Geoff Lighthall's Top Ten Critical Care Articles (3/1/2009)
Dr. Lighthall illustrates the concerning finding of free air under the diaphragm.
Geoff Lighthall, MD, PhD is an Associate Professor of Anesthesia at the Stanford University School of Medicine and is a member of the Critical Care faculty at the Palo Alto Veterans Affairs Hospital.
He graduated from the University of Maryland in 1995. His research interests include critical care education and Medical Emergency Teams (METs).
Dr. Lighthall notes, "Larry asked me to generate a “top ten” list of articles in critical care.
Doing so, of course places you at great risk at looking stupid, [Ed. note: it is highly unlikely that Dr. Lighthall could ever appear stupid!] as you will inevitably miss out on someone else’s pet favorite or what the rest of your colleagues consider a total classic.
Nonetheless, I will make some offerings that I think define current practice critical care, as well as some others that are of interest.
First, it is important to note that very little of critical care medicine is truly evidence-based, with most decisions largely based on the judgment of clinicians weighing between undesirable or imperfect options. Refreshing exceptions are papers demonstrating that there probably is “a best method” for ventilating patients with lung injuries (#1), that giving everyone a hematocrit of 30 is probably a bad idea (#2), that “renal dose dopamine” was a misconception (#3), and that we’re probably driving up health care costs without improving outcomes when we use albumin for patient resuscitation (#4)."
As anesthesiologists, we represent a breed of physicians that attack medical problems before they evolve into something worse, and a number of my favorite critical care articles support this philosophy of practice. Kumar and colleagues(#5) for example, showed that the interval between the onset of shock and administration of antibiotics correlates with mortality, and that we should do whatever we can to speed up antibiotic administration. Rivers and colleagues (#6) likewise demonstrated that if you have an organized and aggressive approach to hemodynamic optimization as soon as patients enter the hospital, they’ll do much better than if you try to address this concern later on. Personally, I think Stanford has been doing the latter for decades prior to this article, but Rivers et al is often quoted and discussed, so go ahead and read it! The Australians have shown us that we should be concerned with the development of critically illnesses outside of the ICU in the medical and surgical wards, and that being proactive in the identification, evaluation, and treatment of these patients produces fewer codes, complications, and deaths (#7, 8, 9). When it takes longer for us to get called to evaluate and care for these patients, mortality is worse (#10)."
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network.
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A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.
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Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group.
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A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit.
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Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock.
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Early goal-directed therapy in the treatment of severe sepsis and septic shock.
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Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates.
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Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study.
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Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a Children's Hospital.
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Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias.
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