Critical care : the official journal of the Critical Care Forum
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The description of a new score of nutrition risk in critically ill patients in the previous issue of Critical Care is very appropriate and timely. However, the use of this score will probably not help the clinician to improve the prescription of nutrition therapy, especially when major uncertainties are raised about the definition of adequate nutrition. The validation of the score will require the use of outcome variables susceptible to influence by nutrition, such as surrogate markers of muscle function. Meanwhile the educational value of a score of nutrition risk is undisputed in settings where the use of scores is incorporated into the usual practice.
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Diagnosis and classification of acute kidney injury was addressed systematically only 8 years ago when the classification called RIFLE (acronym of Risk, Injury, Failure, Loss of function and End stage Kidney disease describing progressive severity of renal damage) was created. Since then, several studies have tried to apply, validate, criticize and modify this initial scheme: as a matter of fact, RIFLE is today one of the most appreciated and utilized medical classification systems worldwide. After an initial period of epidemiological research, it is acceptable to apply it now at the bedside, following both urine output and creatinine criteria, with the purpose of routinely monitoring renal function of critically ill patients.
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ICU capacity strain is associated with increased morbidity and lost hospital revenue, leading many hospitals to increase the number of ICU beds. However, this approach can lead to inefficiency and waste. ⋯ In this case, the authors started a post-anesthesia care unit with an intensivist-led care team, resulting in lower hospital costs with no changes in ICU mortality. Although this type of change carries some risks, and will not work for every hospital, it is an example of the creative solutions hospitals must sometimes undertake to maintain the supply of critical care in response to a rising demand.
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In the previous issue of Critical Care, Rose and colleagues report the results of a survey on the frequency with which ICU nurses are involved in decision-making in ventilator management. About 63 to 88% of the decisions were made by nurses in collaboration with physicians, and as much as 68% of ventilator adjustments were performed by nurses independent of physicians. ⋯ The ICU nurse performs many roles, the most important being the continuous observation of a patient. The diversion of a nurse's attention from constant vigilance by performing tasks of no benefit, such as the use of weaning protocols, would be a most unfortunate turn of events.