Current opinion in critical care
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Curr Opin Crit Care · Aug 2009
ReviewPatient-related risk factors for postoperative adverse events.
The risk of adverse outcome in patients undergoing major surgery is affected both by cardiorespiratory fitness, and the presence and severity of comorbidities. Accurate risk stratification is essential for the identification of patients who may benefit from specific perioperative management strategies or from an augmented level of perioperative care. Risk stratification techniques include risk prediction models, assessment of functional capacity and novel biochemical markers. This review examines the evidence for the use of these different techniques in perioperative patients. ⋯ The development of improved risk stratification techniques would be assisted by large-scale epidemiological studies. Improvements to currently used risk prediction models are likely to result from the use of variables which more objectively measure patient health and fitness than current tools, and may use a combination of all the above techniques to improve predictive accuracy.
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To discuss the recent literature concerning the significance of respiratory complications as a determining factor in postoperative complications after major surgery. Although many studies have identified risk factors focusing on the prevention of respiratory complications, these complications continue to be a significant cause of morbidity and mortality. Here, we will examine the diagnosis, contributing factors, consequences, and early treatment of respiratory complications. ⋯ Postoperative respiratory complications may have significant deleterious consequences. Increasing the understanding of the underlying causes of respiratory complications and developing early treatment strategies will likely provide improved benefits. To date, early treatment with prophylactic or therapeutic continuous positive airway pressure has proved beneficial in an abdominal surgical patient population; however, the efficacy in a general population remains unclear.
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Perioperative cardiac complications remain a major area of concern as our surgical population increases in volume, age and frequency of comorbidity. A variety of strategies can be used to optimize patients and potentially reduce the incidence of these serious complications. ⋯ The complexity of a particular patient's physiologic responses to a wide variety of surgical procedures, which are undergoing constant technological refinement generally associated with lesser degrees of invasivity and stress make calculation of patients' perioperative risk very challenging. At the present time, adequate information is available for the clinician to screen patients with high-risk preoperative predictors, delay elective surgery for patients with recent intracoronary stents and continue chronic beta-blockade in appropriate patients. New large-scale database and subanalyses of major trials (e.g. Perioperative Ischemic Evaluation and Coronary Artery Revascularization Prophylaxis) should provide additional information to minimize perioperative cardiac risk.
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To emphasize the evolving body of evidence that supports the need for a more seamless and interconnected continuum of patient care for a growing compendium of critical care conditions, starting in the prehospital and emergency department (ED) phases of management and continuing through ICU and rehabilitation services. ⋯ This article discusses the basis and rationale for the 'critical care cascade' concept, which contends that the optimal management of critically ill patients should be a continuum of care through the healthcare system. In the critical care cascade, each patient is enrolled on a 'pathway' of management based on their working diagnosis and each and every healthcare provider engaged along that continuum acts as part of a interconnected coordinated team that ensures a specific endpoint for these patients in a bundled manner that seamlessly extends from the prehospital and ED phases to the ICU and rehabilitation services.
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Curr Opin Crit Care · Aug 2009
ReviewLinking the chain of survival: trauma as a traditional role model for multisystem trauma and brain injury.
Trauma systems are central in the care of trauma patients and the concept of 'Critical Care Cascade' matches the concept of the 'Trauma Systems'. Both concepts aim to offer a model of continuum care from prehospital assistance to ICU discharge that can have a significant impact on outcome. In spite of the trauma system concept maturity, many controversies still remain unresolved. This text will review some of the relevant literature related to prehospital and early hospital care of trauma patients. ⋯ Although there is a lack of definitive evidence to support many of the current recommendations for the acute care of trauma patients, the historical development of trauma systems, their long experience and even the existing controversies, can help to establish other critical pathways and can guide performance evaluations so necessary to improve outcomes.