Critical care : the official journal of the Critical Care Forum
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The Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff. ⋯ The FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of +/- 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of +/- 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care.
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Comparative Study
Respiratory support withdrawal in intensive care units: families, physicians and nurses views on two hypothetical clinical scenarios.
Evidence suggests that dying patients' physical and emotional suffering is inadequately treated in intensive care units. Although there are recommendations regarding decisions to forgo life-sustaining therapy, deciding on withdrawal of life support is difficult, and it is also difficult to decide who should participate in this decision. ⋯ Physicians, nurses and families recommended limiting life-support therapy with terminally ill patients and favored family participation. In decisions concerning an incompetent patient, physicians were more likely to maintain the therapy.
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Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes. ⋯ This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.
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From the earliest studies of statins for control of plasma cholesterol, observations have been made that the reductions in mortality observed occurred in a manner seemingly independent from what could be anticipated from cholesterol lowering alone. Over the last decade, the pleiotropic effects of statins have been increasingly elucidated. Perhaps most intriguing are the effects statins appear to have on the immune system, especially the modulation of diffuse or systemic inflammation. There is a growing body of observational literature suggesting that statins can actually reduce hospital mortality through mechanisms far beyond those that can be explained by reductions in cardiovascular events.
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While animal studies indicate that controlled mechanical ventilation (MV) induces diaphragm weakness and myofiber atrophy, there are no data in humans that confirm MV per se produces diaphragm weakness. Whether or not diaphragm weakness results from MV, sepsis, corticosteroids, hyperglycemia, or a combination of these factors, however, is not the most important issue raised by the recent study from Hermans and colleagues. This study makes an important contribution by providing additional evidence that many critically ill patients have profound diaphragm weakness. If diaphragm weakness of this magnitude is present in most mechanically ventilated patients, a strong argument can be made that respiratory muscle weakness is a major contributor to respiratory failure.