Medizinische Klinik, Intensivmedizin und Notfallmedizin
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Acute aortic syndrome (AAS) is a life-threatening disease. Quick and accurate diagnosis is crucial. Patients should be transferred to a competence center without any delay as soon as AAS is suspected. ⋯ However, when associated with complications, endovascular treatment is recommended. A symptomatic intramural hematoma, a penetrating atherosclerotic ulcer or pending aortic rupture are associated with a substantial risk. Therefore, surgical or endovascular therapy is recommended.
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Perioperative acute kidney injury (AKI) is common and is associated with adverse clinical outcomes, excess mortality, and an increased risk for chronic renal failure. Recommendations to prevent perioperative AKI include the early identification of patients at risk, the avoidance of nephrotoxic drugs, and early goal-directed haemodynamic stabilization. The major causes for perioperative AKI are severe sepsis and septic shock, hypovolemia, bleeding and cardiac failure. ⋯ Data from a recent meta-analysis show that, in surgical patients, mortality is reduced when renal replacement therapy is started early. In certain surgical diseases, i.e. acute occlusive disease of the abdominal aorta (Leriche's syndrome) following surgical reperfusion, patients are at risk of severe metabolic acidosis and life-threatening hyperkalemia. In such cases, intraoperative dialysis using a mobile batch system can help to avoid these complications by delivering an effective dialysis therapy at the time of reperfusion.
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The dosing of drugs in critically ill patients remains challenging. While increased volume of distribution after fluid resuscitation and increased cardiac output can increase clearance of antibiotics, liver failure and renal failure can decrease the clearance of drugs. If an extracorporeal device is used, the dosing of drugs becomes even more difficult. Even in intensive care patients with intact renal function, pharmacokinetics and pharmacodynamics are significantly altered. ⋯ The importance of therapeutic drug monitoring is discussed. Global initiatives to increase quantity and quality of pharmacokinetic studies in this patient population through incentives and guidance of the regulatory agencies, as well as the major unmet educational need to integrate basic knowledge in this field into residency and fellowship programs as well as CME are briefly mentioned.