Current opinion in critical care
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Curr Opin Crit Care · Dec 2002
ReviewTechniques for assessing and achieving fluid balance in acute renal failure.
Fluid therapy, together with attention to oxygen supply, is the cornerstone of resuscitation in all critically ill patients. Hypovolemia results in inadequate blood flow to meet the metabolic requirements of the tissues and must be treated urgently to avoid the complication of progressive organ failure, including acute renal failure. The kidney plays a critical role in body fluid homeostasis. ⋯ Although the importance of fluid management is generally recognized, the choice of fluid, the amount, and assessment of fluid status are controversial. As the choice of fluids becomes wider and monitoring devices become more sophisticated, the controversy increases. This article provides an overview of the concept of fluid management in the critically ill patient with acute renal failure.
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The changing landscape of health care has resulted in an increase in the delivery of critical care in the emergency department. Although the emergency department duration is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. The care provided during the emergency department stay for critically ill patients has been shown to significantly impact the progression of organ failure and mortality. ⋯ The need to maximize patient throughput in frequently overcrowded emergency departments hinders the provision of optimal care to the critically ill patient. Methodologies should be developed to examine the quality of patient care and objectively measure the impact of clinical interventions. The potential to improve outcome through educational initiatives and resource allocation should not be viewed as a burden of delivering a higher level of care in this setting but as a significant opportunity to effectively mitigate the socioeconomic consequences.
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Curr Opin Crit Care · Dec 2002
Role of the physician in prehospital management of trauma: North American perspective.
To some extent or another, physicians have been involved in emergency medical services (EMS) systems in North America for decades. Over the years, physicians from different specialties have been involved with EMS, occasionally as full-time or part-time employees of the EMS system but more often on a voluntary or small contractual basis. Regardless of the employment relationship, most states and provinces now require by statute that each EMS system, particularly those providing advanced life support (ALS) services, have a designated EMS medical director. ⋯ However, by becoming an intermittent participating member of the EMS team in the unique out-of-hospital setting, these on-scene physicians can help to better scrutinize the care rendered and thus more effectively modify applicable protocols and training as needed. Historically, such practices have helped many EMS systems-not only in terms of reforming traditional protocols but also by helping to establish improved medical care priorities and even system management changes that affect patient care. In addition, active participation helps the accountable EMS physician not only to identify weaknesses in personnel skills and system approaches, but it also provides an opportunity for role modeling, both medically and managerially.
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Recent epidemiologic data have shown that the burden of drowning is much greater than expected. Prevention and timely rescue are the most effective means of reducing the number of persons at risk. Early bystander cardiopulmonary resuscitation is the most important factor for survival after submersion. ⋯ The most appropriate technique will depend on the available means in the hospital and the condition of the patient. Treatment of pulmonary complications depends on the lung injury that occurred during aspiration and the bacteria involved in aspiration. Understanding the pathophysiology of drowning may help us to understand lung injuries and ischemic brain injuries.
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Critical care medicine is a relatively young specialty that was developed in response to potentially reversible life-threatening illness and was facilitated by developments such as new drugs, support equipment, and monitoring technology. It has been largely practiced within the four walls of an intensive care unit (ICU). However, now there are increasing numbers of critically ill and at-risk patients in acute hospitals who are suffering potentially preventable, serious complications that may result in death because of a lack of appropriate systems, skills, and expertise outside of the ICU. Critical care specialists are expanding their roles beyond the four walls of their ICUs and becoming involved with strategies such as the medical emergency team, a concept designed to recognize critical illness early and to respond rapidly to resuscitate patients wherever they are in the hospital.