Critical care : the official journal of the Critical Care Forum
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An increasing number of diagnostic imaging procedures requires the use of intravenous radiographic contrast agents, which has led to a parallel increase in the incidence of contrast-induced nephropathy. Risk factors for development of contrast-induced nephropathy include pre-existing renal dysfunction (especially diabetic nephropathy and multiple myeloma-associated nephropathy), dehydration, congestive heart failure and use of concurrent nephrotoxic medication (including aminoglycosides and amphotericin B). Because contrast-induced nephropathy accounts for a significant increase in hospital-acquired renal failure, several strategies to prevent contrast-induced nephropathy are currently advocated, including use of alternative imaging techniques (for which contrast media are not needed), use of (the lowest possible amount of) iso-osmolar or low-osmolar contrast agents (instead of high-osmolar contrast agents), hyperhydration and forced diuresis. ⋯ Since only one (nonrandomized) study has been performed in intensive care unit patients, at present it is difficult to draw firm conclusions about preventive measures for contrast-induced nephropathy in the critically ill. Further studies are needed to determine the true role of these preventive measures in this group of patients who are at risk for contrast-induced nephropathy. Based on the available evidence, we advise administration of N-acetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions.
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Advanced age is thought to be associated with increased mortality in critically ill patients. This report reviews available data on factors that determine outcome, on the value of prognostic models, and on preferences regarding life-sustaining treatments in (very) elderly intensive care unit (ICU) patients. ⋯ We advocate the development of new prognostic models, validated in elderly ICU patients, that predict not only survival but also functional and cognitive status after discharge. Such a model may support informed decision making with respect to patients' preferences.
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Prognostic models, such as the Acute Physiology and Chronic Health Evaluation (APACHE) II or III, the Simplified Acute Physiology Score (SAPS) II, and the Mortality Probability Models (MPM) II were developed to quantify the severity of illness and the likelihood of hospital survival for a general intensive care unit (ICU) population. Little is known about the performance of these models in specific populations, such as patients with cancer. Recently, specific prognostic models have been developed to predict mortality for cancer patients who are admitted to the ICU. The present analysis reviews the performance of general prognostic models and specific models for cancer patients to predict in-hospital mortality after ICU admission. ⋯ General prognostic models generally underestimate the risk of mortality in critically ill cancer patients. Both general prognostic models and specific oncology models may reliably identify subgroups of patients with a very high risk of mortality.
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Comparative Study Controlled Clinical Trial
Clinical investigation: thyroid function test abnormalities in cardiac arrest associated with acute coronary syndrome.
It is known that thyroid homeostasis is altered during the acute phase of cardiac arrest. However, it is not clear under what conditions, how and for how long these alterations occur. In the present study we examined thyroid function tests (TFTs) in the acute phase of cardiac arrest caused by acute coronary syndrome (ACS) and at the end of the first 2 months after the event. ⋯ TFTs are significantly altered in cardiac arrest induced by ACS. Changes in TFTs are even more pronounced in patients with longer periods of resuscitation. The changes in the surviving patients were characterized by euthyroid sick syndrome, and this improved by 2 months in those patients who did not progress into a vegetative state.
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The Omagh bombing in August 1998 produced many of the problems documented in other major incidents. An initial imbalance between the demand and supply of clinical resources at the local hospital, poor information due to telecommunication problems, the need to triage victims and the need to transport the most severely injured significant distances were the most serious issues. The Royal Group Hospitals Trust (RGHT) received 30 severely injured secondary transfers over a 5-hour period, which stressed the hospital's systems even with the presence of extra staff that arrived voluntarily before the hospital's major incident plan was activated. ⋯ Coordination of the multidisciplinary teams required for many of these procedures was difficult. Although only seven patients required admission to adult general intensive care, no ICU beds were available for other admissions over the following 5 days. A total of 165 days of adult ICU treatment were required for the victims of the bombing.