Articles: critical-care.
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Pediatric emergency care · Aug 1993
Management of children with epiglottitis during transport: analysis of a survey.
Because nationally accepted guidelines for the management of children with epiglottitis during transport have not been published, we surveyed physicians attending the 1990 Pediatric Critical Care Transport Leadership Conference in order to delineate current practices and to test for correlations between complications and methods of management. A 22-item questionnaire was distributed, addressing demographics, availability and composition of a designated transport team, methods of airway management, use of medications for sedation or paralysis, monitoring techniques, and complications encountered during transport. Forty-three of the 49 attendees completed the questionnaire (87.8%). ⋯ Regarding interhospital transfers, 49% recommended intubation prior to transport in all cases, whereas 49% considered it on an individual basis. The majority of respondents preferred nasal intubation. To prevent dislocation of the endotracheal tube, 79.1% recommended taping it to the face only (as opposed to around the skull), 70.7% administered paralytic agents, but only 35.2% used additional mechanical restraints.(ABSTRACT TRUNCATED AT 250 WORDS)
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Journal of neurosurgery · Aug 1993
The effect of resuscitative moderate hypothermia following epidural brain compression on cerebral damage in a canine outcome model.
A canine model of temporary epidural cerebral compression and standardized intensive care was developed to evaluate the effect of resuscitative (postinsult) moderate systemic hypothermia. A balloon was inflated over the temporal region to maintain contralateral intraventricular pressure (IVP) at 62 mm Hg for 90 minutes. For a 66-hour period after initiation of brain compression, the intubated dogs received controlled ventilation and standard intensive care. ⋯ The mean necrotic volume was 741 +/- 599 cu mm in the normothermic versus 263 +/- 346 cu mm in the hypothermic group (p = 0.07). Microscopically, the damaged regions consisted of ischemic neurons, reactive glia, edema, vascular endothelial hypertrophy, and erythrocyte extravasation. It is concluded that, in this model, immediate postinsult hypothermia of 31 degrees C (not 35 degrees C) for 5 hours prevents a rise in IVP and significantly decreases cerebral tissue damage, but does not prevent brain herniation during rewarming.
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Emergency departments serve many functions in the current U.S. healthcare system, including initial management of patients with critical illnesses and primary care for a growing proportion of the population. Overcrowding of emergency departments is a growing problem. Delays in admitting patients to inpatient units have been reported as a contributing factor to overcrowding. To date, the effect of the critically ill patients on the emergency department has not been fully described. It was the purpose of this study to examine the incidence of critical illness in the emergency department and its total burden as reflected in emergency department length of stay. ⋯ Critically ill patients constitute an important proportion of emergency department practice and may remain in the emergency department for significant periods of time. Solutions to emergency department overcrowding may include alternatives for continuing management of critically ill patients. Given the realities of emergency department practice, emergency medicine practitioners should receive training in the continuing management of critically ill patients.
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Comparative Study Clinical Trial
Continuous venovenous hemodiafiltration compared with conventional dialysis in critically ill patients with acute renal failure.
The morbidity and mortality benefits of new forms of continuous renal replacement therapy remain controversial. The authors have compared a cohort of consecutive prospectively studied critically ill patients with acute renal failure treated with continuous venovenous hemodiafiltration (CVVHD) (n = 76) to a previously described antecedent group of patients treated in intensive care with intermittent hemodialysis or peritoneal dialysis (conventional dialysis [CD]) (n = 84). Patients were comparable for mean age, gender distribution, and mean number of failing organs (CVVHD: 4; CD: 3.9). ⋯ No statistically significant differences were seen at either extreme of illness severity. Complications were significantly fewer during CVVHD (1 vs. 18). These data support the view that CVVHD reduces morbidity and mortality in critically ill patients with acute renal failure.
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Critical care practitioners are faced with ethical dilemmas every day. The increasing costs of health care coupled with the scarcity of resources, including critical care nurses, have created yet another ethical dilemma--rationing of health care. ⋯ This article identifies some of the ethical issues associated with the rationing of critical care and examines the foundations of ethical thought upon which such decisions can be based. Understanding the overall cost containment movement as well as the potential problems associated with medical gatekeeping will allow critical care practitioners to better deal with the ethical dilemmas of today as well as help them anticipate those that will arise in the near future.