Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2016
ReviewLess Is More in the ICU: Resuscitation, Oxygenation and Routine Tests.
The intensive care unit (ICU) was initially developed in the 1950s to treat patients who required invasive respiratory support and hemodynamic resuscitation. Since the beginning, ICU medicine has focused on maintaining sufficient arterial blood flow and oxygenation to provide adequate tissue oxygen delivery to forestall or reverse organ failure. Over time, ICU medicine became more intensive, with the administration of many diagnostic tests and monitors, invasive procedures, and treatments, often with scant evidence of benefit associated with them. ⋯ We outline a case that presents common ICU dilemmas and discusses current data that propose that "less is more" when making key diagnostic or therapeutic choices in the ICU. Further, we assert that providers should skeptically consider common ICU interventions, trying to account for the potential unintended consequences of interventions. Finally, we suggest that the guiding principle of ICU medicine should be primum non nocere: in delicate situations, it may be better not to do something, or even to do nothing, rather than risk causing harm.
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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 · Dec 2015
Review Meta AnalysisMetabolic Management during Critical Illness: Glycemic Control in the ICU.
Hyperglycemia is a commonly encountered metabolic derangement in the ICU. Important cellular pathways, such as those related to oxidant stress, immunity, and cellular homeostasis, can become deranged with prolonged and uncontrolled hyperglycemia. There is additionally a complex interplay between nutritional status, ambient glucose concentrations, and protein catabolism. ⋯ In this review, we will explore the impact of hyperglycemia upon critical cellular pathways and how nutrition provided in the ICU affects blood glucose. Additionally, important clinical trials to date will be summarized. A practical and comprehensive approach to glucose management in the ICU will be outlined, touching upon important issues such as glucose variability, target population, and hypoglycemia.