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1.
Acute kidney injury: A critical care perspective for orthotopic liver transplantation.
MacDonald, AJ, Karvellas, CJ
Best practice & research. Clinical anaesthesiology. 2020;(1):69-78
Abstract
Acute kidney injury (AKI) is associated with high perioperative mortality in patients undergoing liver transplantation (LT). In the era of Model of End-stage Liver Disease score-based allocation, more patients with impaired renal function are receiving LT. The majority of preoperative AKI is secondary to azotemia, including hepatorenal syndrome - a progressive form of renal impairment unique to liver failure. Prompt recognition and initiation of cause-directed therapies are central to improving post-transplant survival. Given that, the healthcare providers must develop an expertise in liver failure-related renal complications, specifically their management and perioperative implications. Notably, AKI may complicate intraoperative course, exacerbating hemodynamic instability, metabolic acidosis, and electrolyte and coagulation abnormalities. Adjunctive intraoperative continuous renal replacement therapy has been employed; however, prospective studies remain necessary to validate potential benefits.
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2.
Is slower advancement of enteral feeding superior to aggressive full feeding regimens in the early phase of critical illness.
Lheureux, O, Preiser, JC
Current opinion in clinical nutrition and metabolic care. 2020;(2):121-126
Abstract
PURPOSE OF REVIEW An excessive caloric intake during the acute phase of critical illness is associated with adverse effects, presumably related to overfeeding, inhibition of autophagy and refeeding syndrome. The purpose of this review is to summarize recently published clinical evidence in this area. RECENT FINDINGS Several observational studies, a few interventional trials, and systematic reviews/metaanalyses were published in 2017-2019. Most observational studies reported an association between caloric intakes below 70% of energy expenditure and a better vital outcome. In interventional trials, or systematic reviews, neither a benefit nor a harm was related to increases or decreases in caloric intake. Gastrointestinal dysfunction can be worsened by forced enteral feeding, whereas the absorption of nutrients can be impaired. SUMMARY Owing to the risks of the delivery of an excessive caloric intake, a strategy of permissive underfeeding implying a caloric intake matching a maximum of 70% of energy expenditure provides the best risk-to-benefit ratio during the acute phase of critical illness.
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3.
Cardiac Intensive Care Unit Management of Patients After Cardiac Arrest: Now the Real Work Begins.
Randhawa, VK, Grunau, BE, Debicki, DB, Zhou, J, Hegazy, AF, McPherson, T, Nagpal, AD
The Canadian journal of cardiology. 2018;(2):156-167
Abstract
Survival with a good quality of life after cardiac arrest continues to be abysmal. Coordinated resuscitative care does not end with the effective return of spontaneous circulation (ROSC)-in fact, quite the contrary is true. Along with identifying and appropriately treating the precipitating cause, various components of the post-cardiac arrest syndrome also require diligent observation and management, including post-cardiac arrest neurologic injury and myocardial dysfunction, systemic ischemia-reperfusion phenomenon with potential consequent multiorgan failure, and the various sequelae of critical illness. There is growing evidence that an early invasive approach to coronary reperfusion with percutaneous coronary intervention, together with active targeted temperature management and optimization of hemodynamic, ventilator, and metabolic parameters, may improve survival and neurologic outcomes in cardiac arrest survivors. Neuroprognostication is complex, as are survivorship issues and long-term rehabilitation. Our paramedics, emergency physicians, and resuscitation specialists are all to be congratulated for ever-increasing success with ROSC… but now the real work begins.
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4.
[Pharmacogenetics in anesthesia and intensive care medicine : Clinical and legal challenges exemplified by malignant hyperthermia].
