Current opinion in critical care
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Curr Opin Crit Care · Dec 2001
ReviewTermination of resuscitative efforts: medical futility for the trauma patient.
Despite years of research on the resuscitation of the patient with critical traumatic injuries, controversy remains surrounding the criteria to waive initiation of resuscitation in the pre-hospital setting or to terminate such efforts in the emergency department. The decision to initiate or continue resuscitation on moribund trauma patients is associated with considerable costs. ⋯ This review presents guidelines to help determine when to initiate resuscitation for the critically injured trauma patient and when to cease these efforts in the emergency department. Since there are economic, societal, and ethical implications, each system should establish their own criteria, using these guidelines as a basis.
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Curr Opin Crit Care · Dec 2001
ReviewPrehospital and resuscitative care of the head-injured patient.
The ultimate neurologic outcome following severe head trauma depends on the extent of primary brain insult sustained at the time of the trauma itself, and the subsequent neurochemical and neurophysiologic pathologic changes occurring as a result of the injury. Although there are currently no specific therapies that have proven to be consistently effective in reversing the devastating consequences of primary brain insult, the reduction or prevention of secondary brain insult is possible. ⋯ As new data are accumulated, traditional and new therapies for severe head injury have come under scrutiny. While no absolute standards have been advanced, guidelines have been established that can help direct the acute stabilization of severely head injured patients.
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That the resources available for intensive care cannot be infinite is self-evident. Parallel increases in medical capability, cost, and community expectations have forced intensivists to confront the reality of resource limitation. Traditional bioethical structures cope poorly with this focus beyond the traditional patient-doctor relationship. ⋯ These techniques involve assessment of the quality of life with the help of several well-validated quantitative approaches. Choosing between competing patients for intensive care beds is often more a theoretical issue than a practical one, because alternative arrangements can almost always be made. Physicians have an ethical and social responsibility to further develop the tools to inform community debate on these issues.
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Curr Opin Crit Care · Dec 2001
ReviewNew issues in severity scoring: interfacing the ICU and evaluating it.
Since the development of the first general outcome prediction models, these instruments have been widely used in the intensive care unit (ICU), both for patient evaluation and for ICU evaluation. Since some of these uses have been serious questioned, we assisted in the last years to the exploration of alternative paths for increasing the predictive power of the models and to enhance their applicability and utility in the real world. ⋯ Also, since it is now widely recognized that the ICU is not an island, but it is integrated in a continuum of care, more and more efforts are being made to optimize and evaluate the interface between the ICU and the hospital, both at ICU admission and at ICU discharge. The objective of this review is to present and discuss, to the clinician working in the ICU, these emerging issues.