Critical care clinics
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Critical care clinics · Apr 1988
ReviewThe febrile granulocytopenic patient in the intensive care unit.
Patients treated aggressively for potentially curable hematologic and neoplastic diseases are often admitted with profound granulocytopenia to an intensive care unit. These patients have a high risk of sustaining life-threatening infections caused by various bacterial, fungal, viral, and protozoal pathogens. Successful management of these critically ill, profoundly granulocytopenic patients by the intensive care team requires an organized, informed, and rational approach to treating their infections.
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Septic shock may occur in otherwise normal individuals but is frequently a fatal sequel to infection in the elderly, the diabetic, or the debilitated patient. Mortality rates range from 40 to 95 per cent depending both on host factors and on the speed of initiation of appropriate therapy. ⋯ Survival is primarily dependent on the rapid delivery of the appropriate antibiotics, surgical drainage and debridement of any infected tissues or abscesses, and aggressive volume resuscitation at the very time early sepsis is diagnosed. Septic shock is a medical emergency.
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Critically ill cancer patients may present special problems. Often these patients are terminally ill and mortality in a critical care unit devoted to cancer patients is higher than in other units. Sedation becomes paramount in the treatment of these patients. ⋯ Nerve blocks, primarily intercostal for chest trauma, were used in the past, but the requirement for frequent reinjection has made them less desirable. Recently thoracic paravertebral block has been used successfully for 9 to 10 hour pain relief with chest trauma. With this armamentarium of techniques and drugs, the critical care physicians should be able to go a long way to relieve pain and suffering of patients in the ICU.
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The allocation of critical care resources must follow criteria of distributive justice. Because most societies cannot indefinitely expand medical care costs, difficult decisions on the quality and quantity of care that can be rendered to each patient are inevitable. ⋯ It is reasonable to anticipate that over the next few years regulations will be formulated to decide which patients can be admitted to the ICU. Critical care physicians have the right and obligation to be involved in all aspects of these decision-making processes.
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Cancer patients are at risk for profound derangements in the hemostatic mechanism due to multiple factors. Depending upon the dominant abnormality, bleeding, thrombosis or both, in conjunction with disseminated intravascular coagulation, may occur. Critical care physicians should have a high index of suspicion for underlying hemostatitic defects when a cancer patient presents with hemorrhage. ⋯ Thrombosis in malignancy is a frequent occurrence and increasing in incidence due in part to the widespread use of indwelling venous catheters. Fibrinolytic therapy is effective and probably under-utilized in treating thrombosis but must be approached with care in these patients. A thorough understanding of diagnostic techniques, indications, and potential complications of anticoagulant therapy in cancer patients is essential.