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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That the resources available for intensive care cannot be infinite is self-evident. Parallel increases in medical capability, cost, and community expectations have forced intensivists to confront the reality of resource limitation. Traditional bioethical structures cope poorly with this focus beyond the traditional patient-doctor relationship. ⋯ These techniques involve assessment of the quality of life with the help of several well-validated quantitative approaches. Choosing between competing patients for intensive care beds is often more a theoretical issue than a practical one, because alternative arrangements can almost always be made. Physicians have an ethical and social responsibility to further develop the tools to inform community debate on these issues.
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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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Curr Opin Crit Care · Dec 2001
ReviewTermination of resuscitative efforts: medical futility for the trauma patient.
Despite years of research on the resuscitation of the patient with critical traumatic injuries, controversy remains surrounding the criteria to waive initiation of resuscitation in the pre-hospital setting or to terminate such efforts in the emergency department. The decision to initiate or continue resuscitation on moribund trauma patients is associated with considerable costs. ⋯ This review presents guidelines to help determine when to initiate resuscitation for the critically injured trauma patient and when to cease these efforts in the emergency department. Since there are economic, societal, and ethical implications, each system should establish their own criteria, using these guidelines as a basis.