Ann Acad Med Singap
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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
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%.
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Ann Acad Med Singap · May 1998
ReviewContributions of respiratory care practitioners to intensive care: a review.
Through the years, the professional practice of respiratory care has continually evolved to include management of critically ill patients. Although the functions and duties of respiratory care practitioners (RCPs) in this setting may vary across different institutions, it is widely recognised throughout the United States that RCPs contribute importantly to intensive care unit (ICU) outcomes. ⋯ Other ICU activities in which RCPs participate include assisting with bronchoscopy, obtaining haemodynamic measurement, and indirect calorimetry and supporting specialised techniques such as extracorporeal membrane oxygenation (ECMO) and continuous veno-venous haemofiltration and/or haemodiafiltration (CVVH/CVVHD). Based on the demonstrated impact of RCPs and their technical and cognitive training, a continuing role expansion for RCPs in the ICU is expected.
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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.
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Advances in medical technology have rendered the ability to provide prolonged physiologic support of incurable or terminally ill patients commonplace in the intensive care unit. In tandem, there has been a global shift in the intensivist's mindset from solely pursuing an unrelenting course of aggressive therapy, to a recognition of the limitations of intensive care and the appropriate discontinuance of nonbeneficial therapy. ⋯ A consensus on withholding or withdrawal of care is often then achieved. The process of foregoing or withdrawing life-sustaining therapy itself, must be carried out with sensitivity and empathy, with the primary goal of providing comfort and reducing suffering.