Ann Acad Med Singap
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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.
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Tissue hypoxia is an important cause for the development of multisystem organ failure in the critically ill. Achieving adequate haemodynamic support of oxygen demand is the mainstay of treatment in these patients. Controversies regarding therapeutic end-points do exist but in general maintaining oxygen delivery by ensuring adequate cardiac output, oxygen saturation and haemoglobin is important in the critically ill.
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The development of the specialty of critical care and the intensivist is outlined and the data that favours critically ill patients being cared for by intensivists are reviewed. The future challenges for intensive and critical care are dealing with the new ethical dilemmas raised by intensive care, providing appropriate intensive care in both developed and developing countries and applying the principles of evidence-based medicine to intensive therapy.
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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.
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Ann Acad Med Singap · May 1998
ReviewVentilatory strategies for acute respiratory distress syndrome.
Acute respiratory distress syndrome (ARDS) is a severe condition that has a high mortality. Mechanical ventilation is required and concepts have evolved over the last few decades as to the methods and principles guiding such ventilatory support. In particular, volutrauma as a feature of ventilator-associated lung injury has been well documented, leading to pressure-limited strategies with consequent permissive hypercapnia. ⋯ Current strategies therefore emphasis lower tidal volumes, adequate positive end-expiratory pressure (PEEP), minimum FiO2, and the use of pressure-control modes (plus or minus inverse-ratio ventilation). Hypercapnia is allowed to develop, and adjunctive methods are employed to improve oxygenation in order to minimise the "pressure-cost" of maintaining adequate oxygenation. With such an approach, overall mortality is reported to be around 40%.