Articles: critical-care.
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The hypermetabolic state in critically ill patients is characterized by wasting of lean body mass and immunosuppression. The gut is among the most metabolically active organs. Failure to maintain gut function by way of early enteral nutrition can lead to increased infectious complications. Early enteral nutrition improves outcomes and may maintain muscle mass by blunting the cytokine-mediated hypermetabolic response.
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This article discusses the advantages of pulmonary artery catheters, with emphasis on the Swan-Ganz catheter. Various studies and published reports confirming the efficacy of pulmonary artery catheter use are reviewed. In the author's opinion, it is evident that the Swan-Ganz catheter has withstood the test of time and scrutiny.
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The PAC has allowed physicians to obtain information that was unavailable prior to its introduction into clinical medicine. There are numerous pitfalls, however, in obtaining and interpreting this information. ⋯ Can PA catheterization lead to an improved outcome in an individual patient? If the patient is chosen carefully, the catheter inserted successfully and safely, the data obtained meticulously and interpreted correctly, and this interpretation leads to a change in therapy to which the patient responds appropriately, then the patient will experience an improved outcome based on PAC use. Does this happen often enough in the millions of catheterizations that are performed each year to improve the outcome of the group significantly as a whole? Almost certainly not.
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Most general anesthetics, opioids, sedatives and local anesthetics perturb thermoregulatory responses. Accordingly the core temperatures triggering sweating, thermoregulatory vasoconstriction and shivering are varied in perioperative periods. Redistribution hypothermia is a quite common phenomenon during not only general anesthesia but epidural/spinal anesthesia. ⋯ However, obtaining effective decrease of core temperature is sometimes difficult because of thermoregulatory vasoconstriction. Subsequently, vasodilation therapy with appropriate drugs is now under investigation. Hypothermia per se causes critical complications in patients, and the maintenance and warming method to maintain normothermia is important in perioperative period.
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At the intensive care unit of the Clinic for General and Abdominal Surgery and the Clinic for Emergency Medicine in Mainz, various scores (APACHE II score, HIS, TISS, ASA score), laboratory parameters (serum creatinine, white blood count, platelet count, serum lactate, serum elastase, Quick), body temperature, age as well as presence of a malignant underlying or associated disease, were analyzed with regard to their prognostic significance in 169 postoperative admissions. Apart from univariate analysis (Wilcoxon test) and a multivariate analysis (stepwise logistic regression), the value of the scores is demonstrated on the basis of sensitivity, specificity and correctness, as well as the behaviour of the scores at certain decisive points (cut-off point). Of the parameters studied, the APACHE II score, the HISS, the TISS and serum lactate had a significant influence on the outcome of intensive care. ⋯ However, insufficient discrimination between patients who die and patients who survive means that these parameters cannot be used for individual therapeutic decisions in severely ill patients. The decision between the institution or cessation of intensive care is made by the physician or the medical team. Due to the use of prognostic factors, such as scores, decision-making can be objectified and therefore made easier.