Swiss medical weekly
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Neuromuscular blocking agents (NMBAs) are used in many critically ill patients, although their use is declining. NMBAs are designed for short term use in the operating theatre, and there are few studies in the critical care setting of either efficacy or safety, in particular their metabolism may be impaired by organ dysfunction. Weakness associated with critical illness is multifactorial, but in many cases is associated with myopathies and neuropathies. The possible role of NMBAs in the development of weakness is unclear, but there is no proven link between the use of NMBAs and neuropathy or myopathy.
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Sensitivity to neuromuscular blocking agents differs between individuals, and residual neuromuscular blockade is a common postoperative problem. Clinical signs such as head lift, hand grip, and inspiratory force are suitable means of showing residual blockade. However, an awake and cooperative patient is needed. Therefore, in clinical practice it is advantageous to use the responses evoked by a nerve stimulator. ⋯ Relaxometry allows monitoring of neuromuscular function independently of the patient's cooperation, and should be standard. In the intensive care unit, relaxometry helps to minimize the risk of overdosing. However, muscular weakness can persist despite adequate drug dosage. Relaxometry is only part one of a concept. Intubating and operating conditions are highly dependent on the depth of anesthesia, and the risk of postoperative residual blockade can be minimized by using short or medium action drugs.
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The properties of the endothelium differ between the brain and the remainder of the body. In most non-CNS tissues the size of the junctions between endothelial cells averages 65 A. Proteins do not cross these gaps, while sodium does. ⋯ However, the therapeutic approach to polytraumatized patients with small intravascular volume (4-6 ml/kg) of hypertonic solutions should not be a substitute for the usual volemic resuscitation technique. The clinical indication for these solutions should be limited to the initial resuscitation maneuvers in traumatized patients. Prolonged use of hypertonic solutions for the purpose of intravascular resuscitation would only contribute to increasing the side effects and eventually counteract the initial beneficial advantages.
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Swiss medical weekly · Sep 1996
Continuous quality improvement in the ICU and the role of a data management system.
Quality improvement may be defined as the effort to improve the level of performance of key processes in the ICU. Based on knowledge of the current level of performance and on systematic analysis of organizational aspects of the ICU, quality improvement will include the implementation of standards, the formulation and analysis of quality indicators (e.g. scores, rate of complications such as nosocomial infections) and the possible introduction of data management systems.