Critical care : the official journal of the Critical Care Forum
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The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. ⋯ A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED.
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An increasing number of diagnostic imaging procedures requires the use of intravenous radiographic contrast agents, which has led to a parallel increase in the incidence of contrast-induced nephropathy. Risk factors for development of contrast-induced nephropathy include pre-existing renal dysfunction (especially diabetic nephropathy and multiple myeloma-associated nephropathy), dehydration, congestive heart failure and use of concurrent nephrotoxic medication (including aminoglycosides and amphotericin B). Because contrast-induced nephropathy accounts for a significant increase in hospital-acquired renal failure, several strategies to prevent contrast-induced nephropathy are currently advocated, including use of alternative imaging techniques (for which contrast media are not needed), use of (the lowest possible amount of) iso-osmolar or low-osmolar contrast agents (instead of high-osmolar contrast agents), hyperhydration and forced diuresis. ⋯ Since only one (nonrandomized) study has been performed in intensive care unit patients, at present it is difficult to draw firm conclusions about preventive measures for contrast-induced nephropathy in the critically ill. Further studies are needed to determine the true role of these preventive measures in this group of patients who are at risk for contrast-induced nephropathy. Based on the available evidence, we advise administration of N-acetylcysteine, preferentially orally, or theophylline intravenously, next to hydration with bicarbonate solutions.
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Prognostic models, such as the Acute Physiology and Chronic Health Evaluation (APACHE) II or III, the Simplified Acute Physiology Score (SAPS) II, and the Mortality Probability Models (MPM) II were developed to quantify the severity of illness and the likelihood of hospital survival for a general intensive care unit (ICU) population. Little is known about the performance of these models in specific populations, such as patients with cancer. Recently, specific prognostic models have been developed to predict mortality for cancer patients who are admitted to the ICU. The present analysis reviews the performance of general prognostic models and specific models for cancer patients to predict in-hospital mortality after ICU admission. ⋯ General prognostic models generally underestimate the risk of mortality in critically ill cancer patients. Both general prognostic models and specific oncology models may reliably identify subgroups of patients with a very high risk of mortality.
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The definition of risk in surgical patients is a complex and controversial area. Generally risk is poorly understood and depends on past individual and professional perception, and societal norms. ⋯ The usefulness of risk assessment and the definition of risk is however in doubt because there are very few studies that have materially altered patient outcome based on information gained by risk assessment. This paper discusses these issues, highlights areas where more research could usefully be performed, and by defining limits for high surgical risk, suggests a practical approach to the assessment of risk using risk assessment tools.