Critical care : the official journal of the Critical Care Forum
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Several recent meta-analyses have shown that the use of SDD can reduce the occurrence of nosocomial pneumonia among ventilated patients in the intensive care unit (ICU) setting. However, the use of SDD has also been demonstrated to increase subsequent patient colonization and infection with antibiotic-resistant bacteria, particularly Gram-positive cocci. ⋯ This is already an accepted practice in most patients during the perioperative period (eg prophylactic parenteral antibiotics for 24 h). Prolonged decontamination of the aerodigestive tract with topical antimicrobials does not appear to influence outcome, and should not be routinely employed.
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A moribund and debilitated patient arrives in an emergency department and is placed on life support systems. Subsequently it is determined that she has a 'living will' proscribing aggressive measures should her condition be judged 'terminal' by her physicians. ⋯ The patient's surrogates are unable to agree on whether she would desire continuation of mechanical ventilation if there was a real chance of improvement or if she would want to have her living will enforced as soon it's terms were revealed. The problem of the potential ambiguity of a living will is explored.
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Review Comparative Study
The appropriate role of colloids in managing fluid imbalance: a critical review of recent meta-analytic findings.
Three meta-analyses have recently been reported on the relationship between choice of resuscitation fluid and risk of mortality in critically ill patients. The relative risk of death (1.16-1.19) in two of the meta-analyses was slightly higher in colloid than crystalloid recipients; however, this observation was not statistically significant. In the third meta-analysis, 6% (95% confidence interval [CI], 3-9%) pooled excess mortality was documented in patients receiving albumin for hypovolaemia, burns or hypoalbuminaemia. ⋯ The meta-analyses do not support the conclusion that choice of resuscitation fluid is a major determinant of mortality in critically ill patients, nor do they support changes to current fluid management practice. Changes such as exclusive reliance on crystalloids would necessitate a reassessment of the goals and methods of fluid therapy. Since the effect on mortality may be minimal or non-existent, choice of resuscitation fluid should rest on whether the particular fluid permits the intensive care unit to provide better patient care.
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The modern intensive care unit (ICU) has evolved into an area where mortality and morbidity can be reduced by identification of unexpected hemodynamic and ventilatory decompensations before long-term problems result. Because intensive care physicians are caring for an increasingly heterogeneous population of patients, the indications for aggressive monitoring and close titration of care have expanded. Agitated patients are proving difficult to deal with in nonmonitored environments because of the unpredictable consequences of the agitated state on organ systems. The severe agitation state that is associated with ethanol withdrawal and delirium tremens (DT) is examined as a model for evaluating the efficacy of the ICU environment to ensure consistent stabilization of potentially life-threatening agitation and delirium.