Arch Intern Med
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Despite the growing availability of advance directives, most patients in the intensive care unit lack written directives, and, therefore, consultation with families about treatment decisions remains the rule. In the context of decision making about withdrawing life-sustaining treatments, we investigated which physician and nurse behaviors families find supportive and which behaviors increase the family's burden. ⋯ Study findings provide an increased understanding of the unmet needs of families and serve to guide physicians and nurses in reducing actions that increase families' burdens as they participate in treatment withdrawal decisions.
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We conducted an on-line search and manual searches for 1966 through 1992 to determine the incidence, diagnosis, risk factors, and treatment of postoperative delirium. Of the 374 citations found, 277 articles were excluded after criteria of relevance were applied. After methodologic criteria for validity were applied to the remaining 80 articles, 26 studies were retained for the final information synthesis. ⋯ Although age, preoperative cognitive impairment, and the use of anticholinergic drugs were significantly associated with postoperative delirium, gender, type and route of anesthesia, and sleep deprivation were not. Two studies demonstrated a decreased incidence of postoperative delirium when patients underwent preoperative psychiatric counseling or participated in a structured perioperative program. These findings indicate a need for (1) accurate incidence data with further definition of risk factors and (2) studies that address the diagnosis and treatment of this common postoperative problem.
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Comparative Study
Appropriate use of heparin. Empiric vs nomogram-based dosing.
A study involving two groups of patients with cardiovascular disease was conducted to compare empiric (clinician-directed) heparin therapy with therapy based on a nomogram-determined dosage. The comparison was based on (1) the average weight-referenced infusion rate yielding a therapeutic activated partial thromboplastin time (APTT) and (2) the time required to reach a therapeutic APTT (55 to 95 seconds) after empiric or nomogram-based heparin therapy was initiated. ⋯ Use of a weight-based nomogram to determine the initial and maintenance heparin infusion rates was associated with a higher percentage of patients admitted to the cardiology service reaching the targeted therapeutic APTT range at a time earlier in the course of therapy compared with empiric dosing.