Cutting edge
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7208.501 (Published 21 August 1999) Cite this as: BMJ 1999;319:501
- Mervyn Singer,
- Rod Little
Few areas of clinical medicine are changing as rapidly as intensive care Greater understanding of the pathophysiology of disease processes, technological innovations, targeted pharmaceutical and “nutriceutical” interventions, and the use of specialised audit and scoring methods to improve patient classification and monitor disease progression have all contributed to changes in practice in the past decade. This article considers developments that may affect patient management in the next 10 years.
Outcome from acute respiratory distress syndrome has improved over the past 15 years. Data from Milberg JA et al. Improved survival of patients with acute respiratory distress syndrome. JAMA 1995;306-9 and Abel SJ et al. Reduced mortality in association with the acute respiratory distress syndrome. Thorax 1998;53:292-4
Prevention
There is an increasing appreciation of the need to prevent critical illness with proactive care rather than to offer reactive support once organ failure is established. This has considerable resource implications, although savings should be made through reduced requirement for intensive care. Emphasis should be placed on identifying patients at risk, with early recognition of physiological disturbances and prompt correction to avoid subsequent major complications.
Factors responsible for organ dysfunction
Maintenance of organ perfusion
The concept of a perioperative tissue oxygen debt resulting in organ dysfunction, which need not be clinically manifest until several days after an operation, is now accepted. Many high risk patients cannot mount an adequate haemodynamic response to the stress of surgery, and this may be compounded by unrecognised hypovolaemia and poor organ perfusion Tissue hypoxia and reperfusion injury both fuel the subsequent systemic inflammatory response.
Several recent studies have shown a strong relation between intraoperative haemodynamic deterioration and postoperative complications. Significant improvements in outcome and reductions in hospital stay have been achieved by optimising perioperative circulatory function using fluid loading with or without vasoactive drugs, and guided by monitoring of cardiac output.
Outcome …
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