ABSTRACT
OBJECTIVES: To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies. DATA SOURCES: Pertinent literature in the English language. STUDY SELECTION: One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services. DATA EXTRACTION: Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought. DATA SYNTHESIS: Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue. CONCLUSIONS: Regionalization of critical care medicine probably is beneficial and the concept should be explored.
Subject(s)
Critical Care/organization & administration , Efficiency, Organizational , Quality of Health Care , Regional Medical Programs/organization & administration , Adult , Child , Clinical Competence , Cost-Benefit Analysis , Critical Care/standards , Critical Care/statistics & numerical data , Focus Groups , Health Resources , Health Services Misuse , Humans , Models, Organizational , Patient Care Team , Patient Transfer/organization & administration , Regional Medical Programs/standards , Societies, Medical , Transportation of Patients , United StatesABSTRACT
BACKGROUND: This study evaluated the dose-response relationship of torsemide, the first pyridine-sulphonylurea loop diuretic, in patients with ascites due to cirrhosis. METHODS: During a 13-day hospitalization period, 17 patients received single, oral doses of 5 mg, 10 mg, or 20 mg of torsemide or placebo in a randomized, double-blind, crossover fashion. All the patients received a constant dose of spironolactone concomitantly beginning at least 7 days before the study. Electrolyte excretion and urine volume were measured for 24 h after each dose. Body weight was measured before, and 24 h after each dose. RESULTS: Torsemide was effective in producing statistically significant, dose-related increases in urinary sodium and chloride excretion, with little effect on potassium or magnesium excretion. Urine volume increased and body weight decreased in a dose-related manner. CONCLUSION: Torsemide increased sodium excretion substantially in patients with cirrhosis and ascites who were receiving spironolactone.
Subject(s)
Ascites/drug therapy , Ascites/etiology , Diuretics/administration & dosage , Liver Cirrhosis/complications , Sulfonamides/administration & dosage , Administration, Oral , Adult , Aged , Body Weight/drug effects , Cross-Over Studies , Dose-Response Relationship, Drug , Double-Blind Method , Electrolytes/urine , Female , Humans , Male , Middle Aged , Safety , Spironolactone/therapeutic use , TorsemideABSTRACT
Water hemlock is a ubiquitous plant that can be mistaken for a turnip as in the case reported. Oral ingestion causes an explosive illness consisting of nausea, vomiting, abdominal cramps, and grand mal seizures that can progress to cyanosis and death. In the reported case a 30-year old man was found semi-comatose some 75 minutes after ingesting a "turnip". The history revealed profuse emesis shortly after eating lunch that changed from bile to frank blood. There was a mean orthostatic blood pressure change of 30 torr, with an increase in the heart rate of 10%. Neurologic examination revealed a lethargic patient. Following administration of 4 liters of Ringer's lactate the patient's blood pressure stabilized and with continued isotonic fluid maintenance he improved rapidly. This case indicates that appropriate management should be directed toward protecting the patient's airway from gastric aspiration, restoring the intravascular and extracellular volume deficit, and controlling cerebral edema.
Subject(s)
Plant Poisoning/diagnosis , Adult , Coma/etiology , Humans , Hypotension/etiology , Male , Plant Poisoning/therapy , Vomiting/etiologyABSTRACT
Fifty-seven patients requiring catheterization with a thermodilution Swan-Ganz catheter in the surgical intensive care unit were prospectively studied to determine the incidence and significance of positive pulmonary arterial blood cultures. Nonseptic (group 1) and septic (group 2) patients were identified, with subdivision of the groups into A and B classes contingent upon a negative or positive pulmonary arterial blood culture respectively. In the nonseptic group, there were no positive blood cultures, provided there was only one catheterization (Swan-Ganz), less than three repositionings of the catheter, and discontinuation of the catheterization within 72 hours after insertion. Although the septic group followed this pattern, 25 percent incidence of positive pulmonary arterial blood cultures was present within the 72-hour period. We believe that the thermodilution Swan-Ganz catheter is presently a valuable clinical tool and does not predispose the patient to an excessive infectious disease risk.
