Critical care : the official journal of the Critical Care Forum
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To systematically review studies evaluating the performance of Sequential Organ Failure Assessment (SOFA)-based models for predicting mortality in patients in the intensive care unit (ICU). ⋯ Models based on SOFA scores at admission had only slightly worse performance than APACHE II/III and were competitive with SAPS II models in predicting mortality in patients in the general medical and/or surgical ICU. Models with sequential SOFA scores seem to have a comparable performance with other organ failure scores. The combination of sequential SOFA derivatives with APACHE II/III and SAPS II models clearly improved prognostic performance of either model alone. Due to the heterogeneity of the studies, it is impossible to draw general conclusions on the optimal mathematical model and optimal derivatives of SOFA scores. Future studies should use a standard evaluation methodology with a standard set of outcome measures covering discrimination, calibration and accuracy.
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Comparative Study
Intensive insulin therapy and mortality in critically ill patients.
Intensive insulin therapy (IIT) with tight glycemic control may reduce mortality and morbidity in critically ill patients and has been widely adopted in practice throughout the world. However, there is only one randomized controlled trial showing unequivocal benefit to this approach and that study population was dominated by post-cardiac surgery patients. We aimed to determine the association between IIT and mortality in a mixed population of critically ill patients. ⋯ A policy of IIT in a group of ICUs from a single institution was not associated with a decrease in hospital mortality. These results, combined with the findings from several recent randomized trials, suggest that further study is needed prior to widespread implementation of IIT in critically ill patients.
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You are appointed director of a new large multi-discipline intensive care unit in an academic center. The hospital is affiliated with a medical school and as such there will be an adequate number of medical students, residents, and fellows (specializing in critical care) rotating through the unit. ⋯ In setting up the call schedule for the intensivists, you need to decide whether the mandate will be for the intensivists to provide 24/7 in-house coverage as opposed to off-hour coverage from home. You wonder about the sustainability of each model.
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Many patients presenting with acute gastrointestinal hemorrhage (GIH) are admitted to the intensive care unit (ICU) for monitoring. A simple triage protocol based upon validated risk factors could decrease ICU utilization. ⋯ Patients presenting to the ED with GIH who have no evidence of ongoing bleeding or unstable comorbidities are at low risk for complication during hospital admission. A triage model based on these variables should be tested prospectively to optimize critical care resource utilization in this common condition.
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Critically ill patients are often treated with continuous intravenous infusions of sedative drugs. However, this is associated with high risk for over-sedation, which can result in prolonged stay in the intensive care unit. ⋯ To introduce these protocols, new agents or new regimens with the well established agents may be required. In this article we briefly discuss these new regimens and new agents, focusing on the short-acting substances.