A Book for Residents, Fellows,Critical care practitioners and Allied health care Weaning. Rajesh Chawla, Vishakh Varma, Rakesh Sharma. Pages PDF. The book describes step-wise management of clinical emergencies seen every day in Intensive care units (ICUs. Targeted readers are intensivists, critical care specialists, and residents involved in the care of patients admitted in ICUs. This monograph provides point-of-care. Evidence-Based Critical Care (eBook, PDF) The book describes step-wise management of clinical emergencies seen every day in Intensive care units (ICUs. Targeted readers are intensivists, critical care specialists, and residents involved in the care of patients admitted in ICUs.
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The Critical Care Reviews Book seeks to summarise, critique and put in context the best critical care trials of The pdf is available as a free download at the Critical. Care Reviews The Best Guidelines: NEURO. ICU Protocols: A stepwise approach - Ebook written by Rajesh Chawla, Subhash Todi. Read this book using Google Play Books app on your PC, android, iOS. MOH Pocket Manual in Critical Care. TABLE OF . Facilitate transfer to the operating room or ICU. . Most guidelines and clinical protocols recommend that.
For example, it would be difficult to reduce variability with a protocol that required the clinician to determine whether the patient 'looked septic,' unless the state 'looked septic' were explicitly defined. Computerized protocols used for complex clinical problems can contain much more detail than is possible with textual guidelines or with paper-based flow diagrams [ 16 ]. The increased detail allows the generation, at the point of care, of patient-specific therapy instructions that can be performed by different clinicians with almost no inter-clinician variability [ 18 ].
This can make both formal clinical inquiries for example, randomized trials and informal clinical inquiries for example, some continuous quality improvement efforts, or clinical practice evaluations more robust [ 9 , 18 ]. Reducing clinician variability might seem to challenge the importance that clinicians assign to individualized patient-specific therapy.
Unexpectedly, individualization of patient therapy is preserved when clinical decisions are standardized with explicit, detailed, patient-data-driven, computerized protocols [ 9 , 19 ]. An essential element in achieving this unexpected result is the use of patient data that is, the patient's unique expression of the disease to drive the decision-support tool protocol rules.
Unlike these specific patient-data-driven explicit methods [ 4 , 5 , 20 , 21 , 22 , 23 , 24 , 25 ], time-driven decision-support tools for example a clinical path that requires discharge of the patient after 3 days of care raise legitimate concerns about patient-invariant 'cookbook' care. Individualizing patient care while standardizing clinical decisions with an explicit method is, in my opinion, one of the most attractive attributes of the point-of-care use of computerized protocols.
Why is there need for protocols in the ICU? This is an expression of the general problem: that human error and injury are unavoidable [ 27 , 35 , 54 , 55 ].
Variation in clinical practice persists even when guidelines based on reputable evidence are available [ 28 , 29 ], and patients can be harmed when clinicians do not comply with standard practice [ 9 , 30 , 31 ].
Widespread distribution of evidence-based guidelines [ 35 , 36 ] and education programs [ 24 , 37 , 38 , 39 , 40 ] has had only a limited effect on low compliance by clinicians. Variability is fostered by incorrect perceptions. The perceptions of physicians in their use of physiological data and the actual use of such data in decision-making for cardiac problems in the ICU are internally inconsistent within-decision-maker inconsistency [ 56 ]. This is in part due to the use of ill-defined terms or statements such as ' This particular inconsistency appeared in a journal issue containing three articles that presented mutually contradictory sets of recommendations about hemodynamic monitoring between-decision-maker inconsistency [ 58 ].
Variation in practices with ICU fluids and electrolytes illustrates the confusion propagated by the imprecise use of words and concepts in medicine.
An analytical scheme addressing three major factors in fluid and electrolyte evaluation 1, effectiveness of the arterial circulation; 2, extracellular fluid volume [ECF]; and 3, state of hydration [ 59 ] is compatible with widely taught precepts [ 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]. Evaluating these three concepts separately is important for clarifying problems with fluids and electrolytes and thereby for reducing unnecessary variation.
Use of fluid and electrolyte terms in a nonstandardized manner leads to confusion.
