Current opinion in critical care
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Renal recovery after acute kidney injury (AKI) is an important outcome, most commonly defined as dialysis independence at hospital discharge. This review focuses on the epidemiology of renal recovery after AKI and provides a framework for determining the relationship of a lack of renal recovery and subsequent outcomes including the development of chronic kidney disease. ⋯ Patients with incomplete renal recovery after AKI are underrepresented in most epidemiologic studies and the precise effect on the incidence and prevalence of end stage renal disease population has yet to be determined. A standardized definition for renal recovery is needed and the influence of an AKI episode on long-term outcomes needs to be better evaluated.
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Curr Opin Crit Care · Dec 2008
ReviewPostinjury immune monitoring: can multiple organ failure be predicted?
Multiple organ failure is the main cause of late morbidity and mortality after severe injury. This disease state is driven by a dysfunctional immune system. Prediction of multiple organ failure on the basis of clinical parameters appears to be insufficient. A better understanding of immunological pathogenesis underlying multiple organ failure may lead to better prediction and innovation in treatment strategy in order to increase the survival of trauma patients. ⋯ General markers of inflammation including cytokines are correlated with posttraumatic complications with a low sensitivity and specificity and are, therefore, of little use as prognostic markers. Current findings regarding the functionality of immune cells are promising and might be of prognostic value in the near future.
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Curr Opin Crit Care · Dec 2008
ReviewAntimicrobial dosing strategies in critically ill patients with acute kidney injury and high-dose continuous veno-venous hemofiltration.
Delivery of appropriate antimicrobial therapy is a great challenge during continuous veno-venous hemofiltration (CVVH), particularly if the recommended higher doses are applied. The present contribution discusses the principles of drug dosing during CVVH and compares the various proposed dosing strategies. ⋯ The delivery of appropriate antimicrobial therapy during CVVH leaves us with uncertainty and presents a great challenge. To ensure efficacy and prevent toxicity, therapeutic drug monitoring is highly recommended. In the absence of therapeutic drug monitoring, adequate concentrations can only be inferred from clinical response. For nontoxic antibiotics overdosing is preferred to underdosing because the danger of underdosing is far greater than that of overdosing.
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Curr Opin Crit Care · Dec 2008
ReviewComputerized clinical decision support for traumatic shock resuscitation.
To review what we learned through implementation of computerized decision support for ICU resuscitation of major torso trauma patients who arrive in shock. ⋯ Fundamental changes are needed in the care of trauma patients who arrive in shock and require a massive transfusion.
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Curr Opin Crit Care · Dec 2008
ReviewSurrogate decision makers for incompetent ICU patients: a European perspective.
Frequently, ICU patients lack the capacity to share discussions and make decisions about their health. Designation of a surrogate and advance directives have been proposed to empower patients and give more place to their autonomy. Even though legitimacy of surrogates is now recognized by physicians, patients' management must take into account new legislations emphasizing patients' autonomy all over Europe. ⋯ The present review compares the legal framework of surrogacy in Belgium, Denmark, England, France, Germany, the Netherlands, Spain, and Switzerland. France is the country that confers the weakest power to surrogates in decision making. Patients' competence and the ability of surrogate decision makers to cope with ICU's burden are discussed as the main limitations of the substitute decision-making process. Measures to improve substitute decision making and to limit harmful repercussions are suggested.