The Journal of critical illness
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The initial work-up of a critically ill patient with fever begins with a hunt for an infectious cause. A positive urine culture, or the presence of dysuria or suprapubic tenderness, suggests urinary tract infection. ⋯ Other common causes of fever in the ICU include abdominal abscesses and catheter-related infections; atelectasis has not been shown to cause fever. If the initial work-up fails to establish a cause of postoperative fever, and the fever resolves within 4 days, no further work-up is required.
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In patients with obstructive lung disease, a strategy of mechanical ventilation that prolongs expiratory time and limits lung hyperinflation can decrease barotrauma. To prolong expiratory time, decrease minute ventilation and inspiratory time. ⋯ Short-acting benzodiazepines and morphine are effective for sedation and analgesia. Paralytic agents should be considered only if adequate control of the patient's cardiopulmonary status cannot be achieved by sedation alone.
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Small-catheter aspiration may be preferable to chest tube drainage in many patients with primary spontaneous or iatrogenic pneumothoraces, as well as in some patients with pneumothoraces resulting from minor trauma. It is also less invasive than chest tube drainage, allows greater control over the rate of air removal, and produces less patient discomfort. ⋯ Addition of a Heimlich valve (with or without a suction device) permits continued air removal. Complications are infrequent and generally minor.
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Review Case Reports
Tips for monitoring the position of a central venous catheter. How placement can go awry--even when the anatomy is normal.
Malpositioning of a central venous catheter can cause potentially life-threatening complications. Knowledge of thoracic anatomy and close attention to proper insertion technique increase the likelihood of, but do not ensure, proper placement. Selection of a right-sided venous entry site reduces the risk of malpositioning. ⋯ Do not assume that venous system valves preclude malpositioning. Use chest films to confirm accurate insertion. When these are equivocal, take simultaneous blood samples from a peripheral artery and the central line; the samples will have markedly different blood gas levels if the catheter is in a vein.
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Major problems facing cardiac transplant recipients include rejection, infection, and transplant coronary artery disease. Commonly used antirejection drugs are high-dose corticosteroids and cytolytic agents. ⋯ Coronary angiography is used to detect transplant coronary artery disease, the only definitive treatment for which is retransplantation. A number of promising new immunosuppressive agents and techniques may prevent some complications and further improve the care cardiac transplant recipients receive.