Current opinion in critical care
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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.
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Although the administration of sedatives is a commonplace activity in the ICU, few guidelines are available to aid the clinician in this practice. The first principle of sedative administration is to define the specific problem requiring sedation and to rationally choose the drug and depth of sedation appropriate for the indication. Next, the clinician must recognize the diverse and often unpredictable effects of critical illness on drug pharmacokinetics and pharmacodynamics. ⋯ Drug accumulation may result in prolonged encephalopathy and mechanical ventilation and may mask the development of neurologic or intra-abdominal complications. Daily interruption of continuous sedative infusions is a simple and effective way of addressing this problem. A glossary of sedative drugs commonly used in the ICU is included in this review.
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Critical illness is a severe and generalized monophasic event, and it is likely that there will be evidence of compromised reserve in all end organs if one looks hard enough for it. The crucial issues are to understand which end organs are the most vulnerable to this insult, in which organ systems the incremental disability is of the most functional consequence, and how to design an effective intervention to ameliorate the dysfunction. ⋯ Studies of survivors of acute respiratory distress syndrome (ARDS) have shown that there are both long-term physical and neuropsychological consequences of severe illness. We need to gain a better understanding of the specific determinants of patients' inability to resume their prior work/lifestyle so that an appropriate multidisciplinary intervention can be designed and tested.