Current opinion in critical care
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Curr Opin Crit Care · Dec 2005
ReviewInformed consent in the intensive care unit: ensuring understanding in a complex environment.
Informed consent in the intensive care unit continues to receive marked attention. As greater numbers of patients enter into the intensive care unit with devastating illness, patients and families are faced with more complex medical problems and decisions regarding therapy. Furthermore, research investigations of critical illness add a level of complexity to informed consent and decision making that mandates a careful approach. ⋯ Quality of informed consent for the critically ill improves as attention is paid to standardizing indications and formalizing training for physicians. In research, conflicts of interest should be recognized and used to guide the investigator's dialogue on research benefits and risks. Patient safety must be maintained as the primary priority; however, waiver of consent may be considered in situations in which the benefit to medical knowledge far exceeds patient risk.
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Curr Opin Crit Care · Dec 2005
ReviewCare near the end-of-life in critically ill patients: a North American perspective.
End-of-life care for critically ill patients has emerged as an area in which significant quality improvement is possible. In this article, we present a North American perspective on recent research and quality improvement initiatives in this field. ⋯ This update presents a North American perspective on six topics of particular importance to end-of-life care in the intensive care unit: (a) The role of advance directives, (b) shared decision-making and the role of the family, (c) conflict and futility in the intensive care unit, (d) cultural aspects of end-of-life care, (e) multidisciplinary care in the intensive care unit, and (f) future directions for improving end-of-life care in the intensive care unit.
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Curr Opin Crit Care · Dec 2005
ReviewManagement of early acute renal failure: focus on post-injury prevention.
In this review, we describe our current understanding of various aspects of secondary renal injury and its prevention. Secondary renal injury indicates any injury to the kidney, which occurs after an initial event has already triggered injury to the organ. ⋯ The pillars of protection from secondary renal injury are similar to those needed to protect the kidney from primary injury: maintenance of adequate intravascular volume, cardiac output, and arterial blood pressure. Novel protective strategies such as intensive insulin therapy require further investigation.
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Curr Opin Crit Care · Dec 2005
ReviewRationing critical care medicine: recent studies and current trends.
This paper reviews the literature on the rationing of critical care resources. ⋯ There is currently no published evidence that overt rationing is taking place in critical care medicine. There is growing evidence that in the future, the need for critical care may outstrip financial resources unless some form of rationing takes place. It is also clear from the literature that choosing how to ration critical care will be a difficult task.
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Curr Opin Crit Care · Dec 2005
ReviewRenal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure.
Although renal replacement therapy is the mainstay of supportive care in patients with severe acute renal failure, its performance can have untoward effects that contribute to the prolongation of renal failure or impede the ultimate recovery of renal function. In this review, we categorize the major complications associated with renal replacement therapy and assess their impact on recovery of renal function. ⋯ Clinical recommendations must be limited to the broad admonishment that complications during renal replacement therapy, including hemodynamic instability and catheter-related bacteremia, be minimized by using best clinical practices, while recognizing that the impact of specific practices on recovery of renal function have not been evaluated. The data do not support recommendations regarding utilization of specific membranes or the modality or dose of renal replacement therapy on the basis of their impact on recovery of renal function.