Crit Care Resusc
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Recommendations exist to guide the design and construction of adult intensive care units, but current guidelines are hampered by the paucity of high-quality research. Much of the current literature on ICU design has focused on patient-centred outcomes, such as nosocomial infections, aspects of psychological and physiological wellbeing, and patient satisfaction, but the design of the ICU environment also affects health care workers. ⋯ For most aspects of ICU design, more research is required before definite conclusions can be drawn. This article discusses the application of evidence-based design to improve the ICU environment and reviews some of the controversial issues and concepts.
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There is no consensus definition on what constitutes a long stay in the intensive care unit, and little published information on the demographic characteristics, resource usage or outcomes of long-stay patients. We used data from the Australian and New Zealand Intensive Care Society Adult Patient Database to identify patients who had spent > 21 days in the ICU. We examined their resource usage, hospital type, diagnoses and outcomes, and trends in these characteristics over 5 years (2000-2004). ⋯ Patients who spend > 21 days in the ICU use significant resources but appear to have worthwhile outcomes in all age brackets.
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Review Meta Analysis
Thrombolysis is not warranted in submassive pulmonary embolism: a systematic review and meta-analysis.
Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in hospitalised patients. While the vast majority of patients with PE survive, a subset die, mostly within a few hours of presentation. Anatomically massive pulmonary emboli account for only half these deaths, while submassive or recurrent embolism accounts for the other half. ⋯ There is also evidence to support the use of thrombolysis in patients with massive PE. However, the optimal management of patients with submassive PE is controversial. This article looks at the definition and diagnosis of submassive PE, and systematically reviews the role of thrombolytic therapy in this subgroup of patients.
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Despite the established role of catecholamines for the treatment of circulatory shock in intensive care medicine, these drugs have been subjected to few randomised controlled trials with high methodological quality and patient-centred outcomes. The literature has been dominated by low-quality, case-control studies of the effects of synthetic catecholamines on surrogate haemodynamic end-points. A recent Cochrane systematic review of the effects of vasopressors on mortality from circulatory shock identified seven randomised controlled trials, none of which demonstrated any conclusive evidence of benefit of one inotrope/vasopressor over another. ⋯ Three higher-quality studies of catecholamines (noradrenaline, adrenaline, dopamine and vasopressin) have been completed, the results of which will provide some evidence of efficacy of catecholamines on mortality and resolution of shock. These studies may provide the basis for designing and conducting a large-scale, pragmatic, randomised controlled trial to analyse the effects of these commonly used drugs on patient-centred outcomes, such as mortality, resolution of organ failure and hospital length of stay. The results of such a study would be particularly important in geographical regions where access to inotropes/vasopressors other than adrenaline remains restricted.
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Discussions of cardiac physiology and pathophysiology most often emphasise the function of the left heart. However, right heart dysfunction plays an important role in critically ill patients and is often not recognised. This is probably because the role of the right ventricle is for generating flow more than pressure, and flow is not easy to evaluate. ⋯ It has recently become evident that the right ventricle also has different genetic origins and characteristics from the left ventricle. The right and left ventricles interact through series effects, diastolic interactions and systolic interactions. The mechanisms of these, and their physiological and pathological significance are discussed.