Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2010
ReviewUsing protocols to improve patient outcomes in the intensive care unit: focus on mechanical ventilation and sepsis.
The care of critically ill patients has become increasingly complex as severity of illness continues to increase, the number of patients requiring intensive care is on the rise, the amount of clinical information available at the bedside is growing, and the quantity of evidence supporting or refuting specific therapies and interventions for this population is escalating. It has become problematic for clinicians to master all of these tasks and to process the quantity of available clinical and scientific information in an effective and safe manner. Additionally, a culture promoting safety and accountability has emerged in the United States and throughout the world in regard to medical care. ⋯ To accomplish this goal, as well as to allow more accurate monitoring of day to day medical practices, several strategies have been developed that have primarily been employed in the intensive care unit (ICU) setting. These strategies include the use of paper-based or electronic protocols for disease (e.g., severe sepsis and septic shock) or process of care (e.g., weaning of mechanical ventilation) management, national guidelines, and targeted clinician education with or without periodic feedback regarding compliance with best medical practices and resultant patient-based outcomes. This review focuses on the use of protocols in the ICU setting and how they can best be utilized to improve patient outcomes.
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Semin Respir Crit Care Med · Feb 2010
Liberation and animation: strategies to minimize brain dysfunction in critically ill patients.
Acute brain dysfunction, usually manifested as delirium, occurs in up to 80% of critically ill patients. Delirium increases costs of hospitalizations and affects short-term outcomes such as duration of mechanical ventilation, intensive care unit (ICU) length of stay, and the hospital length of stay. Long-term consequences-cognitive impairment and increased risk of death-can be devastating. ⋯ Liberation aims to reduce the harmful effects of sedative exposure through use of target-based sedation protocols, spontaneous awakening trials, and proper choice of sedative as well as liberation from the ventilator and the ICU. Animation refers to early mobilization, which reduces delirium and improves neurocognitive outcomes. Delirium is a serious problem with important consequences and can be prevented or improved using the information that we have learned in the last decade.
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Health care delivery in the United States and abroad has undergone tremendous growth over the last several decades. Accompanying this growth in the diagnostic and therapeutic armamentarium, the costs of health care have escalated out of proportion to the rest of the economy. This exuberant growth has engendered careful scrutiny of the practice of medicine with regard to both its effectiveness and its efficiency. ⋯ Cost-effectiveness and cost-utility analyses have become critical evaluative tools in medicine. Explicit articulation of comparative cost-effectiveness is helpful in making choices about allocating limited resources in the setting of increasing competition for these resources. This article provides a primer for understanding the methods and applications of cost-effectiveness and cost-utility analyses in the ICU.
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Critical illness has many devastating sequelae, including profound neuromuscular weakness and psychological and cognitive disturbances that frequently result in long-term functional impairments. Early rehabilitation begun in the intensive care unit (ICU) is emerging as an important strategy both to prevent and to treat ICU-acquired weakness, in an effort to facilitate and improve long-term recovery. ⋯ Studies conducted to date suggest that such ICU-based rehabilitation is feasible, safe, and effective for carefully selected patients. Further research is needed to identify the optimal patient candidates and procedures and for providing rehabilitation in the ICU.
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Semin Respir Crit Care Med · Dec 2009
ReviewHow do we increase activity and participation in our patients?
Patients with chronic respiratory disease such as chronic obstructive pulmonary disease (COPD) are generally very inactive physically, and this physical inactivity is detrimental to their health. Physical inactivity not only impairs quality of life, it probably shortens life expectancy. Therefore, increasing physical activity should be a prominent goal in pulmonary rehabilitation. ⋯ Indeed, an emerging medical literature suggests that this is so. We still need to know how effective we are in this area because meaningful changes in some of our outcomes, such as activity counts from motion detectors, have not been established. Pulmonary rehabilitation should incorporate specific interventions to make increased activity and participation specific goals of this comprehensive intervention.