Critical care clinics
-
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.
-
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.
-
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.
-
Lactate is the end product of the anaerobic metabolism of glucose, and its accumulation in the blood signals an increase in production or a decrease in utilization, or both. The most common etiology of lactic acidosis is hypoperfusion, which represents an imbalance between systemic oxygen demand and oxygen availability with resultant tissue hypoxia. A wide variety of other etiologies of hyperlactatemia have been identified or implicated. ⋯ Clinical recognition of hyperlactatemia is facilitated by an awareness of the clinical settings in which it is likely to occur. Serum electrolyte and arterial blood gas studies are helpful to recognize lactic acidosis, but direct assay of blood lactate is necessary to identify milder degrees of lactate elevation, to confirm and quantitate the severity of more severe degrees, and to monitor the progress of therapy. Therapy should be directed toward measures to ensure adequate systemic oxygen delivery and specific treatment of the underlying causes.
-
Catecholamines (norepinephrine, epinephrine, and dopamine) are released into circulation in response to stress and injury and as part of the body's attempt at vasoregulation in response to circulatory failure. Norepinephrine is released from sympathetic nerve terminal, and epinephrine and dopamine are released from the adrenal medulla. ⋯ These amines have both beneficial and detrimental effects on survival. Both norepinephrine and dopamine are often employed in the critically ill to selectively increase cardiocerebral and renal blood flow, respectively.