Klingler, W, Pfenninger, E
Der Anaesthesist. 2016;(5):380-90
Abstract
Pharmacotherapy is a key component of anesthesiology and intensive care medicine. The individual genetic profile influences not only the effect of pharmaceuticals but can also completely alter the mode of action. New technologies for genetic screening (e.g. next generation sequencing) and increasing knowledge of molecular pathways foster the disclosure of pharmacogenetic syndromes, which are classified as rare diseases. Taking into account the high genetic variability in humans and over 8000 known rare diseases, up to 20 % of the population may be affected. In summary, rare diseases are not rare. Most pharmacogenetic syndromes lead to a weakening or loss of pharmacological action. In contrast, malignant hyperthermia (MH), which is the most relevant pharmacogenetic syndrome for anesthesia, is characterized by a pharmacologically induced overactivation of calcium metabolism in skeletal muscle. Volatile anesthetic agents and succinylcholine trigger life-threatening hypermetabolic crises. Emergency treatment is based on inhibition of the calcium release channel of the sarcoplasmic reticulum by dantrolene. After an adverse pharmacological event patients must be informed and a clarification consultation must be carried out during which the hereditory character of MH is explained. The patient should be referred to a specialist MH center where a predisposition can be diagnosed by the functional in vitro contracture test from a muscle biopsy. Additional molecular genetic investigations can yield mutations in the genes for calcium-regulating proteins in skeletal muscle, e.g. ryanodine receptor 1 (RyR1) and calcium voltage-gated channel subunit alpha 1S (CACNA1S). Currently, an association to MH has only been shown for 35 mutations out of more than 400 known and probably hundreds of unknown genetic variations. Furthermore, MH predisposition is not excluded by negative mutation screening. For anesthesiological patient safety it is crucial to identify individuals at risk and warn genetic relatives; however, the legal requirements of the Patients Rights Act and the Human Genetic Examination Act must be strictly adhered to. Specific features of insurance and employment law must be respected under consideration of the Human Genetic Examination Act.
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5.
[Efficiency of intensive care with cytoflavin in patients of advanced age in combined traumatic brain injury].
Lebedeva, EA, Belousova, ME, Kurtasov, AA, Nemkova, ZA, Kaminskiĭ, MIu, Popov, RV, Trofimovich, SL
Advances in gerontology = Uspekhi gerontologii. 2014;(3):578-83
Abstract
Research objective--determination of efficiency of intensive care with inclusion Cytoflavin in patients of old age in combined traumatic brain injury. A prospective controlled blind randomized study was conducted. In 1st group (21 people) the patients received a standard intensive care, in 2nd group (18 persons) Cytoflavin was included in complex intensive care. Using Cytoflavin starting from 2 days post-traumatic period (with the correction of blood circulation and respiration) had antioxidant and detoxification effects, contributed to the recovery rate of free radical and metabolic processes, reduced the degree of impairment in the structural-functional state of membranes and restored the conformational structure of membrane proteins in the earlier periods. Reduction in reactions of disadaptation led to regression of multiple organ dysfunctions, restoration the level of consciousness at an earlier date. The number of cases of severe respiratory distress syndrome decreased.
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6.
Metabolic and nutrition support in the chronic critical illness syndrome.
Schulman, RC, Mechanick, JI
Respiratory care. 2012;(6):958-77; discussion 977-8
Abstract
Technological innovations in the ICU have led to artificially prolonged life, with an associated cost. Chronic critical illness (CCI) occurs in patients with prolonged mechanical ventilation and allostatic overload, and is associated with a discrete and consistent metabolic syndrome. Metabolic interventions are extrapolated from clinical critical care research, scientific theory, and years of CCI patient care experience. Intensive metabolic support (IMS) is a multi-targeted approach consisting of tight glycemic control with intensive insulin therapy, early and adequate nutrition therapy, nutritional pharmacology, management of metabolic bone disease, and meticulous attention to other endocrine/metabolic derangements. Ideally, IMS should be under the supervision of a metabolic support consultative team. Further research specifically focused on the CCI population is needed to validate this current approach.
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7.
[Tumor lysis syndrome in intensive therapy: diagnostic and therapeutic encare].
Burghi, G, Berrutti, D, Manzanares, W
Medicina intensiva. 2011;(3):170-8
Abstract
The tumor lysis syndrome (TLS) is a life-threatening complication caused by the massive release of nucleic acids, potassium and phosphate into the blood. This complication is the result of tumor cell lysis, which may occur due to treatment of drug sensitive and is characterized by rapid capacity of proliferation, that is often hematological origin. Moreover, the TLS can be observed before starting the treatment due to spontaneous tumor cell death, and frequently worsens when chemotherapy is initiated. TLS has high mortality, so that its prevention continues to be the most important therapeutic measure. In the intensive care unit (ICU), physicians should be aware of the clinical characteristics of TLS, which results in severe electrolyte metabolism disorders, especially hyperkalemia, hyperphosphatemia and hypocalcemia, and acute kidney injury which is a major cause of ICU mortality. An adequate strategy for the management of the TLS, combining hydration, urate oxidase, and an early admission to ICU can control this complication in most patients. The aim of this review is to provide diagnostic tools that allow to the ICU physician to recognize the population at high risk for developing the TLS, and outline a proper strategy for treating and preventing this serious complication.
