Clinical intensive care : international journal of critical & coronary care medicine
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Clin Intensive Care · Jan 1992
ReviewLow volume ventilation with permissive hypercapnia in the Adult Respiratory Distress Syndrome.
Many animal studies have demonstrated that mechanical ventilation with high peak inspiratory pressures (PIP) can result in a form of acute lung injury closely resembling ARDS, ie characterised by hyaline membranes, granulocyte infiltration, increased pulmonary and systemic vascular permeability, and eventually proliferation of fibroblasts and type II pneumocytes. These studies have led to a concern that, in some patients, orthodox ventilatory management in severe ARDS may result in additional lung injury and, possibly, remote organ dysfunction. Mortality may be increased as a consequence. ⋯ The time scales for compensation of intracellular and extracellular acidosis are markedly different. However, even severe acute hypercapnia appears to be remarkably well tolerated. Several clinical studies suggest that the avoidance of high PIP may reduce mortality in ARDS, but a randomised trial will be required to establish whether pressure limitation and permissive hypercapnia do improve outcome.
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Clin Intensive Care · Jan 1992
Comparative StudyPhysician and nursing (personnel) requirements for ICUs. Therapeutic Intervention Scoring System (TISS) versus time requirements for patient care--a comparative study in an interdisciplinary surgical intensive care unit.
To measure total physician manoeuvres and total nursing manoeuvres in intensive care patients and to compare the results with calculated personnel requirements on the basis of TISS scores. ⋯ Physician activities on a surgical ICU averaged 3.9 hours/patient-day. Nursing manoeuvres average 17.9 hours/patient-day. Individual measurements must be made before calculating personnel requirements on the basis of TISS scores.
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Clin Intensive Care · Jan 1992
Rationing and regionalisation of health care services: a critical care physician's opinion.
It is becoming apparent that we have created a demand for medical goods and services that threatens to overwhelm our health care system. Present fiscal policies for financing health care such as excluding a large portion of the population are clearly unacceptable to the public. Current reimbursement policies for health care providers are so murky and, in some cases, so conflicting that they could have been designed only as a method of rationing by inconvenience. ⋯ Regionalisation of medical services has proven to be cost-effective in the specialties of trauma and neonatology. There is accumulating evidence that this same concept, using severity of illness scoring as an objective marker of potential benefit, may maximise cost/benefit for medical and surgical critical care patients. However, multifaceted deterrents to the concept of regionalisation must be addressed, including reimbursement problems, logistics of bed occupancy and physician incentives to participate.