Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2015
ReviewPhysical, Cognitive, and Psychological Disability Following Critical Illness: What Is the Risk?
Critical illnesses affect millions of individuals annually in the United States. As advances in patient care continue to improve, the number of survivors is rapidly growing. Critical illness survivors endure profoundly severe illnesses and live through often frightening experiences throughout the course of ICU hospitalization, resulting in a variety of "survivorship" challenges, expressed through a condition known as post-intensive care syndrome (PICS). ⋯ Organizational change is likely to be a key factor, though the specific components have not yet been established. Throughout this article, we highlight some of the barriers and facilitators to enhancing patient care across the spectrum of critical care environments, while also highlighting the challenges inherent to studying a complex patient population. We address each of the areas potentially affected by critical illness and ICU hospitalization--physical, cognitive, and psychological functional domains--experienced by patients as well as their family caregivers.
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Intensive care unit (ICU) admission is common among patients approaching the end of their lives from acute as well as chronic life-limiting conditions. ICU providers are expected to have basic palliative care skills integrated into their routine practice. Palliative care skills can be applied to all ICU patients, regardless of prognosis, and may improve patient- and family-centered end of life (EOL) care in the ICU. ⋯ This review discusses integrative and consultative palliative care models and the role of triggers for palliative care consultation, particularly when they are tailored to the needs of individual ICUs. We then review the evidence for providing several palliative care domains in the ICU and some of the ethical considerations surrounding EOL care in the ICU. Finally, we highlight the importance of self-care and peer support groups to mitigate the risk of burnout for clinicians providing EOL care in the ICU.
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Semin Respir Crit Care Med · Dec 2015
ReviewCritical Care Beds and Resource Utilization: Current Trends and Controversies.
Recent studies have shown a dramatic increase in the number of intensive care unit (ICU) beds in recent decades. As technologies have become more complex, ICUs continue to grow in size and in specialization. The driving forces behind ICU bed expansion include not only the incorporation of advanced technologies but also other factors such as the increased utilization of ICU beds for patients who previously were not offered ICU care--those who may be terminally ill and those who are not critically ill. ⋯ ICUs are also now commonly used in the care of dying patients. In coming decades it is likely that changes will need to take place to forestall exorbitant costs and labor shortages. In addition to bringing in new forms of medical staff such as hospitalists and physician assistants, recent opinion papers have suggested that a de-escalation of ICU growth and a new tiered system of ICU care will be necessary in the United States.
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Semin Respir Crit Care Med · Dec 2015
ReviewControversies in the Management of Life-Threatening Pulmonary Embolism.
Patients with life-threatening pulmonary embolism (PE) offer clinicians a unique opportunity to intervene effectively on the patient's behalf. Hemodynamic status remains the most important short-term prognostic factor for patients with acute PE. Although the evidence is limited, the use of thrombolytic therapy is recommended for patients with acute symptomatic PE and associated hypotension or shock (i.e., high-risk PE) because these patients have a high short-term mortality risk (i.e., >15%) even when receiving anticoagulant treatment. ⋯ For patients with life-threatening PE at high risk of bleeding, clinicians might consider the use of low-dose thrombolytic therapy, catheter-directed thrombolysis, or surgical embolectomy, if they have access to the required expertise and resources. The evidence does not support the use of inferior vena cava filters in patients with life-threatening PE unless there is a contraindication to anticoagulation. Since various medical and surgical specialties offer different perspectives and expertise, a multidisciplinary approach to patients with intermediate- and high-risk PE might improve patient outcomes.
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The right heart failure (RHF) syndrome is a pathophysiologically complex state commonly associated with dysfunction of the right ventricle (RV). The normal RV is suited for its purposes of distributing venous blood to the low-resistance pulmonary circulation. Myriad stresses imposed upon it, though, can ultimately result in its failure, with the threat of cardiovascular collapse being the most dreaded outcome. ⋯ Appropriate use of diagnostic tools is paramount for understanding the key components of RV function: the preload state of the RV, its contractility, and the afterload burden placed on it. In making these assessments, it remains crucial to understand the limitations of these tools when managing RHF in the intensive care unit. An understanding of each of these components allows for the understanding of the physiology and the clinical presentation which can guide the use of therapies appropriately tailored to manage the condition.