Articles: critical-care.
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Randomized Controlled Trial Clinical Trial
Prevention of infection in critically ill patients by selective decontamination of the digestive tract.
To determine whether selective decontamination of the digestive tract using oral and nonabsorbable antimicrobial agents and parenteral cefotaxime prevents infection in critically ill patients. ⋯ Selective decontamination of the digestive tract decreases subsequent infection rates, especially by gram-negative bacilli, in selected patients during long-term stays in the intensive care unit.
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After two decades, hemodynamic invasive monitoring using a flow-directed, balloon-tipped, pulmonary artery (PA) catheter has established itself as a significant component of acute clinical care. In spite of continued recommendations for limitations, restrictions, moratoria, and even abandonment, growth in catheter use continues. Attempts to replace it by competing technologies for routine clinical practice have not been successful thus far. ⋯ After a brief history, this article focuses on the technical aspects of the insertion procedure, choice of hardware, and acquisition and analysis of information. Indications, contraindications, and clinical utility are briefly described. Major complications from PA catheterization reported in the literature since clinical introduction of the catheter are summarized.
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To optimize the success of defibrillation, the clinician needs to minimize impedance, choose the proper energy level, apply the proper interface, select the appropriate paddle size, and deliver the shock at the earliest possible time. Other factors that may contribute to effective defibrillation include defibrillation during exhalation, maintenance of an effective airway, and correction of electrolyte abnormalities. ⋯ Cardioversion can generally be accomplished safely either as an elective or emergent procedure. Selection of the proper indications, protection of the airway, anticoagulation if necessary, correction of digitalis toxicity, and the utilization of adjuvant therapy ensure an optimal outcome.
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Arterial catheterization is used frequently in the management of critically ill patients, both for continuous blood pressure monitoring and access to the arterial circulation to obtain frequent blood gas measurements. The procedure is usually easily accomplished at the bedside using percutaneous methods such as the Seldinger technique to cannulate the radial, brachial, axillary, femoral, or dorsalis pedis artery. Meticulous attention to aseptic technique is necessary during insertion and catheter maintenance to minimize the risk of catheter-related infection. Other potential complications include hemorrhage, ischemia, arteriovenous fistula, and pseudoaneurysm formation.
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Endotracheal intubation can be accomplished by several different methods, which are discussed herein. Special considerations such as the obstructed tube, air leakage around the tube, tube replacement, and drug therapy are also reviewed, as are the indications for tracheostomy, the use of double lumen tubes, and fiberoptic laryngoscopy or bronchoscopy.