New horizons (Baltimore, Md.)
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The end point of uncorrected shock is cardiac arrest. Once cardiac arrest occurs, the outcome in children is typically poor, reflecting the fact that cardiac arrest does not occur until the child's physiologic reserves are exhausted. Despite more than 35 years of research in cardiac arrest, the optimal management and treatment remain uncertain. ⋯ The role of bicarbonate in the management of acidosis and the role of calcium in restarting the heart remain controversial. If and when the heart is restarted following cardiac arrest, the work is just beginning for the intensivist to manage the postarrest shock state. Dobutamine is useful in the normotensive child while epinephrine infusions are used to stabilize hypotensive, postarrest shock in the child.
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Why some patients develop postoperative surgical wound infection and others do not remains a mystery. There are many risk factors for infection, and mathematical scoring systems are often good predictors of infection; yet, some patients with a plethora of risk factors fail to develop surgical site infections. Even patients with established abdominal infection do not automatically develop wound infection. ⋯ Care and attention to the theater operating environment is important, especially for cases in which airborne transmission of bacteria should be controlled, e.g., ultraclean air systems for implant surgery. In elective surgery, the source of bacteria that cause infection is either the patient's normal flora (e.g., skin or bowel), i.e., endogenous, or the surgical staff or environment, i.e., exogenous. Surgical expertise and theater discipline are essential components in the fight against surgical sepsis.
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The pathophysiology of cardiogenic shock in infants and children is multifactorial and include noncardiac as well as cardiac etiologies, both congenital and acquired heart disease. The management of patients in cardiogenic shock requires a rational approach that is based upon the underlying pathophysiology. ⋯ In this article, the pathophysiology of cardiogenic shock and the use of echocardiography in reaching a differential diagnosis are discussed. In addition, the management of cardiogenic shock is reviewed.
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Technology utilization in acute and critical care holds great promise for improving the management and outcome of patients. However, before this promise can be realized, technology has to be properly evaluated for appropriateness of use. This evaluation must include both the clinical impact on patient outcomes as well as the economic impact. ⋯ Unfortunately, evidence exists which suggests that these three steps are not followed in many, if not most, hospitals in the United States. In this article, a method of implementing these three steps is presented. However, it is essential that national organizations and societies become active in this process, lest widespread variation in technology utilization continue.
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Review
Making changes to improve the intensive care unit experience for patients and their families.
With the technology explosion and scientific advances in the field of critical care in the past three decades came an era in which ICUs were referred to as an arena for punitive survivalists. Although clinicians have developed an increased ability to improve the quality and quantity of life for patients in the long term post discharge, patients and their families often suffered more than is necessary in the short term, during the critical care phase of the illness. ⋯ This article reviews the relevant literature and also reports the experience of those who have created and applied unique strategies that address the patient and family needs, thus promoting their comfort and relieving their distress. Although more outcome studies are needed in this area of care, applying some of the lessons already learned can significantly improve the ICU experience for most patients and families.