Current opinion in critical care
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Although drug therapy is most commonly delivered via the intravenous route, novel inhaled agents have been introduced for use in the ICU. Additionally, drugs previously delivered intravenously are now being delivered via the respiratory tract in an effort to reduce systemic toxicity and maximize effectiveness. ⋯ Inhaled nitric oxide has an established role in neonatal intensive care and a limited role in adult intensive care. Heliox provides symptom relief, but at present cannot be considered routine as a consequence of the multiple technological challenges. Inhaled antimicrobials appear to provide a therapeutic advantage in select individuals with pneumonia. Secretion management is best achieved by adequate humidification and as needed suctioning. The role of inhaled carbon monoxide in critical care holds significant promise, but is currently in early clinical trials.
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Ventilator-associated pneumonia (VAP) is the main nosocomial infection in patients receiving mechanical ventilation. Despite numerous advances in the understanding of this disorder, the incidence rate continues in an unacceptable range. In this review, we discuss some important findings of recently published studies on diagnosis, prevention and treatment. ⋯ In the last year, numerous articles have been published on diagnosis, treatment and prevention of VAP. In this review, we have selected those articles that potentially could lead to changes in clinical practice: Use of noninvasive techniques for diagnosis, new methods and strategies for prevention, and, finally, the efficacy of monotherapy and de-escalation in the treatment of VAP.
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Curr Opin Crit Care · Dec 2008
ReviewImproving quality and safety in the ICU: a challenge for the next years.
The objective of this review is to focus on recent developments in ICU quality improvement. ⋯ Changes described above have impacted the whole practice of intensive care. Quality improvement and offering a safer healthcare will promote deep changes in management and leadership.
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Curr Opin Crit Care · Dec 2008
ReviewMedical decision making: paternalism versus patient-centered (autonomous) care.
Medical literature has increasingly emphasized the need to observe patients' autonomy; however, not all experts agree with this principle. This discord is based on varying credence between the concepts of autonomy and beneficence. In critically ill patients, this conflict involves the patient's family and creates a particular family-physician relationship. The purpose of this review is to assess the evidence on medical decision making and the family-physician relationship. ⋯ Clinicians must understand the range of preferences in a society and should offer the opportunity to participate in treatment by sharing decision-making responsibility. This would involve assessing the preferences of patients and their families in order to provide care accordingly. Clinicians should then ensure proper information is provided for informed decision making and minimize factors that could have potential adverse effect.
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Curr Opin Crit Care · Dec 2008
ReviewPostinjury immune monitoring: can multiple organ failure be predicted?
Multiple organ failure is the main cause of late morbidity and mortality after severe injury. This disease state is driven by a dysfunctional immune system. Prediction of multiple organ failure on the basis of clinical parameters appears to be insufficient. A better understanding of immunological pathogenesis underlying multiple organ failure may lead to better prediction and innovation in treatment strategy in order to increase the survival of trauma patients. ⋯ General markers of inflammation including cytokines are correlated with posttraumatic complications with a low sensitivity and specificity and are, therefore, of little use as prognostic markers. Current findings regarding the functionality of immune cells are promising and might be of prognostic value in the near future.