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An intensive communication intervention for the critically ill

AMERICAN JOURNAL OF MEDICINE 2000年第6期109卷 469-475页

作者： Lilly, CM De Meo, DL Sonna, LA Haley, KJ Massaro, AF Wallace, RF Cody, S Brigham & Womens Hosp Div Resp Dept Med Combined Program Pulm & Crit Care Med Boston MA 02115 USA Harvard Univ Sch Med Boston MA USA USA Environm Med Res Inst Natick MA 01760 USA

PURPOSE: We sought to determine the effects of a communication process that was designed to encourage the use of advanced supportive technology when it is of benefit, but to limit its burdens when it is ineffective. We compared usual care with a proactive, multidisciplinary method of communicating that prospectively identified for patients and families the criteria that would determine whether a care plan was effective at meeting the goals of the patient. This process allowed caregivers to be informed of patient preferences about continued advanced supportive technology when its continuation would result in a compromised functional outcome or death. MATERIALS AND METHODS: We performed a before-and-after study in 530 adult medical patients who were consecutively admitted to a university tertiary care hospital for intensive care. Multidisciplinary meetings were held within 72 hours of critical care admission. Patients, families, and the critical care team discussed the care plan and the patients' goals and expectations for the outcome of critical care. Clinical "milestones" indicative of recovery were identified with time frames for their occurrence. Follow-up meetings were held to discuss palliative care options when continued advanced supportive technology was not achieving the patient's goals. We measured length of stay, mortality, and provider team and family consensus in 134 patients before the intensive communication intervention and in 396 patients after the intervention. RESULTS: Intensive communication significantly reduced the median length of stay from 4 days (interquartile range, 2 to 11 days) to 3 days (2 to 6 days, P = 0.01 by survival analysis). This reduction remained significant after adjustment for acute physiology and chronic health evaluation (APACHE) 3 score [risk ratio (RR) = 0.81;95% confidence interval (CI), 0.66 to 0.99;P = 0.04). Subgroup analysis revealed that this reduction occurred in our target group, patients with acuity scores in the hi

关键词：急性病生理学和长期健康评价波士顿/流行病学病例管理信息交流卫生服务研究医院死亡率重症监护/方法重症监护/标准重症监护病房/统计学和数值数据住院时间 Logistic模型马萨诸塞/流行病学比值比姑息疗法病人医疗护理计划病人医疗小组医师诊疗模式/标准医师诊疗模式/统计学和数值数据比例危险度模型前瞻性研究疾病严重程度指数存活率分析工艺学医学老年人女(雌)性人类男(雄)性中年人

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Surgical airway management in the intensive care unit

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CRITICAL CARE CLINICS 2000年第3期16卷 473-+页

作者： Pryor, JP Reilly, PM Shapiro, MB Univ Penn Sch Med Div Trauma & Surg Crit Care Philadelphia PA 19104 USA

Tracheostomy is one of the most common surgical procedures performed on critically ill and injured patients in the United States today. Despite decades of experience among surgeons, there is still controversy over specific indications, techniques, and timing of performing the surgical airway New techniques, such as percutaneous dilatational tracheostomy and minitracheostomy, have challenged critical care physicians to tailor operative airway methods to each individual patient. Older procedures, such as cricrothyroidotomy, have found a new niche in the intensive care unit. These new techniques, along with new ways to perform traditional tracheostomies, have made the practice of operative airway management dynamic and controversial.

关键词：气道阻塞/外科学危重病重症监护/方法重症监护/统计学和数值数据重症监护/发展趋势病人遴选床旁诊断化验信息系统时间因素气管造口术/仪器和设备气管造口术/方法人类

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Cerebral protection in severe brain injury: physiological determinants of outcome and their optimisation

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BRITISH MEDICAL BULLETIN 1999年第1期55卷 226-258页

作者： Menon, DK Univ Cambridge Addenbrookes Hosp Dept Anaesthesia Sch Clin Cambridge CB2 2QQ England

The primary role of intensive care in acute head injury lies in the prevention, detection and reversal of secondary neuronal injury. The maintenance of optimal systemic and cerebrovascular physiology can substantially contribute to these aims. There is, however, a role for novel neuroprotective interventions, many of which are currently under investigation.

关键词：脑损伤/病理生理学脑损伤/治疗内环境稳定重症监护/方法监测生理学/方法神经保护药/治疗应用预后危险因素人类

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Intensive care medicine tomorrow

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ANASTHESIOLOGIE INTENSIVMEDIZIN NOTFALLMEDIZIN SCHMERZTHERAPIE 2003年第4期38卷 273-276页

作者： Marx, G Leuwer, M Univ Liverpool Univ Dept Anaesthesia Liverpool L69 3GA Merseyside England

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Prone positioning for acute respiratory distress syndrome in the surgical intensive care unit: Who, when, and how long?

