Critical care medicine
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Critical care medicine · Jul 2008
Enrollment of intensive care unit patients into clinical studies: a trinational survey of researchers' experiences, beliefs, and practices.
As critical care practice increases in scope, size, and complexity, enrollment of critically ill patients into clinical studies is increasing. ⋯ Clinical research is highly valued by these intensive care unit communities. Strategies to increase capacity involve enhancing recruitment efficiencies, considering alternative study designs and expanding consent procedures. Thoughtfully implementing these strategies may advance the care of critically ill adults and children.
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The purpose of this article is to present an overview of critical care nursing in current battlefield healthcare environments. The various levels of tactical combat casualty care are described with emphasis on those levels in which military critical care nurses are practicing. ⋯ A vast knowledge of various critical care and trauma processes as well as a wide variety of nursing skills are required to provide appropriate care for these casualties. Critical care nursing competencies, cognitive and skill-focused, required to practice in this environment are described.
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Critical care medicine · Jul 2008
Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal.
To assess decisions to forego life-sustaining treatment (LST) in patients too sick for intensive care unit (ICU) admission, comparatively to patients admitted to the ICU. ⋯ All patients deemed too sick for ICU admission had decisions to forego LST. These decisions were made without direct patient examination in two-thirds of refused patients (vs. none of admitted patients) and were associated with less involvement of nurses and relatives compared with decisions in admitted patients. Further work is needed to improve decisions to forego LST made under the distinctive circumstances of triage.
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As life-sustaining and life-preserving surgical capability is moved far forward, it creates the opportunity to salvage casualties who may have otherwise died of their wounds. The remarkable capabilities and effectiveness of the small, austere surgical resuscitation teams (mobile forward surgical team, flying ambulance surgical trauma, forward resuscitative surgery system teams) has been amply demonstrated during the recent conflicts of Operation Iraqi Freedom and Operation Enduring Freedom. ⋯ The scope of this article describes the origins, composition, equipment sets, medical considerations, and future directions of the en route care support process and the U.S. Air Force Critical Care Aeromedical Transport Teams.
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Critical care medicine · Jul 2008
Sustained hypercapnic acidosis during pulmonary infection increases bacterial load and worsens lung injury.
Hypercapnic acidosis is commonly permitted in patients with acute respiratory distress syndrome during the use of protective ventilation strategies. Hypercapnic acidosis is also a common complication of multiple lung diseases and is associated with a poor prognosis, although the mechanisms by which it leads to increased mortality is not known. Previous studies using noninfective models of lung injury show that acute (<6 hrs) hypercapnic acidosis reduced lung damage by an anti-inflammatory effect. We hypothesized that this anti-inflammatory effect would be detrimental in vivo in the presence of untreated bacterial infection and sustained hypercapnia (>48 hrs) and, furthermore, that if bacterial reproduction were controlled by antibiotic therapy, then the anti-inflammatory effects of hypercapnic acidosis would no longer prove detrimental. ⋯ Prolonged hypercapnic acidosis worsened bacterial infection-induced lung injury. Our findings suggest an immunosuppressive effect of hypercapnic acidosis and have important implications for protective ventilation strategies that permit hypercapnic acidosis in patients with adult respiratory distress syndrome and in the management of hypercapnic acidosis during infective exacerbations of chronic obstructive pulmonary disease and other lung diseases.