An American Medical Association Council report cites isotonic, hypertonic, and hypotonic dehydration, thereby confusing the evaluation of the state of the ECF and the state of hydration [ 68 ].
Cardiovascular evaluation is also inappropriately included in the evaluation of hydration, thereby confusing the evaluation of the effectiveness of the arterial circulation cardiovascular evaluation with the evaluation of the state of hydration.
Hypernatremic dehydration a tautology if standard definitions are used was used to describe both dehydration hypernatremia and ECF contraction [ 69 ].
For patients with traumatic brain injury, dehydration was used in two contradictory ways [ 70 ]. First, the authors recommended inducing dehydration with mannitol producing dehydration or underhydration according to the standard terminology because it was effective in reducing intracranial pressure.
They then recommended avoiding dehydration with diuretics producing ECF contraction due to negative fluid balance because it was ineffective in reducing intracranial pressure [ 70 ].
The use and the teaching of terms in such contradictory ways probably contribute to the uncertainty surrounding fluid and electrolyte therapy for sepsis [ 71 ], shock [ 72 , 73 , 74 ] and ARDS [ 75 ].
Fluid and electrolyte therapy is an important and uncontrolled co-intervention that can influence patient outcome and obscure the effects of therapeutic interventions in clinical trials. Protocols enhance efficiency, safety, and efficacy of care Efficiency is the term assigned to the evaluation of resource consumption for a clinical intervention accepted as part of routine practice.
Marino's, The ICU Book, 4th Ed
At the individual patient level, standardization enhances efficiency by making the clinical plan explicit to all providers dealing with that patient. Nurses, therapist, and physicians thereby achieve a level of uniformity of approach and goals for the specific patient. This reduces within-patient variability of decision-making.
However, this does not reduce unnecessary variation between patients and between physicians. Standardized clinical decisions are important at several levels within the healthcare delivery system. Human decision-making limitations, perceptual inaccuracies, and variation in the use and in the interpretation of important clinical variables all make clinicians unable to consistently generate therapeutic decisions that are coherent, that consider all appropriate options, and that are based on the relevant scientific evidence [ 27 , 34 , 35 , 43 , 44 , 46 , 76 , 77 , 78 , 79 ].
For example, adverse drug events are common, costly, and largely preventable causes of excess morbidity and mortality in ICU patients [ 25 , 80 , 81 , 82 ].
Unfortunately, adverse drug events are generally undetected. Even when the healthcare community understands the proper approach, compliance of physicians with evidence-based treatments or guidelines is low across a broad range of healthcare topics [ 20 , 85 , 86 , 87 , 88 , 89 ].
Patient [ 90 ] and hospital [ 91 ] compliance is approximately as low. Like low compliance by clinicians, this seems to be a feature of our human condition.
A stepwise approach
However, the absence of requisite infrastructure in the ICU environment is an important obstacle to the adoption of clinical decision-support tools such as those demonstrated to produce a favorable clinical outcome in a multicenter randomized clinical trial [ 5 , 6 ].
Step-by-step management of most commonly seen emergencies in intensive care units Point-of-care treatment guidance for critically ill patients Richly supplemented with algorithms, figures, and tables Annotation of key citations in the suggested reading chapters, one chapter devoted to each clinical emergency see more benefits. download eBook. download Hardcover. download Softcover. Rent the eBook.
FAQ Policy. About this book The book describes step-wise management of clinical emergencies seen every day in Intensive care units ICUs.
Show all. From the reviews: Dries, Doody's Book Reviews, March, Pages Weaning Chawla, Rajesh, M. Massive Hemoptysis Bansal, Avdhesh, M. Pulmonary Thromboembolism Chawla, Rajesh, M. Pleural Diseases Kansal, Sudha, M.
Oxygen Therapy Jindal, Surinder K.
Echocardiography Pandit, Rahul, M. Cardiogenic Shock Hegde, Ashit V. Cerebrovascular Accident Devaprasad, V. Dedeepiya, M.
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Finally, Chapters 19 and 20 supply lists of pharmacologic agents and dosages commonly used in the ICU and laboratory values relevant to the ICU.
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