Current opinion in critical care
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Critical illness is a severe and generalized monophasic event, and it is likely that there will be evidence of compromised reserve in all end organs if one looks hard enough for it. The crucial issues are to understand which end organs are the most vulnerable to this insult, in which organ systems the incremental disability is of the most functional consequence, and how to design an effective intervention to ameliorate the dysfunction. ⋯ Studies of survivors of acute respiratory distress syndrome (ARDS) have shown that there are both long-term physical and neuropsychological consequences of severe illness. We need to gain a better understanding of the specific determinants of patients' inability to resume their prior work/lifestyle so that an appropriate multidisciplinary intervention can be designed and tested.
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In recent months, numerous reports concerning total parenteral nutrition in critically ill patients have been published, including the guidelines and recommendations of the American Society for Parenteral and Enteral Nutrition. The old controversy regarding the use of the enteral versus parenteral route still exists. Although the enteral route is indicated in those patients with normal gastrointestinal function, the parenteral route is obviously beneficial in several clinical conditions and appears to be associated with few procedure-related complications when performed by experienced clinicians. There is also continued interest in the supplementation of parenteral formulas with nutrients that were previously considered nonessential, such as arginine, glutamine, and omega-3 fatty acids, but that may become essential in the setting of critical illness.
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Corticosteroids are considered to be essential stress hormones. They are secreted together with adrenocorticotropic hormone (ACTH) in response to the pulsatile secretion of corticotropin-releasing hormone from the paraventricular nucleus of the hypothalamus. Changes in pulse amplitude are responsible for the diurnal rhythm in circulating ACTH and cortisol levels. ⋯ It also potentiates the vasoconstrictor effects of catecholamines. Cortisol helps to stimulate lipolysis, inhibit protein synthesis, facilitate amino acid mobilization from muscle, induce the enzymes of gluconeogenesis, enhance secretion of glucagon, inhibit insulin secretion, and stimulate conversion of lactic acid to glycogen. Because of their anti-inflammatory properties, steroids have been proposed as therapeutic adjuvants in systemic inflammation and may protect the host against overshooting defense reactions by reducing the migration of leukocytes to the inflammatory sites and the incidence of neutrophil-mediated tissue injury and organ dysfunction.
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Critical care providers are under increasing pressure to be attentive to cost concerns. The ICU consumes a significant amount of resources and, as such, is a frequently identified target of efforts to limit escalating healthcare costs. Attempts to reduce costs need not progress in a haphazard fashion. ⋯ ICU physicians, therefore, must become familiar with the basic concepts that underlie cost-effectiveness analysis. Cost-effectiveness analyses that address many different aspects of critical care delivery are now commonly found in the critical care literature. With a framework for evaluating these studies, clinicians can better apply their findings to their own institutions.