Current opinion in critical care
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Curr Opin Crit Care · Dec 2007
ReviewInternational comparisons in critical care: a necessity and challenge.
Understanding variation in critical care resources, and delivery of care between countries will allow for improved disaster planning, evaluation of research findings, and assessment of the utility of critical care itself. This review describes the available data for international comparisons and the many factors that need to be addressed for an appropriate interpretation of results. ⋯ Many recent critical care studies include data from multiple countries. With continued movement towards international studies, and improvements in data collection systems, comparisons between countries are becoming easier. These findings need to be interpreted in the context of all the relevant country information.
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Curr Opin Crit Care · Dec 2007
ReviewAcute coagulopathy of trauma: mechanism, identification and effect.
Acute coagulopathy of trauma has only been described relatively recently. Developing early in the postinjury phase, it is associated with increased transfusion requirements and poor outcomes. This review examines the possible initiators, mechanism and clinical importance of acute coagulopathy. ⋯ Acute coagulopathy results in increased transfusion requirements, incidence of organ dysfunction, critical care stay and mortality. Recognition of an early coagulopathic state has implications for the care of shocked patients and the management of massive transfusion. Identification of novel mechanisms for traumatic coagulopathy may lead to new avenues for drug discovery and therapeutic intervention.
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Curr Opin Crit Care · Dec 2007
ReviewTiming of renal replacement therapy in critically ill patients with acute kidney injury.
Timing of renal replacement therapy in critically ill patients with acute kidney injury is highly subjective, and may influence outcome. We discuss renal and nonrenal criteria for timing considering the recent literature. ⋯ In the absence of large randomized controlled trials we can make no firm recommendations for timing of renal replacement therapy in acute kidney injury. Since rapid recovery of renal function is unlikely when other organ failure persists and the consequences of acute kidney injury may be more severe in critically ill patients, we suggest other organ failure is also considered. Patients with acute kidney injury, persisting shock and poorly recovering functions of other organs may benefit from early therapy. For future studies, we recommend describing renal replacement therapy timing according to the 'RIFLE' classification, as modified by the Acute Kidney Injury Network, and quantifying the severity of other organ failure. Biomarkers may refine acute kidney injury and timing definitions in the future.
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Curr Opin Crit Care · Dec 2007
ReviewIdentifying and implementing quality improvement measures in the intensive care unit.
The movement towards greater accountability in medicine has made quality improvement a routine part of daily clinical practice in the intensive care unit. We review recent advances in the field of quality improvement and discuss some of the challenges to successful quality improvement initiatives in critical care. ⋯ Integrating quality measurement and improvement with daily clinical practice is among the most important challenges facing critical care. Following established principles will help ensure that quality improvement initiatives are interpretable, successful, and meaningful to patients and families.
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Curr Opin Crit Care · Dec 2007
ReviewDrug dosing in continuous renal replacement therapy: general rules.
Continuous renal replacement therapy is increasingly used in the management of acute kidney injury in critically ill patients. The potential extracorporeal removal of drugs, in particular the removal of antimicrobials, is a concern to many clinicians. The results of clinical studies cannot be generalized because different treatment modalities and settings are used in heterogeneous patient populations. This review aims to provide general guidelines for drug dosing during continuous renal replacement therapy. ⋯ Drug dosage adaptation during continuous renal replacement therapy can use several approaches, which all include a degree of unpredictability and thus require maximal reliance on drug monitoring.