Current opinion in critical care
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Curr Opin Crit Care · Oct 2002
ReviewOutcome of cardiac surgery patients with complicated intensive care unit stay.
Risk stratification has become an essential element in the practice of cardiac surgery. Several studies have identified preoperative risk factors for adverse outcome. However, outcome is mostly defined by 30-day mortality and morbidity. ⋯ By reviewing the recent data reported in the literature, we can identify a number of preoperative predictive factors for complicated ICU stay, including advanced age, chronic obstructive pulmonary disease, preoperative low ejection fraction, previous myocardial infarction, reoperation, renal failure, combined surgery (coronary artery bypass grafting plus valve surgery), low hematocrit, and neurologic impairment. Short- and long-term outcomes are dependent on the type of postoperative complication. Unfortunately, data regarding the long-term outcome in these situations are very scarce.
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Surgical infections in the critically ill patient population are a significant cause of morbidity and mortality. Intra-abdominal and surgical soft-tissue infections are responsible for a significant proportion of the disease burden. ⋯ The diagnosis and management of these infections require a high index of suspicion, prompt surgical intervention, and adequate antibiotic therapy and resuscitation. Therefore, these infections present a challenge to the intensivist caring for a critically ill patient.
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Critical care providers are under increasing pressure to be attentive to cost concerns. The ICU consumes a significant amount of resources and, as such, is a frequently identified target of efforts to limit escalating healthcare costs. Attempts to reduce costs need not progress in a haphazard fashion. ⋯ ICU physicians, therefore, must become familiar with the basic concepts that underlie cost-effectiveness analysis. Cost-effectiveness analyses that address many different aspects of critical care delivery are now commonly found in the critical care literature. With a framework for evaluating these studies, clinicians can better apply their findings to their own institutions.
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In recent months, numerous reports concerning total parenteral nutrition in critically ill patients have been published, including the guidelines and recommendations of the American Society for Parenteral and Enteral Nutrition. The old controversy regarding the use of the enteral versus parenteral route still exists. Although the enteral route is indicated in those patients with normal gastrointestinal function, the parenteral route is obviously beneficial in several clinical conditions and appears to be associated with few procedure-related complications when performed by experienced clinicians. There is also continued interest in the supplementation of parenteral formulas with nutrients that were previously considered nonessential, such as arginine, glutamine, and omega-3 fatty acids, but that may become essential in the setting of critical illness.
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Curr Opin Crit Care · Aug 2002
ReviewLocation, location, location: regionalization and outcome in pediatric critical care.
This article briefly reviews some of the background, recent studies, and unanswered questions related to regionalization of critical care services for children. Evidence and arguments in support of centralized services for critically ill children are increasing. ⋯ More recent studies have provided additional evidence supporting regionalization and documenting its effects. Unfortunately, a growing body of evidence suggests that many hospitalized critically ill children with fatal outcomes in the United States never received the highest level of care available.