Critical care : the official journal of the Critical Care Forum
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Multicenter Study
The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients.
To estimate the mortality and length of stay in the intensive care unit (ICU) attributable to clinically important gastrointestinal bleeding in mechanically ventilated critically ill patients. ⋯ Clinically important upper gastrointestinal bleeding has an important attributable morbidity and mortality, associated with a RR of death of 1-4 and an excess length of ICU stay of approximately 4-8 days.
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Multicenter Study Clinical Trial Controlled Clinical Trial
Practising evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol.
Evidence from recent literature shows that protocol-directed extubation is a useful approach to liberate patients from mechanical ventilation (MV). However, research evidence does not necessarily provide guidance on how to implement changes in individual intensive care units (ICUs). We conducted the present study to determine whether such an evidence-based strategy can be implemented safely and effectively using a multidisciplinary team (MDT) approach. ⋯ An MDT approach to protocol-directed extubation can be implemented safely and effectively in a multidisciplinary ICU. Such an effort is viewed favourably by the entire team and is useful in enhancing team building.
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Randomized Controlled Trial Clinical Trial
Red blood cell transfusion does not increase oxygen consumption in critically ill septic patients.
Red blood cell (RBC) transfusion is commonly used to increase oxygen transport in patients with sepsis. However it does not consistently increase oxygen uptake at either the whole-body level, as calculated by the Fick method, or within individual organs, as assessed by gastric intra-mucosal pH. ⋯ Hemoglobin increase does not improve either global or regional oxygen utilization in anemic septic patients. Furthermore, RBC transfusion may hamper right ventricular ejection by increasing the pulmonary vascular resistance index.
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This commentary on the World Trade Center attack is written from the perspective of a New York City critical care service, with a long history of activity in disaster management, which is located at the Montefiore Medical Center/Albert Einstein College of Medicine. The paper describes some of the local concerns of the service in the first hours, the reality of dispersal of victims throughout the New York City hospital system, and some of the resources made available and their utilization. ⋯ A large capacity is subsequently in place to provide care to critically ill patients resulting from manmade as well as natural disasters. It was the nature of the World Trade Center attack in terms of the ratio of injured survivors to dead victims that did not allow the full capacity and capability of the system to engage.
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Review
The World Trade Center attack. Disaster preparedness: health care is ready, but is the bureaucracy?
When a disaster occurs, it is for governments to provide the leadership, civil defense, security, evacuation, and public welfare. The medical aspects of a disaster account for less than 10% of resource and personnel expenditure. Hospitals and health care provider teams respond to unexpected occurrences such as explosions, earthquakes, floods, fires, war, or the outbreak of an infectious epidemic. ⋯ In other locations, disaster drills become pro forma and have no similarity to real or even projected and predicted disasters. The World Trade Center disaster on 11 September 2001 provides new information, and points out new threats, new information systems, new communication opportunities, and new detection methodologies. It is time for leaders of medicine to re-examine their approaches to disaster preparedness.