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The role of urea-induced osmotic diuresis and hypernatremia in a critically ill patient: case report and literature review.
Distenhreft, JIQ, Vianna, JGP, Scopel, GS, Ramos, JM, Seguro, AC, Luchi, WM
Jornal brasileiro de nefrologia. 2020;(1):106-112
Abstract
Hypernatremia is a common electrolyte problem at the intensive care setting, with a prevalence that can reach up to 25%. It is associated with a longer hospital stay and is an independent risk factor for mortality. We report a case of hypernatremia of multifactorial origin in the intensive care setting, emphasizing the role of osmotic diuresis due to excessive urea generation, an underdiagnosed and a not well-known cause of hypernatremia. This scenario may occur in patients using high doses of corticosteroids, with gastrointestinal bleeding, under diets and hyperprotein supplements, and with hypercatabolism, especially during the recovery phase of renal injury. Through the present teaching case, we discuss a clinical approach to the diagnosis of urea-induced osmotic diuresis and hypernatremia, highlighting the utility of the electrolyte-free water clearance concept in understanding the development of hypernatremia.
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2.
Physiological and management implications of obesity in critical illness.
Shashaty, MG, Stapleton, RD
Annals of the American Thoracic Society. 2014;(8):1286-97
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Abstract
Obesity is highly prevalent in the United States and is becoming increasingly common worldwide. The anatomic and physiological changes that occur in obese individuals may have an impact across the spectrum of critical illness. Obese patients may be more susceptible to hypoxemia and hypercapnia. During mechanical ventilation, elevated end-expiratory pressures may be required to improve lung compliance and to prevent ventilation-perfusion mismatch due to distal airway collapse. Several studies have shown an increased risk of organ dysfunction such as the acute respiratory distress syndrome and acute kidney injury in obese patients. Predisposition to ventricular hypertrophy and increases in blood volume should be considered in fluid management decisions. Obese patients have accelerated muscle losses in critical illness, making nutrition essential, although the optimal predictive equation to estimate nutritional needs or formulation for obese patients is not well established. Many common intensive care unit medications are not well studied in obese patients, necessitating understanding of pharmacokinetic concepts and consultation with pharmacists. Obesity is associated with higher risk of deep venous thrombosis and catheter-associated bloodstream infections, likely related to greater average catheter dwell times. Logistical issues such as blood pressure cuff sizing, ultrasound assistance for procedures, diminished quality of some imaging modalities, and capabilities of hospital equipment such as beds and lifts are important considerations. Despite the physiological alterations and logistical challenges involved, it is not clear whether obesity has an effect on mortality or long-term outcomes from critical illness. Effects may vary by type of critical illness, obesity severity, and obesity-associated comorbidities.
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[Paraquat poisoning. Case report and overview].
Spangenberg, T, Grahn, H, van der Schalk, H, Kuck, KH
Medizinische Klinik, Intensivmedizin und Notfallmedizin. 2012;(4):270-4
Abstract
Paraquat poisoning in Germany is rare. Because plasma levels do not necessarily match the ingested amount of paraquat, repeated measurement of plasma levels is imperative. There is a large potential in the prehospital phase to improve prognosis: further resorption must be terminated by rigorous charcoal administration and early tracheal intubation if necessary. Because paraquat can be resorbed by dermal contact, steps to ensure sufficient protection of emergency medical personnel must be taken.As soon as further resorption has been prevented sufficiently, forced diuresis, renal replacement therapy, and hemoperfusion can be of help, but still remain controversial. To reduce pulmonary fibrosis, inspiratory oxygen concentrations must be adjusted to the minimal amount needed to ensure satisfactory tissue oxygenation. Data supporting the advantageous use of cyclophosphamide combined with methylprednisolone for the treatment of pulmonary fibrosis were recently published. Since the toxic mechanism implies a mismatch of oxidants and anti-oxidants, co-administration of ascorbic acid and N-acetylcysteine are simple treatments with few side effects.
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Manganese encephalopathy: an under-recognized condition in the intensive care unit.
Chalela, JA, Bonillha, L, Neyens, R, Hays, A
Neurocritical care. 2011;(3):456-8
Abstract
BACKGROUND Manganese encephalopathy is a potential complication of parenteral nutrition. Lack of early recognition leads to unnecessary testing and to continued exposure to manganese. METHODS Case report and review of the literature. RESULTS We describe the clinical and imaging findings of a patient with manganese encephalopathy in whom the diagnosis was delayed due to lack of recognition of the characteristic imaging findings. CONCLUSION Manganese encephalopathy has protean clinical and imaging findings that can easily be overlooked.
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[Nutrition in the critically ill].
