Medicine of the Future in America

Category Archives: Intensive Care and Emergency Medicine

Intensive Care and Emergency Medicine: Conclusions

Progress in intensive care medicine has been considerable over the past quarter century, accomplished usually by a succession of small steps rather than by any one dramatic change, and linked to advances in health care across other disciplines. Importantly, we have learned that not everything that improves physiologic measures improves survival; thus, physiologic surrogates need to be tested in large-scale trials whenever feasible. Indeed, prospective randomized clinical trials are ongoing to clarify many of the areas of confusion and debate highlighted in this document, and further studies will be needed to evaluate supportive care modalities as well as new pharmacologic interventions. read

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Intensive Care and Emergency Medicine: Our Failures

To complement and augment these studies, scoring systems (Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, Sequential Organ Failure Assessment, and Therapeutic Intervention Scoring System) have been developed and have provided a level of sophistication and detail not available to any other speciality. In the United Kingdom, an ongoing audit has provided the necessary proof to convince the government into funding more critical care beds by demonstrating the impact of refused/delayed admissions, premature discharges, and nighttime discharges.
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Intensive Care and Emergency Medicine: Critical Care Without walls

Intensive Care and Emergency Medicine: Critical Care Without wallsPioneered in Australia, now widely adopted in the United Kingdom and being introduced elsewhere in the world, is the development of “outreach” services or medical emergency teams to the general wards to both identify and treat at an earlier stage patients who are deteriorating and at risk of becoming critically ill, and to follow up patients discharged from the ICU to ensure that adequate care is being provided in this “step-down” environment. However, a recent study suggests this approach may not affect the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death. cialis professional 20 mg

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Intensive Care and Emergency Medicine: Fluid Administration and Transfusion

The use of blood transfusions has decreased, especially after an important prospective, randomized Canadian study showed that a conservative approach to transfasion may result in lower mortality rates. This may be related to immune effects as the same investigators have shown improved outcomes with leukode-pleted blood (against historical controls). Improved separation and preservation technology now facilitates selective and timely administration of appropriate blood components. Erythropoietin reduces the need for transfusion in long-term patients but has not been associated with changes in outcome.
Albumin administration has been controversial for decades, as it is hard to demonstrate beneficial effects and the costs are high. It had been suggested that albumin administration results in higher mortality rates, but a large study in Australia and New Zealand has demonstrated that albumin and normal saline solution result in equivalent outcomes when used for fluid resuscitation. cialis professional 20 mg

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Intensive Care and Emergency Medicine: Nutrition

The concept 25 years ago was to administer relatively high caloric intake to cope with the catabolic state, and that we could administer this support parenterally just as easily as enterally. Since then, we have learned that gut-associated lymphatic tissue represents a major immune barrier and that enteral feeding promotes its activation, while total parenteral nutrition without enteral feeding induces gut-associated lymphatic tissue atrophy and increased risk of infection. Evidence has shown that overfeeding is not only useless but also potentially deleterious and that the enteral route is superior to the parenteral route; either the former route is actually better (to preserve gut structure and integrity), and/or the latter route is worse (for increasing infectious complications in particular). cialis professional online

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Intensive Care and Emergency Medicine: Polytrauma

Intensive Care and Emergency Medicine: PolytraumaTrauma care has improved considerably over the past 25 years, largely from combined improvements in assessment, triage, resuscitation, and emergency and intensive care. The development of trauma centers has continued to evolve in North America with data supporting their efficacy. However, a study in patients with penetrating torso injuries rapidly transferred to a level 1 trauma center has shown that IV fluid resuscitation should be limited in the absence of significant head trauma, as massive fluid administration early after hemorrhage may increase bleeding by raising in-travascular pressures, disrupting clot formation, and diluting coagulation factors.
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Intensive Care and Emergency Medicine: Cardiopulmonary Resuscitation

The utilization of life-saving medication for AMI such as (3-blockade, angiotensin-converting enzyme inhibitors, anticoagulants, and inhibitors of platelet adhesiveness has not been universal in AMI patients outside the ICU setting; however, in the ICU, their utilization is often precluded by dependence on (3-agonists, hypotension, and coagulopathy. Importantly, a too-liberal administration of antiar-rhythmic agents in such patients may be more harmful than beneficial. New approaches to AMI in critically ill patients have not been developed, but the management of cardiogenic shock secondary to myocardial infarction has improved considerably. Source

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Intensive Care and Emergency Medicine: Cardiovascular Management

Intensive Care and Emergency Medicine: Cardiovascular ManagementThe need for invasive hemodynamic monitoring has been increasingly challenged, and its use has decreased over the last decade. Other less invasive techniques have been developed, but whether this results in improved outcomes in all patients remains to be seen. Increasingly, continuous, noninvasive, and metabolic monitors are becoming available that may supplant more invasive monitoring devices in resuscitation algorithms. Using functional hemodynamic monitoring to define responsiveness in the optimization of blood flow has been shown to improve outcomes in cardiac surgery patients. website

There is still debate regarding superiority of the available vasopressor agents. We have learned that the maintenance of cardiac output or oxygen delivery at predetermined, supranormal levels does not universally result in better outcomes, although so-called “preoptimization” may be beneficial in high-risk surgical patients, especially when it involves the correction of underlying hypovolemia.
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Intensive Care and Emergency Medicine: Sepsis

We see that there is a marked temporal change with early up-regulation of these systems, often followed in prolonged sepsis by a down-regulation that may be equally, if not more, injurious. The degree of perturbation of each of these systems has been shown to correlate with poor outcomes, yet we still do not fully understand the additive or mitigating interactions among them.
Better understanding of the complex network of mediators has led to the development of new strategies based on an immunomodulatory therapeutic approach, to be used in conjunction with the still essential hemodynamic resuscitation and eradication of infection.

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Intensive Care and Emergency Medicine: Infections

Intensive Care and Emergency Medicine: InfectionsDespite improvement in some hygiene measures, nosocomial infections remain an important and widespread problem. In particular, the emergence of multiresistant organisms has even led to the temporary closure of some units. Belatedly, more rapid screening tools and diagnostic techniques based on molecular probes are being developed, which should facilitate early identification of pathogens, resulting perhaps in more effective isolation of patients and earlier institution of targeted antibiotics. Development in imaging techniques has considerably improved identification of the source of infection, and the need for “empirical laparotomies” has almost disappeared. in detail

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