Current opinion in critical care
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That the resources available for intensive care cannot be infinite is self-evident. Parallel increases in medical capability, cost, and community expectations have forced intensivists to confront the reality of resource limitation. Traditional bioethical structures cope poorly with this focus beyond the traditional patient-doctor relationship. ⋯ These techniques involve assessment of the quality of life with the help of several well-validated quantitative approaches. Choosing between competing patients for intensive care beds is often more a theoretical issue than a practical one, because alternative arrangements can almost always be made. Physicians have an ethical and social responsibility to further develop the tools to inform community debate on these issues.
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Curr Opin Crit Care · Dec 2001
ReviewNew issues in severity scoring: interfacing the ICU and evaluating it.
Since the development of the first general outcome prediction models, these instruments have been widely used in the intensive care unit (ICU), both for patient evaluation and for ICU evaluation. Since some of these uses have been serious questioned, we assisted in the last years to the exploration of alternative paths for increasing the predictive power of the models and to enhance their applicability and utility in the real world. ⋯ Also, since it is now widely recognized that the ICU is not an island, but it is integrated in a continuum of care, more and more efforts are being made to optimize and evaluate the interface between the ICU and the hospital, both at ICU admission and at ICU discharge. The objective of this review is to present and discuss, to the clinician working in the ICU, these emerging issues.
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Curr Opin Crit Care · Dec 2001
ReviewPrehospital and resuscitative airway care: should the gold standard be reassessed?
In the context of prehospital care and resuscitation, tracheal intubation has been regarded as the standard in airway treatment. The evidence for this status is rather weak. ⋯ When healthcare providers lack adequate skills in tracheal intubation, alternative airway devices, such as the laryngeal mask airway or the Combitube, may be better options than a simple facemask. Healthcare personnel using any of these devices should be adequately trained and maintain frequent practice.
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Curr Opin Crit Care · Dec 2001
ReviewLow-volume fluid resuscitation for presumed hemorrhagic shock: helpful or harmful?
For the past 4 decades, the standard approach to the trauma victim who is hypotensive from presumed hemorrhage has been to infuse large volumes of fluids as early and as rapidly as possible. The goals of this treatment strategy are rapid restoration of intravascular volume and vital signs towards normal, and maintenance of vital organ perfusion. The most recent laboratory studies and the only clinical trial evaluating the efficacy of these guidelines however, suggest that in the setting of uncontrolled hemorrhage, today's practice of aggressive fluid resuscitation may be harmful, resulting in increased hemorrhage volume and subsequently greater mortality. ⋯ Limited resuscitation provides a mechanism of avoiding the detrimental effects associated with early aggressive resuscitation, while maintaining a level of tissue perfusion that although decreased from the normal physiologic range is adequate for short periods. Large randomized clinical trials are necessary to confirm this new laboratory data. Future research should focus on developing resuscitation methods that may actually enhance tissue perfusion during limited resuscitation and therefore offset its potential detrimental effects.