Current opinion in critical care
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Curr Opin Crit Care · Dec 2003
ReviewAcid-base and electrolyte analysis in critically ill patients: are we ready for the new millennium?
Disorders of acid-base and electrolytes are commonly seen in critically ill patients. The presence of these disorders typically signals the development of an underlying pathology. These disturbances can be severe and are often associated with worse outcome. Indeed, metabolic acidosis is one of the ways we quantify organ failure. Although acid-base and electrolyte disorders may be a result of the underlying pathophysiology (eg, renal failure, respiratory failure, shock), they may also result from the way in which we manage critically ill patients. ⋯ By adopting a physical-chemical approach to acid-base analysis we are gaining insight to the complexities of acid-base disorders and how their treatments may affect outcome.
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The subject of research ethics and informed consent in the ICU has recently received unprecedented attention during the past year, the reasons for which are reviewed herein. ⋯ Clinical trials should compare new therapies with "standard" ones if a standard of care exists. Surrogate consent is required for research involving most critically ill subjects, and state laws in the United States and national statutes in Europe should reflect this requirement. Conflicts of interest should be identified at both the individual and the institutional levels. Institutional review boards should focus on ethical issues after conflicts of interest are evaluated. Making the investigator-subject relationship transparent should help protect subjects.
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Curr Opin Crit Care · Dec 2003
Review Comparative StudyDialysis strategies in critically ill acute renal failure patients.
Acute renal failure requiring dialysis is a frequent complication in critically ill patients, with a high morbidity and mortality. Until now, no evidence-based guidelines on the optimal treatment of acute renal failure on the ICU are available. This article reviews recent publications that shed light on several specific topics, like optimal treatment modality, dose of dialysis, type of dialysis membrane, and new developments such as slow extended daily dialysis. ⋯ Adequate dialysis is needed to reduce mortality related to acute renal failure in ICU patients. This necessitates an approach that is completely different from that in chronic renal failure.
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Curr Opin Crit Care · Dec 2003
ReviewOrganized trauma care: does volume matter and do trauma centers save lives?
Trauma is the leading cause of death during the first four decades of life. Since the 1970s, organized systems for trauma care, including a prehospital emergency medical system and a network of hospitals designated as trauma centers, have been developed. The model of the trauma system and its efficacy have been reviewed. ⋯ Concentration of severely injured patients in trauma centers is associated with better outcomes. Population-based investigations provide the strongest evidence regarding effects of the trauma system on patient outcomes, other than survival outcome measures because long-term functional status may be more appropriate.
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As the elderly population expands and adopts increasingly more active lifestyles, trauma and critical care practitioners will be faced with providing care for greater numbers of severely injured patients. However, because of their associated preexisting medical conditions and poor relative physiologic reserve, geriatric patients have higher mortality rates and poorer long-term functional outcomes than their younger counterparts. A thorough understanding of the causes for these disparate outcomes is critical if successful strategies and treatments for this unique patient population are to be developed. ⋯ Ironically, the field of geriatric trauma is still in its infancy. Given the relation between advanced age, associated preexisting medical conditions, and poor physiologic reserve, a poor outcome may be inevitable by the time the geriatric patient presents for medical attention. Greater emphasis should therefore be placed on injury prevention efforts in this patient population. There is a dire need for well-designed prospective studies in geriatric trauma.