Current opinion in critical care
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Curr Opin Crit Care · Aug 2001
ReviewHypothermia for the management of intracranial hypertension in acute liver failure.
Increased intracranial pressure in patients with acute liver failure remains a major cause of mortality. Treatment options are limited, and without urgent liver transplantation, mortality rates of up to 90% are common in those who fulfill criteria for poor prognosis. Several studies in animal models of acute liver failure set the stage for the clinical application of moderate hypothermia in humans. ⋯ However, data indicate that moderate hypothermia is a safe and effective method of treatment for increased intracranial pressure that is unresponsive to other medical therapies, and that this treatment can be used as a successful bridge to liver transplantation. Recent data also suggest that increases in intracranial pressure can be prevented during the dissection and reperfusion phases of liver transplantation for acute liver failure if patients are kept hypothermic during the surgical procedure. This article focuses on the use of moderate hypothermia for the treatment of increased intracranial pressure in patients with acute liver failure.
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The abdominal compartment syndrome is an increasingly recognized complication of both medical and surgical patients in the ICU setting. This syndrome has been described in a wide variety of clinical scenarios and results from a persistent elevation in intra-abdominal pressure characterized by graded organ system dysfunction. Manifestations of abdominal compartment syndrome include cardiovascular, pulmonary, renal, splanchnic, and neurologic impairment. ⋯ Patients at risk for abdominal compartment syndrome warrant close monitoring and we recommend prompt abdominal decompression following documentation of increased intra-abdominal pressure in the setting of physiologic compromise. Abdominal compartment syndrome can significantly contribute to the morbidity and mortality of both medical and surgical patients alike in the ICU. The signs and symptoms of abdominal compartment syndrome should become familiar to all critical care practitioners.
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Effective use of sedative-hypnotic and analgesic agents is an integral part of providing patient comfort and safety. Of the numerous drugs administered, benzodiazepines, propofol, and narcotics are the most popular. Even these proven, time-tested sedative-hypnotics and analgesics are not perfect, however, and modern intensive care demands a more ideal product. ⋯ Slower bolus loading over 20 minutes results in minimally decreased heart rate and blood pressure. Continuous infusion maintains unique sedation (patients appear to be asleep, but are readily roused), analgesic sparing effect, and minimal depression of respiratory drive. More experience with dexmedetomidine infusion in medical ICU patients and patients with complex end-organ dysfunction such as respiratory failure or systemic inflammatory response syndrome is needed before conclusions can be drawn about the drug's potential for wider application and its long-term (> 24 h) safety and effectiveness.
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Curr Opin Crit Care · Aug 2001
ReviewDeveloping and implementing measures of quality of care in the intensive care unit.
As consumers, payers, and regulatory agencies require evidence regarding quality of care, the demand for intensive care unit (ICU) quality measures will likely grow. ICU providers and professional societies may need to partner with experts in quality measurement to develop and implement quality measures. ⋯ On the other hand, structure and process measures may be feasible to implement broadly. Given the steps for developing quality measures outlined in this essay and the growing evidence in the literature regarding the impact of ICU care, the future should realize the development and implementation of ICU quality indicators that are rigorously developed and provide insights into opportunities to improve the quality of ICU care.
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Curr Opin Crit Care · Aug 2001
ReviewNew ways to reduce unnecessary variation and improve outcomes in the intensive care unit.
The care of critically ill patients and the advent of the modern day intensive care unit (ICU) present a large person power and cost burden to society. The high cost of critical care is attributed to high overhead expenses (eg, experienced staff and equipment), high resource utilization (eg, pharmaceutical resources, lab testing, imaging procedures), and high demand for services. ⋯ A number of large, randomized, prospective trials have demonstrated that protocol-based strategies can not only reduce variation and cost of ICU medicine but also improve morbidity and mortality of critically ill patients requiring ICU support. In this article, we discuss examples of these trials investigating four major areas of modern ICU medicine: ventilator management, ventilator weaning, sedation and analgesia, and blood transfusions.