Critical care : the official journal of the Critical Care Forum
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Case Reports
Re-examining ethical obligations in the intensive care unit: HIV disclosure to surrogates.
Physicians treating newly incapacitated patients often must help navigate surrogate decision-makers through a difficult course of treatment decisions, while safeguarding the patient's autonomy. We offer guidance for intensive care physicians who must frequently address the difficult questions concerning disclosure of confidential information to surrogates. ⋯ This balanced consideration of the direct duties of physicians to patients, and their indirect duties to surrogates and third-party contacts, may be used as a framework for considering other ethical obligations in the intensive care unit. We also provide a tabulation of individual US state laws relevant to disclosure of HIV status.
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Comparative Study
Causes of metabolic acidosis in canine hemorrhagic shock: role of unmeasured ions.
Metabolic acidosis during hemorrhagic shock is common and conventionally considered to be due to hyperlactatemia. There is increasing awareness, however, that other nonlactate, unmeasured anions contribute to this type of acidosis. ⋯ Large amounts of unmeasured anions were generated after hemorrhage in this highly standardized model of hemorrhagic shock. Capillary electrophoresis suggested that the hitherto unmeasured anions citrate and acetate, but not sulfate, contributed significantly to the changes in strong ion gap associated with induction of shock.
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Do-not-resuscitate (DNR) orders are commonly implemented in the critical care setting as a prelude to end-of-life care. This is often based on presumed prognosis for favorable outcome and interpretation of patient, family, and even physician wishes. While DNR orders explicitly apply only to an individual patient, the hospital culture and milieu in which DNR orders are implemented could potentially have an overall impact on aggressiveness of care across patients. As illustrated by the example of intracerebral hemorrhage, this may unexpectedly influence outcome even in patients without DNR orders in place.
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Assessment of left ventricular diastolic function in the critically ill patient remains a difficult issue in clinical practice. Combined use of routine transmitral and pulmonary venous Doppler patterns in conjunction with tissue Doppler imaging have been claimed to allow bedside diagnosis of diastolic dysfunction. Although in the previous issue of Critical Care it was clearly demonstrated there might be a difference in load dependency of the early myocardial tissue Doppler velocity between lateral and septal placed sample volume, there remain still several unanswered questions, particularly with respect to the preload dependency of these indices.
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Randomized Controlled Trial Multicenter Study Comparative Study
Effect of mode of hydrocortisone administration on glycemic control in patients with septic shock: a prospective randomized trial.
Low-dose hydrocortisone treatment is widely accepted therapy for the treatment of vasopressor-dependent septic shock. The question of whether corticosteroids should be given to septic shock patients by continuous or by bolus infusion is still unanswered. Hydrocortisone induces hyperglycemia and it is possible that continuous hydrocortisone infusion would reduce the fluctuations in blood glucose levels and that tight blood glucose control could be better achieved with this approach. ⋯ Strict normoglycemia is more easily achieved if the hydrocortisone therapy is given to septic shock patients by continuous infusion. This approach also reduces nursing workload needed to maintain tight blood glucose control.