Ann Acad Med Singap
-
The Western Pacific region has seen rapid recent economic development but variation in the provision and organisation of intensive care units (ICUs) between different countries remains. While Japan, Australia, New Zealand, Singapore, Taiwan, Korea and Hong Kong have well developed intensive care facilities, in other countries the more limited funding for healthcare can be reflected by differential availability of modern medical technology between the public and private sectors. Other factors important to intensive care include physician training, availability of other staff and whether intensive care is delivered in "open" or "closed" units. ⋯ Future development of intensive care in the region will parallel economic development. In most countries increasing patient expectations, ageing populations and "Western" diseases will increase demand for intensive care services. Only a few countries currently have recognised programmes of training and certification in intensive care but as more adopt this process it should lead to a clearer recognition and acceptance of the role of the intensivist.
-
Septic shock is a major cause of death among patients in intensive care units. It has a mortality rate of 20% to 80%. The clinical syndrome of septic shock is characterised by hypotension, hyporesponsiveness to vasoconstrictors and volume depletion which will then lead to multiorgan dysfunction and death. ⋯ Inhibition of NO synthase, the enzyme responsible for NO production, has been proposed as a new therapy for septic shock. However, experimental reports have provided conflicting results, demonstrating both beneficial and detrimental effects. A brief review of the role of NO in septic shock and the possible use of NO synthase inhibitors as potential therapeutic agents is presented here.
-
In recent years, several factors have led to increasing focus on the meaning of appropriateness of care and clinical performance in the intensive care unit (ICU). The emergence of new and expensive treatment modalities, a deeper reflection on what constitutes a desirable outcome, increasing financial pressure from cost containment efforts, and new attitudes regarding end-of-life decisions are reshaping the delivery of intensive care worldwide. ⋯ Their application has broadened to include ICU performance assessment, individual patient decision-making, and pre- and post-hoc risk stratification in randomised trials. In this paper, we review the popular scoring systems currently in use; design issues in the development and evaluation of new scoring systems; current applications of scoring systems; and future directions.
-
Ann Acad Med Singap · May 1998
ReviewControlled observations in critical care medicine: the therapeutic trial.
The practice of critical care medicine revolves around the monitoring of patients to identify acute physiologic deterioration and the titration of therapies aimed at supporting internal homeostasis. Central to this practice is the evaluation of therapies or stresses designed to assess homeostatic reserve and to uncover pathologic processes. Both the cardiovascular and respiratory systems have received particular attention because of the ease with which specific haemodynamic and respiratory parameters can be measured, the ability to modulate their status with therapies, and the intimacy of both cardiovascular and respiratory status to overall homeostasis. ⋯ Clinical trials form much of the basis for titration of therapy, wherein a specific therapy is adjusted so as to optimise its effectiveness in an individual. Titration is typically done once a diagnosis has already been made or a treatment identified, such as with the titration of antihypertensive therapy in either hospital or outpatient setting. This review will focus on the exploratory aspect of clinical trials wherein a specific manoeuvre is performed to determine either the aetiology or severity of a pathophysiologic problem.
-
Ann Acad Med Singap · May 1998
Comparative StudyPredictors of long-term outcome in severe head injury.
Severe head injury is associated with significant morbidity and mortality. We conducted a retrospective study to assess the long-term outcome of these patients using the Glasgow Outcome Score (GOS) and evaluate the variables that might predict outcome. Data were collected from all post-traumatic neurosurgical patients with severe head injury (Glasgow Coma Scale 8 or less) admitted to the Surgical Intensive Care Unit over a 29-month period. ⋯ Patients with a poor outcome (defined as GOS scores of 1 to 3) had a significantly higher mean age, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and a lower Glasgow Coma Scale than those with a good outcome (GOS 4 to 5). The APACHE II score correlated better with outcome than the Glasgow Coma Scale or age. The APACHE II score may be used to prognosticate the long-term outcome in severe head injury.