Critical care: Difference between revisions

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==Preventing complications in the critically ill patient==
==Preventing complications in the critically ill patient==
===Glucose control===
===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>
[[Randomized controlled trial]]s of tight glucose control in the intensive care setting 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>
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>
===Preventing anemia===
===Preventing anemia===
====Blood transfusion====
====Blood transfusion====

Revision as of 10:30, 23 January 2008

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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]

Among outpatients with possible pulmonary embolism, the A-a gradient may be a better test.[5]

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 in the intensive care setting 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."[6]

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."[7]

Preventing anemia

Blood transfusion

There may not be a meaningful difference in outcomes between transfusing blood to maintain a hemoglobin > 7.0 g/dl versus a hemoglobin > 10.0 g/dl.[8]

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."[9]

Selective gastrointestinal decontamination

Systematic reviews conclude that selective decontamination of the digestive tract may reduce morbidity in critically ill patients[10][11][12] although some randomized controlled trials have[13][14][15] and others have not found benefit[16].

Preventing gastrointestinal tract ulceration

Preventing deep venous thrombosis

For more information, see: Deep venous thrombosis.


Preventing healthcare-associated pneumonia

References

  1. ↑ Anonymous. Critical care. National Library of Medicine. Retrieved on 2008-01-07.
  2. ↑ 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. ↑ 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. ↑ 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]
  5. ↑ McFarlane MJ, Imperiale TF (1994). "Use of the alveolar-arterial oxygen gradient in the diagnosis of pulmonary embolism". Am. J. Med. 96 (1): 57–62. PMID 8304364. [e]
  6. ↑ 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]
  7. ↑ 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.
  8. ↑ Hébert PC, Wells G, Blajchman MA, et al (1999). "A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group". N. Engl. J. Med. 340 (6): 409–17. PMID 9971864. [e]
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 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]
  14. ↑ 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]
  15. ↑ 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.
  16. ↑ 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]
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