Critical care medicine
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During the last several years, many governmental and nongovernmental organizations have championed the application of the principles of quality improvement to the practice of medicine, particularly in the area of critical care. ⋯ The quality revolution is having a significant effect in the critical care unit and is likely to be facilitated by the transition to the electronic medical record.
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Critical care medicine · Feb 2007
Randomized Controlled TrialN-acetylcysteine for patients with prolonged hypotension as prophylaxis for acute renal failure (NEPHRON).
Acute renal failure is a common complication in critically ill patients and carries an increased morbidity and mortality. N-acetylcysteine is an antioxidant and anti-inflammatory agent that may counteract some of the pathophysiologic derangements in shock states. ⋯ There were no significant differences in any of our primary or secondary end points between patients treated with N-acetylcysteine or placebo. Trends toward reduced incidence of acute renal failure in patients with baseline SOFA score >8, reduced SOFA scores during the first 4 days, and reduced mortality in patients<65 yrs of age are provocative but require further study to determine their clinical significance.
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Critical care medicine · Feb 2007
Meta AnalysisTopical chlorhexidine for prevention of ventilator-associated pneumonia: a meta-analysis.
To assess the efficacy of topical chlorhexidine for prevention of ventilator-associated pneumonia (VAP) in a meta-analysis. ⋯ Our analysis showed that topical chlorhexidine is beneficial in preventing VAP; the benefit is most marked in cardiac surgery patients. A large randomized trial is needed to determine the impact of topical chlorhexidine on mortality.
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Critical care medicine · Feb 2007
Multicenter StudyPrognostication during physician-family discussions about limiting life support in intensive care units.
Prognostic information is important to the family members of incapacitated, critically ill patients, yet little is known about what prognostic information physicians provide. Our objectives were to determine the types of prognostic information provided to families of critically ill patients when making major end-of-life treatment decisions and to identify factors associated with more physician prognostication. ⋯ Prognostication occurred frequently during physician-family deliberations about whether to forego life support, but physicians did not discuss the patient's prognosis for survival in more than one third of conferences. Less educated families received less information about prognosis. Future studies should address whether these observations partially explain the high prevalence of family misunderstandings about prognosis in intensive care units.
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Critical care medicine · Feb 2007
ReviewLegal issues in the practice of critical care medicine: a practical approach.
The intensive care unit is characterized by severely ill patients who frequently succumb to their disease, despite complex modern therapies and the best efforts of dedicated care teams. Although critical care is not historically characterized as a high-risk medical specialty with respect to litigation, the urgency, complexity, and invasive nature of intensive care unit care clearly increases legal risk exposure. Physicians do not practice in a vacuum. ⋯ Therefore, at a time when the practice of medicine itself is becoming increasingly more complex, physicians and other healthcare providers also face increasing administrative and legal challenges. Therefore, it is imperative that physicians develop an understanding of basic substantive and procedural law; first, so that their practices can be more focused and rewarding and less a fear of the unknown; second, that we can work proactively to minimize our legal risk; third, so that we can better communicate with risk managers, attorneys, and insurers; and finally, so that we can better understand and participate in future legal, legislative, regulatory, and public policy development. Accordingly, this general overview briefly addresses the substantive law of medical malpractice, informed consent, the law relating to research in critical care, Emergency Medical Treatment and Active Labor Act, the False Claims Act, peer review, state board disciplinary issues, and the Health Insurance Portability and Accountability Act; in addition, relevant procedural considerations will be briefly summarized.