Weimann, A, Andrä, J, Sablotzki, A
Deutsche medizinische Wochenschrift (1946). 2011;(44):2251-62
Abstract
The prognostic impact of inadequate energy and protein supply in malnourished intensive care patients has been recently reemphasized. Consent exists about the beneficial effects of early enteral nutrition in the critically ill. However, gastrointestinal intolerance of the critically ill may be a major problem for the feasibility of enteral nutrition bearing additional risks. In case adequate enteral nutrition cannot be realized, there is controversy about the appropriate time to start total parenteral or combined enteral / parenteral nutrition. Due to potential adverse effects immune-enhancing substrates have to be cautiously administered. For standardization implementation of a guideline based nutritional protocol is recommended. The review refers to the recent guidelines of the European Society for Clinical Nutrition and Metabolism (2009), the American Society for Parenteral and Enteral Nutrition (ASPEN) (2009) and the German Sepsis Society (DSG) (2010).
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Pharmacogenetics in critical care: atrial fibrillation as an exemplar.
Prows, CA, Beery, TA
Critical care nursing clinics of North America. 2008;(2):223-31, vi-vii
Abstract
Pharmacogenetic testing is currently not routine in critical care settings but recent changes in the warfarin label are likely to lead to critical care nurses encountering physician or nurse practitioner orders for such testing. Although the science for pharmacogenetics is complex, the components of patient teaching are not beyond that which nurses already provide about other laboratory, disease, and treatment-based information. It is reasonable to expect that as the science of pharmacogenetics and pharmacogenomics expands and discoveries are translated in clinical settings, the additional information from pharmacogenetic test results will help prescribers select or adjust medication doses to reduce the risk for adverse drug reactions and improve the chances of achieving therapeutic targets in a timely fashion.
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7.
Diarrhea: applying research to bedside practice.
Sabol, VK, Carlson, KK
AACN advanced critical care. 2007;(1):32-44
Abstract
Diarrhea is one of many symptoms that may complicate the hospitalization of a critically ill patient. Diarrhea is caused by a variety of etiologies; identifying the etiology aids in the appropriate selection of interventions. Care of the patient with diarrhea should be guided by the evidence and best practices available in the literature. This article defines and describes diarrhea and its pathophysiology. An evidence-based plan of care for the assessment, planning, intervention, and evaluation of the patient with diarrhea is presented, using levels of recommendation based on the strength of the available evidence. A case study is presented to illustrate application to clinical practice. Commentary about the case is provided to review salient points of care.
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8.
Pulmonary arterial hypertension.
Traiger, GL
Critical care nursing quarterly. 2007;(1):20-43
Abstract
Pulmonary arterial hypertension (PAH) is a rare and debilitating disease characterized by abnormal proliferation and contraction of pulmonary vascular smooth muscle cells. The resulting increase in pressure and pulmonary vascular resistance results in progressive right heart failure, low cardiac output, and ultimately death if left untreated. PAH is defined by a persistent elevation in pulmonary artery pressure with normal left-sided pressures, differentiating it from left-sided heart disease. Symptoms progress from shortness of breath and decreasing exercise tolerance to right heart failure, with peripheral edema and marked functional limitation. Exercise-induced syncope, worsening symptoms at rest, and intractable right heart failure indicate critical disease. PAH may be idiopathic with no identifiable cause or associated with collagen vascular diseases, drugs, HIV, liver disease, and/or congenital heart disease. Familial or genetically mediated PAH accounts for a small percentage of cases. Advances in the understanding of pathobiological pathways that contribute to vascular proliferation and remodeling have resulted in new therapies that improve quality of life and survival. Emerging therapies focus on the nitric oxide, prostacyclin, and endothelin pathways. Nursing interventions are critical to ensure patients' success with these expensive and complex treatments and their optimal adjustment to living with PAH.
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Cardiac cell therapy: a treatment option for cardiomyopathy.
Shepler, SA, Patel, AN
Critical care nursing quarterly. 2007;(1):74-80
Abstract
Cardiomyopathy is a common clinical disorder affecting the heart muscle. This disease process frequently leads to congestive heart failure and will often progress to end-stage heart failure. Present standard of care treatment options for cardiomyopathy include medical management, lifestyle changes, and surgical procedures including left ventricular assist devices as a destiny therapy or bridging to heart transplantation. Even despite advances in drug therapy, mechanical assist devices, and organ transplantation, more than half of the persons with cardiomyopathy will die within 5 years of diagnosis. Small uncontrolled clinical trials have demonstrated cardiac stem cells as a treatment option for cardiomyopathy. The theory for the individual or combined mechanism of action for stem cells includes (1) transdifferentiation to blood vessels or myocardium, (2) fusion with the native dysfunctional myocytes to augment function, and (3) homing that may be a systemic or panacrine response for recruiting other cells, and growth factors to help improve oxygen delivery and myocardial function. The field of cardiac cell therapy is rapidly progressing to gather more data with intermediate-size, double-blinded trials that will demonstrate the safety and efficacy of cell therapy.
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10.
Acute iron poisoning: what every pediatric intensive care unit nurse should know.
Aldridge, MD
Dimensions of critical care nursing : DCCN. 2007;(2):43-8; quiz 49-50
Abstract
Iron is a substance commonly found in the homes of many children, leading to a high potential for accidental ingestion. Without proper recognition and treatment, iron poisoning can be fatal. This article reviews the case of a toddler who presents to the pediatric intensive care unit with iron poisoning.