Current opinion in critical care
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Curr Opin Crit Care · Oct 2009
ReviewIs MOF an outcome parameter or a transient, adaptive state in critical illness?
The term 'multiorgan failure' (MOF) carries the negative connotation of major homeostatic breakdown and severe malfunction. However, this traditional paradigm may not be necessarily accurate. This review will investigate the rationale for no longer considering MOF to be simply a 'failed' pathophysiological state. ⋯ The concept of MOF could be revisited as a transient state of metabolic shutdown analogous to hibernation. Avoiding the detrimental effects of inappropriate and counter-adaptive iatrogenic interventions is an important cornerstone of therapeutic management.
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Natriuretic peptides are markers of heart failure and/or cardiac dysfunction that provide useful diagnostic and prognostic information in patients with dyspnea and/or respiratory failure in the emergency department. Cardiac troponins (cTn) have markedly simplified the diagnosis of myocardial infarction. In critically ill patients, conditions like coexisting organ dysfunction multiorgan involvement or altered synthesis/clearance may confound interpretation of designated biomarkers, including natriuretic peptides and cTn. This review focuses on recently published articles relating to the use of natriuretic peptides and cTn in critically ill patients. ⋯ Recent studies confirm the excellent prognostic value of natriuretic peptide measurements in ICU patients. Diagnostic properties of natriuretic peptide in ICU patients still remain ambiguous and require further evaluation. Systematic screening with cTn reveals more myocardial infarctions and provides important prognostic information.
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Vasoactive drugs are the mainstay of hemodynamic management of vasodilatory shock when fluids fail to restore adequate tissue perfusion. In this review, studies published during the past year that increase our understanding of the use of vasoactive drugs in the ICU are discussed. ⋯ Current evidence does not support a clear recommendation of one vasopressor over another; indeed norepinephrine, vasopressin, terlipressin, phenylephrine and epinephrine may be used safely with similar survival outcomes.
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Curr Opin Crit Care · Oct 2009
ReviewHealth-related quality of life in critically ill patients: how to score and what is the clinical impact?
Traditionally, the assessment of critical care has focused largely on mortality. However, in the last few years, there is more attention on the quality of survival. Health-related quality of life (HRQOL) is an important issue for both patients and family. The purpose of this review is to describe HRQOL scoring in critically ill patients and to discuss the clinical impact on HRQOL. ⋯ In this article, we reviewed the methods and description of measurement instruments used in critically ill patients. The most recently used instruments to measure HRQOL, how to score HRQOL before ICU admission and the impact of critical illness on HRQOL are discussed. Assessment of HRQOL can improve the answers given by critical care physicians and nurses about the prospects of their patients. To get insights in these issues regarding the impact of ICU treatment, we should incorporate not only short-term outcomes, for example length of stay and mortality, but also HRQOL.
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In this article we discuss our experiences benchmarking eight ICUs in The Netherlands. Benchmarks must be carefully designed and implemented to generate meaningful results. We define prerequisites that we have identified for successful benchmarking and discuss the development, implementation and results of ICU benchmarks that we have completed. ⋯ Benchmarking is an increasingly common activity, however it is difficult to prove that benchmarks result in improved outcomes. Concurrent with our benchmarking activities the Standardized Mortality Ratio in Dutch ICUs has decreased. We have been able to show that larger ICUs in our benchmarks generally had improved outcomes despite a higher average patient severity. Quality assurance in healthcare is maturing and benchmarks will become an increasingly useful way of comparing performance between institutions.