Critical care clinics
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In critical care medicine, catecholamines are most widely used to reverse circulatory dysfunction and thus to restore tissue perfusion. However, catecholamines not only influence systemic and regional hemodynamics, but also exert a variety of significant metabolic, endocrine, and immunologic effects. Arginine vasopressin is a vasomodulatory hormone with potency to restore vascular tone in vasodilatory hypotension. Although the evidence supporting the use of low doses of vasopressin or its analogs in vasodilatory shock is increasing, lack of data regarding mortality and morbidity prevent their implementation in critical care protocols.
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Critical care clinics · Jan 2006
ReviewThe neuroendocrine response to critical illness is a dynamic process.
Striking alterations in the hypothalamic-anterior pituitary-peripheral hormone axes hallmark the state of critical illness, their severity being associated with high risk for morbidity and mortality. Early endocrine intervention strategies aimed to correct the hormone balance have been shown ineffective or even harmful because of lack of thorough pathophysiologic understanding of these neuroendocrine changes. Extensive research, however, has provided crucial insights, with the demonstration of the biphasic response of the anterior pituitary to the severe stress of critical illness.
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Hyperglycemia is a common feature of the critically ill patient and has been associated with increased mortality. Maintaining normoglycemia with insulin therapy improves survival and reduces morbidity in surgical ICU patients, as shown by a large randomized controlled study. Prevention of glucose toxicity by strict glycemic control but also other metabolic and non-metabolic effects of insulin contribute to these clinical benefits.
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Critical care clinics · Jan 2006
ReviewRelative adrenal failure in the ICU: an identifiable problem requiring treatment.
Critically ill patients at some stage may develop adrenal insufficiency (AI). This article reviews the mechanisms, diagnosis criteria, consequences, and treatment of AI in various ICU conditions. ⋯ Diagnosis relies on clinical suspicion and ACTH test results. The length of cortisol replacement therapy should be at least 7 days and the adjunction of fludrocortisone is recommended.
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Trauma, sepsis, and surgery are associated with global hypercatabolism and a negative nitrogen balance. When critical illness is prolonged the relentless loss of lean tissue becomes functionally important. ⋯ Unexpectedly, however, two large prospective randomized controlled trials (PRCTs) demonstrated that administration of rhGH to long-stay critically ill adults increases morbidity and mortality. Some progress has been made in understanding the mechanisms underlying this observation.