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8.
Current progress in blood purification methods used in critical care medicine.
Saito, A
Contributions to nephrology. 2010;:100-111
Abstract
The prognosis of patients with an acute accumulation of pathogenic or toxic substances in their body fluids--a condition that severely affects survival--can be significantly improved by blood purification. The most appropriate blood purification method and the duration for which it should be used must be selected on the basis of efficacy and cost. Several blood purification techniques--such as hemodialysis (HD), hemofiltration (HF), hemodiafiltration, continuous hemofiltration (CHF), hemadsorption and plasma exchange--have been developed. Each modality has different removal capacities and limitations; therefore, it is necessary to thoroughly evaluate the time and the duration of use in the case of different disease conditions. The survival rate of patients treated with HF with 35 ml/min of average filtrate is higher than that observed after conventional HD. In patients with systemic inflammatory response syndrome and multiple organ dysfunction syndrome, proinflammatory cytokines should be removed by HF or CHF, as should the toxins accumulated in the original disease. Thus far, no ideal filter has been developed for the removal of a considerable amount of proinflammatory cytokines with minimal albumin loss. In the case of acute liver failure, ammonia, amino acid metabolites and albumin-binding bilirubin should be removed by a combination of HF and plasma exchange. The use of fresh frozen plasma as a replacement fluid in plasma exchange is also important in order to replenish the deficient coagulation factors and essential metabolic factors. Activation of tissue/organ regeneration by the removal of pathogenic factors or by the substitution of factors essential for regeneration might be important in the case of multiple organ dysfunction syndrome. In critically ill patients with composite conditions, the use of more than two blood purification techniques at the same time or at different times during the course of the diseases can improve patient prognosis more than the use of single methods.
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9.
Nutrition support in the intensive care unit: an evolving science.
Blackburn, GL, Wollner, S, Bistrian, BR
Archives of surgery (Chicago, Ill. : 1960). 2010;(6):533-8
Abstract
Recent investigations of nutrition support in the intensive care unit (ICU) have revived discussion of optimal strategies for tight glucose control and the administration of total parenteral nutrition. Mode, timing, and adequacy of nutritional support affect glycemic control and outcomes in critically ill patients. The delivery of correctly formulated and safely administered nutritional and metabolic support is a matter of life or death in surgical and critical care units. High-quality research, adequately powered to detect differences in clinically meaningful outcomes, is needed to inform the delivery of nutrition support and serve as the foundation for future clinical trials. These are issues that will need to be addressed in the months and years ahead. Today, the field is in the midst of challenges and change, and though much has been accomplished, much remains to be done. The last 30 years have seen radical changes in the rates of severe obesity, metabolic syndrome, and weight loss surgery. Obese patients heighten surgical risk and require extra caution by ICU nutrition support specialists. This commentary will address the direction of nutrition support services by covering the history, progress, and potential of the field. It will review parenteral nutrition from its inception to its current standing in ICU patient care and discuss the future role of parenteral nutrition in a rapidly changing and increasingly diverse population.
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10.
Critical care of the burn patient: the first 48 hours.
Latenser, BA
Critical care medicine. 2009;(10):2819-26
Abstract
OBJECTIVE The goal of this concise review is to provide an overview of some of the most important resuscitation and monitoring issues and approaches that are unique to burn patients compared with the general intensive care unit population. STUDY SELECTION Consensus conference findings, clinical trials, and expert medical opinion regarding care of the critically burned patient were gathered and reviewed. Studies focusing on burn shock, resuscitation goals, monitoring tools, and current recommendations for initial burn care were examined. CONCLUSIONS The critically burned patient differs from other critically ill patients in many ways, the most important being the necessity of a team approach to patient care. The burn patient is best cared for in a dedicated burn center where resuscitation and monitoring concentrate on the pathophysiology of burns, inhalation injury, and edema formation. Early operative intervention and wound closure, metabolic interventions, early enteral nutrition, and intensive glucose control have led to continued improvements in outcome. Prevention of complications such as hypothermia and compartment syndromes is part of burn critical care. The myriad areas where standards and guidelines are currently determined only by expert opinion will become driven by level 1 data only by continued research into the critical care of the burn patient.