Seminars in dialysis
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The appropriate and timely evaluation and treatment of patients with severely elevated blood pressure is essential to avoid serious adverse outcomes. Most importantly, the distinction between a hypertensive emergency (crisis) and urgency needs to be made. A sudden elevation in systolic (SBP) and/or diastolic blood pressure (DBP) that is associated with acute end organ damage (cardiovascular, cerebrovascular, or renal) is defined as a hypertensive crisis or emergency. ⋯ In patients with a hypertensive emergency, blood pressure control should be attained as expeditiously as possible with parenteral medications to prevent ongoing and potentially permanent end organ damage. In contrast, with hypertensive urgency, blood pressure control can be achieved with the use of oral medications within 24-48 hours. This paper reviews the management of hypertensive emergencies.
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Seminars in dialysis · Nov 2006
ReviewPerioperative fluid management: current consensus and controversies.
The scientific knowledge base that supports clinical decisions about perioperative fluid management continues to evolve. However, despite these advancements in the understanding of the physiology of fluid replacement, the definition of ''optimal'' perioperative fluid management remains a matter of clinical judgment. With an appreciation of the many factors, both sensible and insensible, that contribute to changes in blood and extracellular fluid volume during surgery, clinicians have tried to create reproducible and generally applicable formulas for replacement of fluid during surgery. ⋯ The relative ease of pre-identified fluid replacement protocols is being slowly replaced by data-guided interventions that take into account a variety of factors. Clinicians are therefore required to tailor their fluid replacement strategies based on preoperative patient characteristics, the type of surgery and even the type of anesthetic that is utilized. Some of the benefits of this new approach range from relatively ''minor'' outcomes such as diminished nausea after surgery to preventing postoperative complications such as wound breakdown and cardiopulmonary failure.
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Seminars in dialysis · May 2006
ReviewDiagnosis and management of sleep apnea syndrome and restless legs syndrome in dialysis patients.
Sleep complaints are very common in patients with end-stage renal disease (ESRD) and contribute to their impaired quality of life. Both obstructive and central sleep apnea syndromes are reported more often in patients on dialysis than in the general population. Impaired daytime functioning, sleepiness, and fatigue, as well as cognitive problems, are well known in patients with sleep apnea. ⋯ We also briefly review current data regarding sleep problems after transplantation, since these studies may indirectly shed light on the possible pathophysiological role of uremia or dialysis in the etiology of sleep disorders. Considering the importance of sleep disorders, more awareness among professionals involved in the care of patients on dialysis is necessary. Appropriate management of sleep disorders could improve the quality of life and possibly even impact upon survival of renal patients.
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Seminars in dialysis · Jan 2006
Case ReportsSevere lactic acidosis treated with prolonged hemodialysis: recovery after massive overdoses of metformin.
We report two cases of severe lactic acidosis due to massive metformin ingestion. The first case was a 37-year-old man who was discovered several hours after ingesting 45 g of metformin. He had severe lactic acidosis (blood pH 6.81, bicarbonate 4 mEq/L, lactate 25.7 mEq/L). ⋯ He has subsequently made a complete recovery. Metformin-associated lactic acidosis carries a high mortality rate. Prolonged hemodialysis should be considered as an early treatment option in these cases.
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Seminars in dialysis · Jan 2006
ReviewPulse high-volume hemofiltration in critically ill patients: a new approach for patients with septic shock.
Mortality rates in septic shock remain unacceptably high despite advances in our understanding of the syndrome and its treatment. Humoral factors are increasingly recognized to participate in the pathogenesis of septic shock, giving a biological rationale to therapies that might remove varied and potentially dangerous humoral mediators. While plasma water exchange in the form of hemofiltration can remove circulating cytokines in septic patients, the procedure, as routinely performed, does not have a substantial impact on their plasma levels. ⋯ Hemodynamic improvements were obtained after 6 hours of PHVHF and were maintained subsequently by standard CVVHas demonstrated by the reduction in norepinephrine dose. PHVHFbut not CVVHsignificantly reduces apoptotic plasma activity within 1 hour and the pattern was maintained in the following hours. PHVHF appears to be a feasible modality that may provide the same or greater benefits as HVHFwhile reducing the workload and cost.