Critical care medicine
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Critical care medicine · May 2009
ReviewDeveloping a team performance framework for the intensive care unit.
There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework. ⋯ Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.
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Critical care medicine · May 2009
Review Meta Analysis Comparative StudyUse of corticosteroids in acute lung injury and acute respiratory distress syndrome: a systematic review and meta-analysis.
Controversy remains as to whether low-dose corticosteroids can reduce the mortality and morbidity of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) without increasing the risk of adverse reactions. We aimed to evaluate all studies investigating prolonged corticosteroids in low-to-moderate dose in ALI or ARDS. ⋯ The use of low-dose corticosteroids was associated with improved mortality and morbidity outcomes without increased adverse reactions. The consistency of results in both study designs and all outcomes suggests that they are an effective treatment for ALI or ARDS. The mortality benefits in early ARDS should be confirmed by an adequately powered randomized trial.
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Hyperglycemia, be it secondary to diabetes, impaired glucose tolerance, impaired fasting glucose, or stress-induced is common in the critically ill. Hyperglycemia and glucose variability in intensive care unit (ICU) patients has some experts calling for routine administration of intensive insulin therapy to normalize glucose levels in hyperglycemic patients. Others, however, have raised concerns over the optimal glucose level, the accuracy of measurements, the resources required to attain tight glycemic control (TGC), and the impact of TGC across the heterogeneous ICU population in patients with diabetes, previously undiagnosed diabetes or stress-induced hyperglycemia. Increased variability in glucose levels during critical illness and the therapeutic intervention thereof have recently been reported to have a deleterious impact on survival, particularly in nondiabetic hyperglycemic patients. The incidence of hypoglycemia (<40 mg/dL or 2.2 mmol) associated with TGC is reported to be as high as 18.7%, by Van den Berghe in a medical ICU, although application of various approaches and computer-based algorithms may improve this. The impact of hypoglycemia, particularly in patients with septic shock and those with neurologic compromise, warrants further evaluation. This review briefly discusses the epidemiology of hyperglycemia in the acutely ill and glucose metabolism in the critically ill. It comments on present limitations in glucose monitoring, outlines current glucose management approaches in the critically ill, and the transition from the ICU to the intermediate care unit or ward. It closes with comment on future developments in glycemic care of the critically ill. ⋯ Hyperglycemia develops commonly in the critically ill and impacts outcome in patients with diabetes but, even more so, in patients with stress-induced hyperglycemia. Despite calls for TGC by various experts and regulatory agencies, supporting data remain somewhat incomplete and conflicting. A recently completed large international study, Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation, should provide information to further guide best practice. This concise review interprets the current state of adult glycemic management guidelines to provide a template for care as new information becomes available.