Current opinion in critical care
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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.
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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
Protocols and guidelines in critical care: development and implementation.
Variation in clinical management has been associated with suboptimal outcomes and increased costs. Guidelines, protocols, and clinical pathways have evolved as a strategy to standardize care, principally by limiting variation, thereby reducing complications, decreasing length of stay and improving outcomes. However, the nature of critical care makes it difficult to conduct blinded, randomized, and controlled clinical trials, the specific type of science required for evidenced-based medicine and guideline development. Areas in which ICU-based guidelines have been successful include, among others, sedation and neuromuscular blockade use, ventilator management, antibiotic selection, and vascular surgical interventions.
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Ethical issues have emerged in recent years as a significant component of care in the critically ill patient. Recently, the primary emphasis has been directed to care at the end-of-life. ⋯ This leads to tremendous potential for conflict between the physician and the family, as the patients are often incapable of participating in any discussion regarding end-of-life care. Advance planning on the part of the patient in terms of making their wishes known and education of the health care professionals is essential in promoting effective communication, thereby avoiding conflict in these difficult end-of-life decisions.