Articles: critical-illness.
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Randomized Controlled Trial Clinical Trial
The use of oxygen consumption and delivery as endpoints for resuscitation in critically ill patients.
Oxygen consumption (VO2I) and delivery (DO2I) indices have been stated to be superior to conventional parameters as endpoints for resuscitation. However, another interpretation of published data is that inability to increase VO2I/DO2I given adequate volume resuscitation reflects inadequate physiologic reserve and poor outcome. ⋯ No difference was found in the incidence of OF or death in patients resuscitated based on oxygen transport parameters compared to conventional parameters. These data suggest that given adequate volume resuscitation, oxygen-based parameters are more useful as predictors of outcome than as endpoints for resuscitation.
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Increasing DO2 to supranormal levels, spontaneously or therapeutically, correlates with better survival in the critically ill patient, but not all patients who attain a DO2I greater than 600 mL/min/m2 survive. Conversely, there is often a 50% or greater survival rate in patients who do not reach normal DO2I values. No investigator has been able to show an incremental increase in survival with increasing DO2I; but studies have shown improved survival rates with increasing SVO2. ⋯ SVO2 should be normalized when low, again by increasing DO2. Data continue to support clinical interventions aimed at optimizing DO2. Does increasing DO2 increase the survival rates of critically ill patients? Sometimes.
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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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Comparative Study
Do-not-resuscitate practices in the chronically critically ill.
To determine the frequency of do-not-resuscitate (DNR) orders in the chronically critically ill; to identify the differences in clinical and demographic characteristics of chronically critically ill patients who have DNR orders and those who do not; to identify the differences in the cost of care between patients with and without DNR orders; and to identify the differences in DNR practices between an experimental special care unit and the traditional intensive care unit (ICU). ⋯ There was no difference in the frequency of DNR orders between the special care unit versus the intensive care unit--although patients in the special care unit had a longer interval between hospital admission and initiation of the DNR order. DNR patients differed from non-DNR in that they were older, less likely to be married, and had a higher Acute Physiology and Chronic Health Evaluation II score on admission to the study. The mortality rate in the DNR group was 71% versus 6% in the non-DNR group. There was no difference in total costs. DNR patients were also more likely to have an impaired mental status on admission, and more likely to have deterioration in mental status by the time of discharge than the non-DNR patients.
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To study the feasibility of multicomponent noninvasive monitoring, consisting of a new bioimpedance method for estimating cardiac output together with routine pulse oximetry and transcutaneous oximetry, and to compare physiologic data obtained noninvasively with hemodynamic and oxygen transport data obtained by standard invasive pulmonary artery thermodilution catheter to evaluate circulatory function in high-risk surgical patients. ⋯ The multicomponent noninvasive monitoring provides continuous online, real-time displays of physiologic data that allow immediate recognition of circulatory dysfunction as well as the means to titrate therapy to appropriate predetermined therapeutic goals. The noninvasive systems are easy to apply, safe, inexpensive, reasonably accurate, and cost-effective.