Current opinion in critical care
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Curr Opin Crit Care · Dec 2001
Impact of critical care physician workforce for intensive care unit physician staffing.
The Society for Critical Care Medicine has advocated for intensivist lead multi-disciplinary critical care for our 30 years; growing evidence supports their assertion. It is estimated that if intensive care unit (ICU) physician staffing (IPS) was implemented in non-rural United States hospitals, 53,000 lives and $5.4 billion would be saved annually. ⋯ In this essay, we discuss issues regarding the future supply of and demand for critical care physicians beginning with an overview of how to evaluate physician supply and demand in general. We then discuss supply and demand for critical care physicians considering emerging issues such as the Leapfrog standard that may impact estimates of the supply and demand for critical care physicians.
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Curr Opin Crit Care · Dec 2001
ReviewPrehospital and resuscitative airway care: should the gold standard be reassessed?
In the context of prehospital care and resuscitation, tracheal intubation has been regarded as the standard in airway treatment. The evidence for this status is rather weak. ⋯ When healthcare providers lack adequate skills in tracheal intubation, alternative airway devices, such as the laryngeal mask airway or the Combitube, may be better options than a simple facemask. Healthcare personnel using any of these devices should be adequately trained and maintain frequent practice.
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Curr Opin Crit Care · Dec 2001
ReviewLow-volume fluid resuscitation for presumed hemorrhagic shock: helpful or harmful?
For the past 4 decades, the standard approach to the trauma victim who is hypotensive from presumed hemorrhage has been to infuse large volumes of fluids as early and as rapidly as possible. The goals of this treatment strategy are rapid restoration of intravascular volume and vital signs towards normal, and maintenance of vital organ perfusion. The most recent laboratory studies and the only clinical trial evaluating the efficacy of these guidelines however, suggest that in the setting of uncontrolled hemorrhage, today's practice of aggressive fluid resuscitation may be harmful, resulting in increased hemorrhage volume and subsequently greater mortality. ⋯ Limited resuscitation provides a mechanism of avoiding the detrimental effects associated with early aggressive resuscitation, while maintaining a level of tissue perfusion that although decreased from the normal physiologic range is adequate for short periods. Large randomized clinical trials are necessary to confirm this new laboratory data. Future research should focus on developing resuscitation methods that may actually enhance tissue perfusion during limited resuscitation and therefore offset its potential detrimental effects.
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Ethical issues have emerged in recent years as a significant component of care in the critically ill patient. Recently, the primary emphasis has been directed to care at the end-of-life. ⋯ This leads to tremendous potential for conflict between the physician and the family, as the patients are often incapable of participating in any discussion regarding end-of-life care. Advance planning on the part of the patient in terms of making their wishes known and education of the health care professionals is essential in promoting effective communication, thereby avoiding conflict in these difficult end-of-life decisions.
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Curr Opin Crit Care · Dec 2001
ReviewPrehospital and resuscitative care of the head-injured patient.
The ultimate neurologic outcome following severe head trauma depends on the extent of primary brain insult sustained at the time of the trauma itself, and the subsequent neurochemical and neurophysiologic pathologic changes occurring as a result of the injury. Although there are currently no specific therapies that have proven to be consistently effective in reversing the devastating consequences of primary brain insult, the reduction or prevention of secondary brain insult is possible. ⋯ As new data are accumulated, traditional and new therapies for severe head injury have come under scrutiny. While no absolute standards have been advanced, guidelines have been established that can help direct the acute stabilization of severely head injured patients.