Articles: critical-illness.
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Elderly people in the United States often receive treatment through an enormous array of medical technology when they become critically ill. Some, or all, such interventions may be unwanted, and patients have the right to be informed about what prospects lie ahead. CPR, with survival rates of 2% to 20%, rarely has the effect for which it was intended, as studies over the last two decades have repeatedly demonstrated. ⋯ This is unfortunate, because both surrogates and physicians are poor judges of patients' resuscitation preferences. Advance directives, especially when coupled with effective physician-patient communication, will aid elderly persons in making decisions about life support. We encourage all physicians who care for the elderly to avert many of tomorrow's ethical dilemmas by communicating with their healthy patients today.
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Critical care medicine · Feb 1994
Variability of cardiac output over time in medical intensive care unit patients.
To determine the amount of spontaneous variability of cardiac output over time in critically ill patients, and to determine the effect of mechanical ventilation on cardiac output variability over time. ⋯ The spontaneous variability of cardiac output should be considered when interpreting two cardiac output determinations made at separate times. Due to spontaneous variability alone, a patient with a baseline cardiac output of 10.0 L/min would be expected (95% confidence interval) to have a cardiac output range of 9.2 to 10.8 L/min if covariables were stable, and a range of at least 8.8 to 11.2 L/min if covariables were unstable. Patients who were mechanically ventilated displayed less variability than patients who were breathing spontaneously.
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To evaluate the incidence and cause of parenteral nutrition-induced lipogenesis. ⋯ Net fat synthesis was found in a surprisingly large number of critically ill patients receiving central venous nutrition. Many of these patients received carbohydrate calories in excess of their measured energy expenditure, even though it appeared that they needed this level of caloric intake by clinical assessment. The high carbohydrate total parenteral nutrition (TPN) solutions with lipids provided only for prevention of essential fatty acid depletion resulted in an unacceptably high incidence of fat synthesis. The results suggest that caloric intake may be optimized in critically ill patients using indirect calorimetry. When calorimetry is not available, a total caloric intake of up to 140 percent of the BEE with glucose infusion rates not exceeding 4 mg/kg-min and fats providing 40 to 60 percent of calories will meet the energy requirements of most critically ill patients without forcing the RQ > 1.
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Clin Intensive Care · Jan 1994
Comparative StudyQuality of life at three months following admission to intensive and coronary care units.
Measurement of quality of life three months following critical illness, to assess impact on health expectations. ⋯ ICU patient quality of life three months after admission compares favourably with a corresponding group of CCU patients, particularly in areas of sleep and social isolation. CCU patients' general functional status deteriorated significantly compared to their pre-admission status. Critical illness is a costly area of medicine, but the results suggest that outcomes are beneficial in terms of quality of life for those surviving acute illness.
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To examine the relationship of expired capnograms and respiratory system resistance (Rrs) in intubated critically ill patients, we consecutively studied 41 mechanically ventilated patients to (1) analyze the association between expired CO2 slope and auto-positive end-expiratory pressure (auto-PEEP), between Rrs and auto-PEEP, between Rrs and expired CO2 slope, and between Rrs and arterial minus end-tidal PCO2 gradient (PaCO2-PETCO2 gradient) and (2) to investigate the capacity of the expired CO2 slope and PaCO2-PETCO2 gradient to predict Rrs during mechanical ventilation. Regression analysis found a close correlation between Rrs and expired CO2 slope (r = 0.86; p < 0.001), between Rrs and auto-PEEP (r = 0.75; p < 0.001), and between auto-PEEP and expired CO2 slope (r = 0.74; p < 0.001). ⋯ These observations suggest that CO2 elimination in critically ill patients is strongly modulated by lung, airway, endotracheal tube, and ventilator equipment resistances. Although continuous capnogram waveform monitoring at the bedside might be useful to assess Rrs, very accurate predictions could be done only in determinate patients.