Journal of intensive care medicine
-
J Intensive Care Med · Jul 1995
Clinical Trial Controlled Clinical TrialA prospective study of continuous venovenous hemodiafiltration in critically ill patients with acute renal failure.
We studied the biochemical and the clinical consequences of the application of continuous venovenous hemodiafiltration to the management of acute renal failure in critically ill patients. One hundred consecutive surgical and medical ICU patients with acute renal failure were entered into a prospective clinical study at an intensive care unit of tertiary institution. ⋯ included the following: mean patient age was 60.9 years (range 21-81 yr); mean APACHE II score, 28.6 (95% confidence interval; 27.4-29.8); and number of failing organs, mean, 4.1 (95% confidence interval; 3.8-4.4). At commencement of continuous venovenous hemofiltration with dialysis, 79% of patients were receiving inotropic drugs and 72% were septic, and, in 35%, bacteremia or fungemia was demonstrated. Renal replacement therapy was applied for a mean duration of 186.2 hours (95% confidence interval; 149.2-223.7), with a mean hourly net ultrafiltrate production of 621 mL (95% confidence interval; 594-648) and a mean urea clearance of 28.1 mL/min (95% confidence interval; 26.7-29.5). Azotemia was controlled in all patients (plasma urea < 30 mmol/L). During the more than 18,000 hours of treatment, there was no therapy-associated hemodynamic instability. Complications were rare. They included two cases of hemofilter rupture with minor blood loss and a single case of bleeding at the site of the vascular-access catheter. Forty-three patients survived to ICU discharge, and 40 survived to hospital discharge. Continuous venovenous hemodiafiltration is a safe and an effective form of renal replacement therapy in critically ill patients. In such patients, who have a high predicted mortality rate, it was associated with a 40% survival rate. These findings suggests that continuous venovenous hemodiafiltration may be ideally suited to patients with multisystem organ failure with acute renal failure.
-
Inhalation remains the most frequent and serious comorbid event that occurs in thermally injured patients. A thorough understanding of the pathophysiology enables individualization of therapy and appropriate triage of patients. We summarize our current knowledge of the pathophysiology, diagnosis, and treatment of inhalation injury, with a focus on newer treatment strategies that are evolving secondary to laboratory research.
-
J Intensive Care Med · Mar 1995
ReviewMedical therapy of acute myocardial infarction: Part I. Role of thrombolytic and antithrombotic therapy.
Thrombolytic therapy has been established as a safe and effective therapeutic strategy in acute myocardial infarction (MI). Its efficacy is improved with early administration, although modest benefits can be demonstrated for up to 12 hours. Tissue plasminogen activator (TPA) appears to offer benefits over streptokinase when administered to patients who present within 4 hours, those with an anterior MI, and who are less than 75 years old. ⋯ These issues and the role of newer antiplatelet and antithrombin agents are being examined in ongoing clinical trials. The objective of this review is to provide the information needed for careful and appropriate judgment in the use of thrombolytic agents and antithrombotic therapy. General principles are emphasized, and specific recommendations are included as guidelines.
-
J Intensive Care Med · Jan 1995
ReviewGastric tonometry: a new monitoring modality in the intensive care unit.
In many critically ill patients, systemic measures of hemodynamic and O2 transport variables may not be sufficiently sensitive to portray the complex interaction between energy requirements and energy supply in all tissues. Gastric or intestinal tonometry has been proposed as a relative noninvasive index of the adequacy of aerobic metabolism in the gut mucosa, a tissue that is particularly vulnerable to alterations in perfusion and oxygenation. The gut mucosa lacks some of the microvascular control mechanisms that allow other tissues, such as the heart, skeletal muscle, and the brain, to increase tissue perfusion during times of stress, and, just like the canary, it will display metabolic changes indicative of dysoxia earlier than those more "vital" tissues. ⋯ Increases in mucosal PCO2, or conversely, decreases in mucosal pH (pHi), are associated with the development of intestinal mucosa ischemia. The clinical utility of pHi to detect intestinal mucosal ischemia has been demonstrated in patients undergoing abdominal aortic surgery. Further, a low gastric mucosal pHi on admission to the ICU appears to be predictive of mortality and pHi-guided resuscitation may improve outcome in a subpopulation of patients admitted to the ICU with normal pHi, perhaps by preventing splanchnic ischemia and the development of a systemic oxygen deficit.