Advances in chronic kidney disease
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Adv Chronic Kidney Dis · Jan 2013
ReviewUpdate in critical care for the nephrologist: transfusion in nonhemorrhaging critically ill patients.
A growing number of guidelines and recommendations advocate a restrictive transfusion strategy. Strong evidence exists that a hemoglobin threshold of less than 7 g/dL conserves resources and may improve outcomes in critically ill patients and that platelet counts greater than 10,000/μL are well tolerated. Patients with coronary artery disease can be safely managed with a restrictive transfusion strategy, utilizing a hemoglobin threshold of less than 7 or 8 g/dL; a threshold of less than 8 g/dL can be applied to patients with acute coronary syndromes. ⋯ Complications from transfusion are significant and previously under-recognized immunologic complications pose a more serious threat than infections. Erythropoietin and iron administration do not reduce transfusion needs in the critically ill. Interventions to reduce blood loss and educate clinicians are successful in reducing transfusion requirements.
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Hemodynamic monitoring is essential to the care of the critically ill patient. In the hemodynamically unstable patient where volume status is not only difficult to determine, but excess fluid administration can lead to adverse consequences, utilizing markers that guide resuscitation can greatly affect outcomes. ⋯ Technological advances have lead to the creation of invasive and noninvasive devices that guide the physician through the resuscitative process. In this manuscript, we review the physiologic rationale behind hemodynamic monitoring, define the markers of volume status and volume responsiveness, and explore the various devices and technologies available for the bedside clinician.
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Sepsis and septic shock are syndromes that overlap between several disciplines and subspecialties. Emerging evidence suggests that sepsis may be associated with short- and long-term adverse outcomes, even when the syndrome does not appear to be severe and is not managed in the intensive care unit. Hence, all practicing clinicians need to be familiar with the fundamental principles of diagnosis and management of sepsis. In this review, we have summarized the key components in the management of sepsis/septic shock, including early recognition, early resuscitation, principles of antibiotic therapy, organ support, and role of adjunctive therapies.