The Journal of critical illness
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Many critically ill patients require nutritional support to avoid protein-calorie malnutrition. Enteral administration is preferred because it is less expensive than parenteral nutrition and is associated with fewer complications. ⋯ To lower the risk of aspiration, check the level of gastric residuum before initiating, or increasing the level of, nutritional support. Diarrhea is not an indication for stopping enteral nutrition.
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In patients with shock and evidence of hypoperfusion, target therapy at increasing oxygen delivery and decreasing oxygen consumption. To augment delivery, increase arterial oxygenation (with mechanical ventilation and high levels of inspired oxygen), hemoglobin level to at least 10 g/dL (with transfusions of red blood cells), and cardiac output (with hydration and inotropic support). ⋯ To reduce oxygen consumption, consider antipyretics (to lower metabolic demand) and mechanical ventilation plus sedatives or paralytics (to decrease the work of breathing). Continue therapy until oxygen consumption is no longer coupled to delivery.
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Elderly patients are susceptible to acute renal failure largely because of functional impairment of the kidneys secondary to diseases such as arteriosclerosis, hypertension, and heart failure. Successful prevention of renal failure in the elderly hinges on understanding the age-associated changes in renal anatomy and physiology. To prevent renal failure, rehydrate elderly patients who suffer significant fluid loss to avoid volume depletion. In addition, maintain adequate blood pressure in these patients, consider glomerular filtration rate when determining the dosage of nephrotoxic antibiotics, and administer saline preparation before injecting radiocontrast dyes.
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Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. ⋯ Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.
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Use the following organized approach to determine whether a patient can be weaned from tracheostomy. Consider airway decannulation only if the original upper airway obstruction has resolved, if mechanical ventilation is no longer needed, and if airway secretions are controlled. ⋯ The tracheostomy button is an ideal weaning device; it maintains the stoma tract and allows the patient to breathe and clear secretions through the upper airway. Monitor the patient for up to 48 hours to ensure tolerance to decannulation.