Current opinion in critical care
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Acute kidney injury (AKI) continues to contribute significantly to morbidity and mortality in the ICU setting, especially when associated with distant organ dysfunction. There is increasing evidence that AKI directly contributes to organ dysfunction in lung, brain, liver, heart and other organs. This review will examine our current understanding of the deleterious organ crosstalk in the critically ill, which can provide a framework for developing novel therapeutics. ⋯ There is increasing knowledge of AKI and deleterious interorgan crosstalk that arises, at least in part, due to the imbalance of immune, inflammatory, and soluble mediator metabolism that attends severe insults to the kidney. Further studies can build on these new mechanistic observations to develop strategies to improve outcomes in the critically ill patient.
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Curr Opin Crit Care · Dec 2009
ReviewImpaired blood flow in acute kidney injury: pathophysiology and potential efficacy of intrarenal vasodilator therapy.
Acute kidney injury (AKI) is a common complication of hospitalized patients and associated with significant morbidity and mortality. Numerous studies have documented that acute reductions in glomerular filtration rates are associated with significant in-hospital mortality. Moreover, patients progressing to dialysis-dependent AKI can have mortality rates that exceed 60%. The pathophysiology of AKI is unknown, but marked reductions in corticomedullary blood flow leads to significant reductions in glomerular filtration rate during early phases of the disease. The recognition that hypoperfusion of the outer medulla is common to many forms of AKI and contributes to tubular ischemia has led many investigators to re-examine the use of vasodilators to restore blood flow and stabilize renal function. ⋯ Previous trials utilizing vasodilator therapy to stabilize renal function in AKI have given conflicting results. This study will critically review trial design and dose selection used in previous studies of vasodilator therapy in AKI. Lastly, the potential for high-dose therapy using intrarenal drug delivery systems will be discussed.
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Curr Opin Crit Care · Dec 2009
ReviewCritical care organ support: a focus on extracorporeal systems.
An extensive search of the literature published in the past 2 years related to critical care organ support was undertaken. This review is limited to those that focus on extracorporeal life support modalities for adults. ⋯ Multiple-organ dysfunction followed by traumatic injury can be treated with multiple-organ support. A total extracorporeal organ support system may be used in the future as a portable, bedside organ support device.
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Curr Opin Crit Care · Dec 2009
ReviewAirway management and initial resuscitation of the trauma patient.
This review will analyze and comment on selected recent literature pertaining to airway management and initial fluid resuscitation in the trauma patient. It will also review airway devices currently being used in the trauma setting. ⋯ As trauma continues to be a major cause of morbidity and mortality worldwide, the use of newer airway adjuncts needs to be specifically investigated in trauma patients, as this population frequently has airway management difficulties. Further research is also required to elucidate the type and amount of fluid that will provide an adequate organ perfusion without increasing nonsurgical bleeding.
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Bleeding and death from hemorrhage remain a leading cause of morbidity and mortality in the trauma population. Early resuscitation of these gravely injured patients has changed significantly over the past several years. The concept of damage control resuscitation has expanded significantly with the experience of the US military in southwest Asia. This review will focus on this resuscitation strategy of transfusing blood products (red cells, plasma, and platelets) early and often in the exsanguinating patient. ⋯ The current evidence supports that the acute coagulopathy of trauma is present in a high percentage of trauma patients. Patients who will require a massive transfusion will have improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells.