Critical care clinics
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Critical care clinics · Apr 2019
ReviewHemoglobin A1c and Permissive Hyperglycemia in Patients in the Intensive Care Unit with Diabetes.
Glycated hemoglobin A1c can be used to assess intensive care unit patients' level of chronic glycemic control. Compared with patients with normal glycated hemoglobin A1c, patients with elevated glycated hemoglobin A1c seem to better tolerate hyperglycemia and large glucose fluctuations during critical illness. ⋯ Observational studies suggest that more liberal targets further decrease the occurrence of hypoglycemia in patients with diabetes with elevated glycated hemoglobin A1c. Whether glycated hemoglobin A1c should be used to individualize glucose control during critical illness should be assessed in randomized trials.
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Melatonin is involved in regulation of a variety of physiologic functions, including circadian rhythm, reproduction, mood, and immune function. Exogenous melatonin has demonstrated many clinical effects. ⋯ Recent studies also demonstrate the analgesic, anxiolytic, antiinflammatory, and antioxidative effects of melatonin. This article reviews the principal properties of melatonin and how these could find clinical applications in care of the critically ill patients.
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Vasodilatory shock is the most common type of circulatory shock in critically ill patients; sepsis the predominant cause. Steroid use in septic shock gained favor in the 1970s; however, studies of high-dose steroids demonstrated excess morbidity and mortality. ⋯ Two recent trials are likely to reinforce the role of steroids in septic shock and change the recommendation in future clinical practice guidelines. Future work could include elucidating mechanisms of shock reversal, interaction of hydrocortisone with other agents, identifying steroid responsiveness using biochemical or gene signatures, and clarifying the role of fludrocortisone.
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The Renaissance of glucose-lowering therapies has arrived with multiple agents that lower blood glucose and demonstrate cardiovascular and renal benefits in people with type 2 diabetes. This article summarizes these new classes of therapies, including the sodium glucose co-transporter-2 inhibitors, glucagon-like peptide-1 agonists, and dipeptidyl peptidase-4 inhibitors. ⋯ As more options become available to treat type 2 diabetes, clinicians need to be aware of the advantages of each class of medications, beyond their glycemic lowering effects. The safety profiles are summarized in this article.
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Critical care clinics · Apr 2019
ReviewTherapeutic Opportunities for Hepcidin in Acute Care Medicine.
Iron homeostasis is often disrupted in acute disease with an increase in catalytic free iron leading to the formation of reactive oxygen species and subsequent tissue-specific oxidative damage. This article highlights the potential therapeutic benefit of exogenous hepcidin to prevent and treat iron-induced injury, specifically in the management of infection from enteric gram-negative bacilli or fungi, malaria, sepsis, acute kidney injury, trauma, transfusion, cardiopulmonary bypass surgery, and liver disease.