Current opinion in critical care
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Curr Opin Crit Care · Aug 2004
ReviewAcute respiratory distress syndrome, the critical care paradigm: what we learned and what we forgot.
In the last several years, we definitely learned that the acute respiratory distress syndrome lung is small, nonhomogeneous, and that mechanical ventilation in this baby lung may cause physical damage as well as inflammatory reaction. The clinical benefit of the gentle lung treatment, based on a decrease of global/regional stress and strain into the lung, has been finally proved. However, we forgot the importance of lung perfusion and its distribution in this syndrome and, besides a low tidal volume, we still do not know how to handle the other variables of mechanical ventilation. Measurements of variables as transpulmonary pressure and end expiratory lung volume, for a rational setting of mechanical ventilation, should be introduced in routine clinical practice.
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Recently, three fundamental changes have been introduced in medical education, all of particular importance to critical care medicine: (1) clinical teaching and medical practice now emphasize evidence-based medicine, (2) patient safety aspects are increasingly stressed, and (3) use of simulation in medical training is spreading rapidly. In 1999, the disturbingly high frequency of life-threatening or even lethal medical complications was emphasized by the Institute of Medicine in the book To Err Is Human. The Institute of Medicine recommended establishing interdisciplinary team training programs incorporating efficient methods such as simulation. ⋯ Courses taught include clinical procedures and decision making in perioperative medicine, acute medicine, pharmacology, anesthesiology, airway management, bronchoscopy, pediatric versus adult crisis management, critical events in obstetrics, and crisis team training. Advantages of simulation training over traditional medical education methods include (1) provision of a safe environment for both patient and student during training in risky procedures, (2) unlimited exposure to rare but complicated and important clinical events, (3) the ability to plan and shape training opportunities rather than waiting for a suitable situation to arise clinically, (4) the ability to provide immediate feedback, (5) the opportunity to repeat performance, (6) the opportunity for team training, and (7) lower costs, both direct and indirect. Within the next decade, use of computerized simulators for evidence-based education and training in medicine is expected to develop considerably and spread rapidly into a very important domain of medical schools throughout the entire world.
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Curr Opin Crit Care · Aug 2004
ReviewResearch: advances in cell biology relevant to critical illness.
During the past decade, enormous advances have been made in cell biology. Major advances included the publication of the human genome sequence, the development of proteomics, and DNA microarray technologies and techniques to selectively "silence" genes using short strands of double-stranded RNA. Some areas of great progress that are particularly relevant to critical care medicine include huge improvements in our understanding of the signal transduction pathways involved in the innate immune response and adaptation to hypoxia. Other areas of important progress include improvements in our understanding of how inflammation causes derangements in epithelial structure and function and impairs cellular utilization of oxygen.
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Curr Opin Crit Care · Aug 2004
ReviewIntensive care in developing countries in the Western Pacific.
The rapid economic, scientific, and technologic development in Asia probably is the most important in the world today. Eventually, the development of health care and critical care medicine in the Western Pacific will be affected. Even with the problems that have to be faced, the future of critical care medicine in the region looks promising. ⋯ Simple ventilators with inexpensive monitors and defibrillators are the technology that is most needed. Good referral systems and greater use of physician extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness should be promoted. A few high-standard ICUs with good facilities for education and training should be organized on a regional basis in each country.
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Critical care in India has grown very rapidly in the past decade. The Indian Society of Critical Care Medicine has developed into a strong national body that has established its own journal, academic program, and Web site. Its annual national congresses are well organized and very well attended and have a high degree of academic content. ⋯ Development of guidelines, starting formal training through a certificate course, and formation of a resuscitation council have been some of the other achievements of Indian Society of Critical Care Medicine. A number of problems still exist in the field of critical care in India. Considering that India as a portal for medical tourism, growth of this field is expected in the next decade.