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SURGERY 2000年第4期128卷 708-714页

作者： Johannigman, JA Davis, K Miller, SL Campbell, RS Luchette, FA Frame, SB Branson, RD Univ Cincinnati Dept Surg Cincinnati OH 45267 USA Univ Cincinnati Dept Anesthesia Cincinnati OH 45267 USA

Background. We evaluated the effects of prone positioning (PP) on surgery and trauma patients with acute respiratory distress syndrome (ARDS). Methods. Patients with ARDS were studied. Exclusion criteria were contraindications to PP. Patients were evaluated in the supine position and after being turned to the PP. After 6 hours, patients were returned to the supine position for 3 hours. One hour after each position change, arterial and mixed venous blood was drawn and analyzed for blood gases and pH, and hemodynamics were measured. Results. Over 20 months, 27 patients met the criteria, and 20 of the patients were entered into the study. On day 1, 18 of 20 patients (90 %) responded with an increase in PaO2 during PP. On day 2, 16 of 17 patients (94 %) responded;on clay 3, 15 of 16 patients responded (94 %);on day 4, 11 of 13 patients responded (85 %);on day 5, 8 of 8 patients responded (100 %);and on day 6, 4 of 5 patients responded (80 %). PaPO2/FIO2 and Qs/Qt were significantly improved (P <. 05) during PP. There were 91 periods of PP, lasting 10.3 +/- 1.2 hours. Of 91 changes to PP, 78 changes (86%) resulted in an improvement in PaO2/FIO2 of more than 20%. Conclusions. PP improves oxygenation in ARDS for 6 days with few complications.

关键词：血气分析重症监护/方法肺顺应性氧/血液正压呼吸手术后医护/方法俯卧位/生理学前瞻性研究肺换气呼吸窘迫综合征成人/治疗治疗结果成年人老年人女(雌)性人类男(雄)性中年人

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Sedation and analgesia

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BRITISH MEDICAL BULLETIN 1999年第1期55卷 76-95页

作者： Lerch, C Park, GR Addenbrookes Hosp John Farman Intens Care Unit Cambridge CB2 2QQ England

Sedation is a process of soothing(1). The concept of the ideal level of sedation is controversial and has changed over the last decade. A shift from deep sedation, often enhanced by muscle relaxants that completely detaches the patient from their environment, to light sedation rendering the patient sleepy but easily arousable has been widely accepted(2,3) This change in attitude has been brought about by sophisticated modes of ventilation allowing the ventilator to synchronise with the patient's own breathing pattern. In addition, the increasingly recognised adverse effects of over-sedation have contributed to the reduction in the depth of sedation(4,5).

关键词：镇痛/方法清醒镇静/方法危重病催眠药和镇静药重症监护/方法人类

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The acute myocardial infarction

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PRIMARY CARE 2000年第3期27卷 631-+页

作者： Pollard, TJ Cent Maine Med Ctr Family Practice Residency Lewiston ME 04240 USA

Cardiovascular death is the number one cause of death in the United States, with a rate that is more than double that for cancer. Over half of these cardiovascular deaths are due to acute myocardial infarction. Management of the patient with acute myocardial infarction during and after hospitalization is discussed with an emphasis on primary and secondary prevention, patient autonomy and decision making. There is also a review of the directions that treatment of acute myocardial infarction will take in the future.

关键词：心血管药物/治疗应用重症监护/方法心肌梗死/并发症心肌梗死/诊断心肌梗死/康复心肌梗死/治疗心肌血管重建术门诊部医院老年人女(雌)性人类男(雄)性

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Active prophylactic management of respiratory obstruction after standard thyroidectomy for giant goitre in the middle belt region of Nigeria

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TROPICAL DOCTOR 1999年第2期29卷 75-78页

作者： Obekpa, PO Onuminya, JE Punnoose, VA Univ Jos Dept Surg Fac Med Sci Jos Nigeria

Respiratory obstruction is a lethal complication of thyroidectomy for giant goitre. Prophylactic tracheal splintage by retaining the endotracheal tube in situ for 24 h post-operatively and its meticulous management in the intensive care unit (ICU) is a safe and rewarding practice. Over a 7-year period, 33 patients, all women who had standard thyroidectomy for giant goitre were managed accordingly. There was no incidence of post-operative respiratory distress, nor mortality in the series. The average duration of stay in ICU was 2 days for all patients and the average hospital stay was 6 days for 27 of the 33 patients (81.8%). We suggest that judicious post-thyroidectomy management of giant goitre patients in ICU with endotracheal tube in situ for 24 h improves their survival chances.

关键词：气道阻塞/预防和控制甲状腺肿/外科学重症监护/方法插管法气管内尼日利亚手术后期间成年人老年人女(雌)性人类男(雄)性中年人

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Immunonutrition in the critically ill

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INTENSIVE CARE MEDICINE 1999年第6期25卷 631-633页

作者： Jolliet, P Pichard, C Univ Hosp Geneva Div Med Intens Care Geneva Switzerland

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Colonization with Pseudomonas aeruginosa in critically ill patients and measures for its prevention

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NETHERLANDS JOURNAL OF MEDICINE 1999年第3期55卷 100-102页

作者： Drakulovic, MB Djokic, D Torres, A Univ Barcelona Fdn Clin Inst Clin Pneumol & Cirurgia Torac Barcelona Spain Univ Barcelona Hosp Clin Serv Pneumol & Allergia Resp IDIBAPS Barcelona Spain Univ Belgrade Sch Publ Hlth Inst Publ Hlth Serbia Dr Milan Jovanovic Batut Belgrade Yugoslavia

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