Current opinion in critical care
-
Acute renal failure is a serious condition that affects as many as 20% of ICU patients. The most common causes of acute renal failure in the ICU patient are severe sepsis and septic shock. The mortality of acute renal failure in septic critically ill patients remains high despite our increasing ability to support vital organs. This is partly the result of our poor understanding of the pathogenesis of sepsis-induced renal dysfunction. Accordingly, a review of our current understanding of the pathogenesis of septic acute renal failure is timely and relevant. ⋯ This review suggests that, on the evidence available, septic acute renal failure is more likely to be an immune or toxic state rather than simply a hemodynamic condition. The authors speculate that future insights into its pathogenesis might lead to a paradigm shift away from the concept of acute tubular necrosis, which has never been convincingly shown in sepsis, to that of acute tubular apoptosis.
-
Curr Opin Crit Care · Dec 2003
ReviewAcid-base and electrolyte analysis in critically ill patients: are we ready for the new millennium?
Disorders of acid-base and electrolytes are commonly seen in critically ill patients. The presence of these disorders typically signals the development of an underlying pathology. These disturbances can be severe and are often associated with worse outcome. Indeed, metabolic acidosis is one of the ways we quantify organ failure. Although acid-base and electrolyte disorders may be a result of the underlying pathophysiology (eg, renal failure, respiratory failure, shock), they may also result from the way in which we manage critically ill patients. ⋯ By adopting a physical-chemical approach to acid-base analysis we are gaining insight to the complexities of acid-base disorders and how their treatments may affect outcome.
-
Curr Opin Crit Care · Dec 2003
ReviewCommunication with family members of patients dying in the intensive care unit.
In intensive care units the patient is usually unconscious and/or incompetent so that the relationship shifts to the family. Interactions between caregivers and families usually follow one of three models. In the first model, a family representative receives information from the caregivers but does not participate in decisions or physical care. ⋯ In the third model, the family members communicate their own wishes, provide physical care to the patient, and participate in medical decision-making. After a description of the studies that measured the quality of information provided to ICU families and by discussing the extent to which respecting the principle of patient autonomy is feasible in the ICU, we will review the literature on studies that identified specific needs of families of dying patients and specific challenges faced by intensivists as they seek to inform the families of dying patients. The need for family-centered care and for a better communication within the patient-family-caregiver trio is also highlighted.
-
Curr Opin Crit Care · Dec 2003
ReviewOrganized trauma care: does volume matter and do trauma centers save lives?
Trauma is the leading cause of death during the first four decades of life. Since the 1970s, organized systems for trauma care, including a prehospital emergency medical system and a network of hospitals designated as trauma centers, have been developed. The model of the trauma system and its efficacy have been reviewed. ⋯ Concentration of severely injured patients in trauma centers is associated with better outcomes. Population-based investigations provide the strongest evidence regarding effects of the trauma system on patient outcomes, other than survival outcome measures because long-term functional status may be more appropriate.
-
As the elderly population expands and adopts increasingly more active lifestyles, trauma and critical care practitioners will be faced with providing care for greater numbers of severely injured patients. However, because of their associated preexisting medical conditions and poor relative physiologic reserve, geriatric patients have higher mortality rates and poorer long-term functional outcomes than their younger counterparts. A thorough understanding of the causes for these disparate outcomes is critical if successful strategies and treatments for this unique patient population are to be developed. ⋯ Ironically, the field of geriatric trauma is still in its infancy. Given the relation between advanced age, associated preexisting medical conditions, and poor physiologic reserve, a poor outcome may be inevitable by the time the geriatric patient presents for medical attention. Greater emphasis should therefore be placed on injury prevention efforts in this patient population. There is a dire need for well-designed prospective studies in geriatric trauma.