Critical care: Difference between revisions
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===Ventilation=== | ===Ventilation=== | ||
<!-- end tidal carbon dioxide --> | <!-- end tidal carbon dioxide --> | ||
==Treatments provided in the intensive care unit== | |||
===Circulatory support=== | |||
===Respiratory support=== | |||
==Preventing complications in the critically ill patient== | ==Preventing complications in the critically ill patient== | ||
===Glucose control=== | |||
Randomized controlled trials of tight glucose control have produced mixed results. Regarding surgical patients, a trial concluded "intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit."<ref name="pmid11794168">{{cite journal |author=van den Berghe G, Wouters P, Weekers F, ''et al'' |title=Intensive insulin therapy in the critically ill patients |journal=N. Engl. J. Med. |volume=345 |issue=19 |pages=1359–67 |year=2001 |pmid=11794168 |doi=}}</ref> | |||
Regarding medical patients, a trial concluded "intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy."<ref name="pmid16452557">{{cite journal |author=Van den Berghe G, Wilmer A, Hermans G, ''et al'' |title=Intensive insulin therapy in the medical ICU |journal=N. Engl. J. Med. |volume=354 |issue=5 |pages=449–61 |year=2006 |pmid=16452557 |doi=10.1056/NEJMoa052521}}</ref> | |||
===Erythropoietin=== | |||
A [[randomized controlled trial]] reported "epoetin alfa does not reduce the incidence of red-cell transfusion among critically ill patients, but it may reduce mortality in patients with trauma. Treatment with epoetin alfa is associated with an increase in the incidence of thrombotic events."<ref name="pmid17804841">{{cite journal |author=Corwin HL, Gettinger A, Fabian TC, ''et al'' |title=Efficacy and safety of epoetin alfa in critically ill patients |journal=N. Engl. J. Med. |volume=357 |issue=10 |pages=965–76 |year=2007 |pmid=17804841 |doi=10.1056/NEJMoa071533}}</ref> | |||
===Selective gastrointestinal decontamination=== | ===Selective gastrointestinal decontamination=== | ||
[[Systematic review]]s conclude that selective decontamination of the digestive tract may reduce morbidity in critically ill patients<ref name="pmid17387118">{{cite journal |author=Chan EY, Ruest A, Meade MO, Cook DJ |title=Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis |journal=BMJ |volume=334 |issue=7599 |pages=889 |year=2007 |pmid=17387118 |doi=10.1136/bmj.39136.528160.BE}}</ref><ref name="pmid17244516">{{cite journal |author=Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A |title=Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials |journal=J. Hosp. Infect. |volume=65 |issue=3 |pages=187–203 |year=2007 |pmid=17244516 |doi=10.1016/j.jhin.2006.10.014}}</ref><ref name="pmid15895205">{{cite journal |author=Silvestri L, van Saene HK, Milanese M, Gregori D |title=Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomized controlled trials |journal=Intensive Care Med |volume=31 |issue=7 |pages=898–910 |year=2005 |pmid=15895205 |doi=10.1007/s00134-005-2654-9}}</ref> although some [[randomized controlled trial]]s have<ref name="pmid14522530">{{cite journal |author=de Jonge E, Schultz MJ, Spanjaard L, ''et al'' |title=Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial |journal=Lancet |volume=362 |issue=9389 |pages=1011–6 |year=2003 |pmid=14522530 |doi=}}</ref><ref name="pmid1524328">{{cite journal |author=Cockerill FR, Muller SR, Anhalt JP, ''et al'' |title=Prevention of infection in critically ill patients by selective decontamination of the digestive tract |journal=Ann. Intern. Med. |volume=117 |issue=7 |pages=545–53 |year=1992 |pmid=1524328 |doi=}}</ref><ref name="pmid17146635">{{cite journal |author=Stoutenbeek CP, van Saene HK, Little RA, Whitehead A |title=The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial |journal=Intensive Care Med |volume=33 |issue=2 |pages=261–70 |year=2007 |pmid=17146635 |doi=10.1007/s00134-006-0455-4}}</ref> and others have not found benefit<ref name="pmid1734249">{{cite journal |author=Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S |title=A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract |journal=N. Engl. J. Med. |volume=326 |issue=9 |pages=594–9 |year=1992 |pmid=1734249 |doi=}}</ref>. | [[Systematic review]]s conclude that selective decontamination of the digestive tract may reduce morbidity in critically ill patients<ref name="pmid17387118">{{cite journal |author=Chan EY, Ruest A, Meade MO, Cook DJ |title=Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis |journal=BMJ |volume=334 |issue=7599 |pages=889 |year=2007 |pmid=17387118 |doi=10.1136/bmj.39136.528160.BE}}</ref><ref name="pmid17244516">{{cite journal |author=Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A |title=Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials |journal=J. Hosp. Infect. |volume=65 |issue=3 |pages=187–203 |year=2007 |pmid=17244516 |doi=10.1016/j.jhin.2006.10.014}}</ref><ref name="pmid15895205">{{cite journal |author=Silvestri L, van Saene HK, Milanese M, Gregori D |title=Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomized controlled trials |journal=Intensive Care Med |volume=31 |issue=7 |pages=898–910 |year=2005 |pmid=15895205 |doi=10.1007/s00134-005-2654-9}}</ref> although some [[randomized controlled trial]]s have<ref name="pmid14522530">{{cite journal |author=de Jonge E, Schultz MJ, Spanjaard L, ''et al'' |title=Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial |journal=Lancet |volume=362 |issue=9389 |pages=1011–6 |year=2003 |pmid=14522530 |doi=}}</ref><ref name="pmid1524328">{{cite journal |author=Cockerill FR, Muller SR, Anhalt JP, ''et al'' |title=Prevention of infection in critically ill patients by selective decontamination of the digestive tract |journal=Ann. Intern. Med. |volume=117 |issue=7 |pages=545–53 |year=1992 |pmid=1524328 |doi=}}</ref><ref name="pmid17146635">{{cite journal |author=Stoutenbeek CP, van Saene HK, Little RA, Whitehead A |title=The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial |journal=Intensive Care Med |volume=33 |issue=2 |pages=261–70 |year=2007 |pmid=17146635 |doi=10.1007/s00134-006-0455-4}}</ref> and others have not found benefit<ref name="pmid1734249">{{cite journal |author=Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S |title=A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract |journal=N. Engl. J. Med. |volume=326 |issue=9 |pages=594–9 |year=1992 |pmid=1734249 |doi=}}</ref>. | ||
