Critical care medicine
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Critical care medicine · Nov 2006
ReviewWhen is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature.
Receiving care in an intensive care unit can greatly influence patients' survival and quality of life. Such treatments can, however, be extremely resource intensive. Therefore, it is increasingly important to understand the costs and consequences associated with interventions aimed at reducing mortality and morbidity of critically ill patients. Cost-effectiveness analyses (CEAs) have become increasingly common to aid decisions about the allocation of scarce healthcare resources. ⋯ Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money. However, overall there is a paucity of CEA literature on the management of the critically ill, and further high-quality CEA is needed. In particular, research should focus on costly interventions such as 24-hr intensivist availability, early goal-directed therapy, and renal replacement therapy. Recent guidelines for the conduct of CEAs in critical care may increase the number and improve the quality of future CEAs.
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Patients in the intensive care unit develop generalized weakness due to a number of factors. Neuromuscular weakness is a common cause of failure to wean from the ventilator and decreased limb movements. A rational approach to evaluation of weakness will help to identify most of the common causes of neuromuscular weakness in the intensive care unit. ⋯ The most common acquired causes of weakness in the critically ill patient in the intensive care unit are critical illness polyneuropathy and critical illness myopathy. In the intensive care unit setting, electrophysiological studies, biopsies, and imaging studies are often necessary to complement the clinical impression.
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Critical care medicine · Nov 2006
ReviewEnd-of-life care in the intensive care unit: state of the art in 2006.
Evidence suggests that change is occurring in end-of-life care in the intensive care unit (ICU). There is a growing need and appreciation for the importance of education for the multidisciplinary team, but particularly for physicians, in gaining communication skills to improve the quality of end-of-life care and provide palliative care in the ICU. ⋯ Interventions have been tested in numerous ICUs that others can evaluate for application to their own facility in an attempt to create a global standard for end-of-life care in the ICU. Quality indicators have been defined, and an audit tool can help assess levels of performance.
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Critical care medicine · Nov 2006
Comparative StudyEffects of levosimendan versus dobutamine on pressure load-induced right ventricular failure.
A transient increase in pulmonary arterial (PA) pressure can persistently depress right ventricular (RV) contractility. We investigated the effects of dobutamine and levosimendan on RV-PA coupling in this model of RV failure. ⋯ A transient increase in PA pressure persistently worsens PA hemodynamics, RV contractility, RV-PA coupling, and cardiac output. Levosimendan restores RV-PA coupling better than dobutamine because of similar inotropic effects and additional pulmonary vasodilatory effects.
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Critical care medicine · Nov 2006
Integrating palliative and critical care: description of an intervention.
A large proportion of deaths in the United States occur in the intensive care unit (ICU) or after a stay in the ICU, and there is evidence of problems in the quality of care these patients and their families receive. In an effort to respond to this problem, we developed a multifaceted, nurse-focused, quality improvement intervention that is based on self-efficacy theory applied to changing clinician behavior. ⋯ The goal of this report is to describe the conceptual model that led to the development of the intervention, and for each of the five components, we describe the theoretical and empirical support for each component, the content of the component, and the lessons we have learned in implementing the component. Future reports will need to examine the ability of the interventions to improve outcomes of palliative care in the ICU.