Critical care clinics
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Physiologic alterations in critically ill patients can significantly affect the pharmacokinetics of drugs used in the critically ill patient population. Understanding these pharmacokinetic changes is essential relative to optimizing drug therapy. This article outlines the major differences seen in the absorption, distribution, metabolism, and excretion of drugs in critically ill patients. Important strategies for drug therapy dosing and monitoring in these patients are also addressed.
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Critical care clinics · Apr 2006
ReviewContemporary issues in the pharmacologic management of acute heart failure.
Acute heart failure is an evolving syndrome that continues to be defined by ongoing studies and registries. It is associated with significant morbidity and mortality and places a huge economic burden on health care systems. ⋯ Diuretics, vasodilators, and inotropes remain the mainstays of therapy with several new classes of agents on the horizon. Clinicians should understand the rationale for use and limitations of each therapy to maximize benefit and cost-effectiveness, while minimizing the potential for adverse outcomes.
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Antimicrobial resistance in the ICU is characterized by increasing overall resistance rates among gram-negative and gram-positive pathogens and increased frequency of multidrug-resistant organisms. In addition to basic principles of appropriate drug selection for empiric and definitive therapy, other specific strategies that may decrease problems of resistance through improved use of antimicrobials include appropriate application of pharmacokinetic and pharmacodynamic principles to antimicrobial use, aggressive dosing of antimicrobials, use of broad-spectrum and combination antimicrobial therapy for initial treatment, decreased duration of antimicrobial therapy, hospital formulary-based antimicrobial restrictions, use of antimicrobial protocols and guidelines, programs for restriction of target antimicrobials, scheduled antimicrobial rotation, and use of antimicrobial management programs. Combinations of various approaches may offer the best potential for effectively intervening in and reducing the spread of resistant pathogens in critically ill patients.
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Critically ill patients generally are older, frequently have organ failure, and commonly receive multiple medications, all of which make them susceptible to adverse effects of drugs. Drug interactions are a common adverse effect, and many are predictable based on understanding the mechanisms that underlie drug interactions. This article identifies commonly used medications in critically ill patients and the associated drug interactions that may occur with emphasis on the cytochrome P450 enzyme system.
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This review addresses the use of corticosteroid replacement in critically ill patients. Low-dose corticosteroid replacement for critically ill patients with septic shock has been shown to reduce the duration of vasopressor-dependent shock, to shorten ICU length of stay, and, in recent trials, to reduce mortality. Numerous questions remain to be fully answered about patient selection, corticotropin-stimulation testing methods, and interpretation of results.