to the critical illness must be modified to a new approach that incorporates ultrasonographic information. Clinicians should not only be trained in image acquisition and interpretation but also be up to date on the new ultrasonography-guided diagnosis, therapy, and management.