Revision as of 01:50, 10 January 2008
Critical care medicine is the "health care provided to a critically ill patient during a medical emergency or crisis".[1]
Monitoring the critically ill patient
Swan-Ganz catheterization
Oxygenation
- PaO2/FiO2 ratio (PF ratio)
This measure is easier to calculate. Comparative studies suggest it correlates better with pulmonary shunts than does the A-a gradient.[2][3][4]
- Alveolar-arterial oxygen (A-a) gradient (alveolar-arterial oxygen difference - AVO2D)
The A-a gradient is harder to calculate, but accounts for changes in ventilation as measured by the partial pressure of carbon dioxide. However, this calculation relies on the respiratory quotient being constant in the prediction of alveolar CO2 When compared to the PF ratio, the A-a gradient is found to correlate less well with pulmonary shunting.[2][3][4]
Ventilation
Treatments provided in the intensive care unit
Circulatory support
Respiratory support
Preventing complications in the critically ill patient
Glucose control
Randomized controlled trials of tight glucose control have produced mixed results. Regarding surgical patients, a trial concluded "intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit."[5] Regarding medical patients, a trial concluded "intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy."[6]
Erythropoietin
A randomized controlled trial reported "epoetin alfa does not reduce the incidence of red-cell transfusion among critically ill patients, but it may reduce mortality in patients with trauma. Treatment with epoetin alfa is associated with an increase in the incidence of thrombotic events."[7]
Selective gastrointestinal decontamination
Systematic reviews conclude that selective decontamination of the digestive tract may reduce morbidity in critically ill patients[8][9][10] although some randomized controlled trials have[11][12][13] and others have not found benefit[14].
Preventing gastrointestinal tract ulceration
Preventing deep venous thrombosis
Preventing healthcare-associated pneumonia
References
- ↑ Anonymous. Critical care. National Library of Medicine. Retrieved on 2008-01-07.
- ↑ 2.0 2.1 Covelli HD, Nessan VJ, Tuttle WK (1983). "Oxygen derived variables in acute respiratory failure". Crit. Care Med. 11 (8): 646–9. PMID 6409506. [e]
- ↑ 3.0 3.1 El-Khatib MF, Jamaleddine GW (2004). "A new oxygenation index for reflecting intrapulmonary shunting in patients undergoing open-heart surgery". Chest 125 (2): 592–6. PMID 14769743. [e]
- ↑ 4.0 4.1 Cane RD, Shapiro BA, Templin R, Walther K (1988). "Unreliability of oxygen tension-based indices in reflecting intrapulmonary shunting in critically ill patients". Crit. Care Med. 16 (12): 1243–5. PMID 3191742. [e]
- ↑ van den Berghe G, Wouters P, Weekers F, et al (2001). "Intensive insulin therapy in the critically ill patients". N. Engl. J. Med. 345 (19): 1359–67. PMID 11794168. [e]
- ↑ Van den Berghe G, Wilmer A, Hermans G, et al (2006). "Intensive insulin therapy in the medical ICU". N. Engl. J. Med. 354 (5): 449–61. DOI:10.1056/NEJMoa052521. PMID 16452557. Research Blogging.
- ↑ Corwin HL, Gettinger A, Fabian TC, et al (2007). "Efficacy and safety of epoetin alfa in critically ill patients". N. Engl. J. Med. 357 (10): 965–76. DOI:10.1056/NEJMoa071533. PMID 17804841. Research Blogging.
- ↑ Chan EY, Ruest A, Meade MO, Cook DJ (2007). "Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis". BMJ 334 (7599): 889. DOI:10.1136/bmj.39136.528160.BE. PMID 17387118. Research Blogging.
- ↑ Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A (2007). "Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials". J. Hosp. Infect. 65 (3): 187–203. DOI:10.1016/j.jhin.2006.10.014. PMID 17244516. Research Blogging.
- ↑ Silvestri L, van Saene HK, Milanese M, Gregori D (2005). "Impact of selective decontamination of the digestive tract on fungal carriage and infection: systematic review of randomized controlled trials". Intensive Care Med 31 (7): 898–910. DOI:10.1007/s00134-005-2654-9. PMID 15895205. Research Blogging.
- ↑ de Jonge E, Schultz MJ, Spanjaard L, et al (2003). "Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial". Lancet 362 (9389): 1011–6. PMID 14522530. [e]
- ↑ Cockerill FR, Muller SR, Anhalt JP, et al (1992). "Prevention of infection in critically ill patients by selective decontamination of the digestive tract". Ann. Intern. Med. 117 (7): 545–53. PMID 1524328. [e]
- ↑ Stoutenbeek CP, van Saene HK, Little RA, Whitehead A (2007). "The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial". Intensive Care Med 33 (2): 261–70. DOI:10.1007/s00134-006-0455-4. PMID 17146635. Research Blogging.
- ↑ Gastinne H, Wolff M, Delatour F, Faurisson F, Chevret S (1992). "A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract". N. Engl. J. Med. 326 (9): 594–9. PMID 1734249. [e]