Postgraduate medicine
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Postgraduate medicine · Mar 2002
ReviewOptimal management of septic shock. Rapid recognition and institution of therapy are crucial.
Septic shock is a common problem in hospitalized patients. Optimal management depends on rapid recognition, aggressive restoration of circulating volume with fluid boluses, initiation of appropriate antibiotic therapy, implementation of adequate monitoring, and meticulous attention to the details of care. Mean arterial pressure should be increased to between 65 and 75 mm Hg as soon as possible to reduce the likelihood of multiorgan dysfunction. Despite these therapeutic maneuvers, however, mortality rates are likely to remain high until the development of therapies that better target the underlying mechanisms of sepsis.
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Postgraduate medicine · Feb 2002
ReviewEvaluating the comatose patient. Rapid neurologic assessment is key to appropriate management.
Coma is defined as a sleeplike state in which the patient is unresponsive to self and the environment. Coma should be distinguished from the persistent vegetative state and locked-in syndrome. ⋯ A pupil unreactive to light often points to a structural brain lesion and the need for urgent neurosurgical consultation. The prognosis for coma depends on the cause.
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Postgraduate medicine · Feb 2002
ReviewSedation and analgesia in intensive care. Medications attenuate stress response in critical illness.
The stress response to critical illness can have many deleterious effects. Appropriate use of sedation and analgesia can attenuate the stress response, alleviate pain and anxiety, and improve compliance with care. ⋯ In select cases, neuromuscular blocking agents are required, but they should not be used without concomitant sedation and analgesia. Use of agents needs to be tailored to the needs of individual patients; indications, anticipated length of need, and underlying organ system derangements are important considerations.
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Postgraduate medicine · Oct 2001
Practice GuidelineThe expert consensus guideline series. Pharmacotherapy of depressive disorders in older patients.
Depression in older patients contributes to personal suffering and family disruption and increases disability, medical morbidity, mortality, suicide risk, and healthcare utilization. The majority of clinical trials of antidepressant treatments are conducted in younger patients. For this reason, clinicians often have to extrapolate from studies in populations that do not present the same problems as older patients. For example, older patients often have serious coexisting medical conditions that may contribute to the depression and complicate the choice of treatment. Older patients as a rule need to be on many medications, some of which may contribute to depression and/or interact with antidepressants. Finally, older adults metabolize medications slowly and are more sensitive to side effects than younger patients. Because of these complexities, we conducted a consensus survey of expert opinion on the pharmacotherapy of depressive disorders in older patients to address clinical questions not definitively answered in the research literature. ⋯ The experts reached a high level of consensus on the appropriateness of including both antidepressant medication, specifically SSRIs, and nonpharmacological modalities in treatment plans for severe depression. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for addressing common clinical dilemmas in older individuals. They can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions. Nonetheless, the guidelines cannot address the complexities involved in the care of each individual patient and can be most helpful in the hands of experienced clinicians.