Critical care medicine
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Until recently, the intensive care unit has largely escaped the withering criticism of those bent on measuring and improving the quality of care. The evidence base for practice in the intensive care unit is growing, as is the pressure to measure and improve this practice. ⋯ Therefore, as a routinely provided medical therapy, palliative care is certainly an appropriate target for quality improvement activities in critical care. This article considers, from the point of view of a clinical intensivist, the similarities and differences between improving palliative care in the intensive care unit and implementing other practice change to improve the quality of critical care.
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Critical care medicine · Nov 2006
Merging cultures: palliative care specialists in the medical intensive care unit.
We summarize the key interventions and general findings from a 3-yr project titled, "Merging Palliative and Critical Care Cultures in the Medical Intensive Care Unit." This multifaceted demonstration project was designed so palliative care and intensive care clinicians would share their expertise and develop projects that promote end-of-life care in a medical intensive care unit (ICU) setting. A variety of interventions are described, including collaborating with ICU leaders, training nurses as "palliative care champions," opening visiting hours, educating house officers and other staff about relevant palliative practices, establishing the presence of a palliative care specialist during work rounds, teaching about and promoting family meetings, introducing a "Get to Know Me" poster, staff support efforts, and modeling of interdisciplinary teamwork. Additional problems were noted but not well addressed, particularly routine communication with families and continuity of care for complex patients leaving the ICU.
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Deaths occur frequently in the intensive care unit, yet clinicians in this unique practice environment are often untrained in the care of patients who are dying. Palliative care consultation in the intensive care unit may bridge the gaps between what should be done for dying patients and their families and what is often the default, that is, a prolonged death with inadequate symptom management and not enough family support. ⋯ Palliative care consultants who seek referrals from the intensive care unit will be successful if strategies such as getting acquainted, learning about the environment and patterns of care, seeking feedback, and respecting the intensive care unit's life-saving efforts are employed. Intensive care staff satisfaction with palliative care consultation will drive future referrals.
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Critical care medicine · Nov 2006
Comparative StudyNeuronal damage in rat brain and spinal cord after cardiac arrest and massive hemorrhagic shock.
Severe global ischemia often results in severe damage to the central nervous system of survivors. Hind-limb paralysis is a common deficit caused by global ischemia. Until recently, most studies of global ischemia of the central nervous system have examined either the brain or spinal cord, but not both. Spinal cord damage specifically after global ischemia has not been studied in detail. Because the exact nature of the neuronal damage to the spinal cord and the differences in neuronal damage between the brain and spinal cord after global ischemia are poorly understood, we developed a new global ischemia model in the rat and specifically studied spinal cord damage after global ischemia. Further, we compared the different forms of neuronal damage between the brain and spinal cord after global ischemia. ⋯ The combination in the global ischemia model (i.e., hemorrhagic shock followed by cardiac arrest) caused severe neuronal damage in the central nervous system. Thereby, hind-limb paralysis after global ischemia might result from spinal cord damage. These results suggest that therapeutic strategies for preventing spinal cord injury are necessary when treating patients with severe global ischemia.
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Critical care medicine · Nov 2006
Evaluation of short-term consequences of hypoglycemia in an intensive care unit.
Introduction of strict glycemic control has increased the risk for hypoglycemia in the intensive care unit. Little is known about the consequences of hypoglycemia in this setting. We examined short-term consequences (seizures, coma, and death) of hypoglycemia in the intensive care unit. ⋯ In this study, no association between incidental hypoglycemia and mortality was found. However, this data set is too small to definitely exclude the possibility that hypoglycemia is associated with intensive care unit mortality. In three patients with possible hypoglycemia-associated coma or seizures, a causal role for hypoglycemia seemed likely but could not fully be established.