Current opinion in critical care
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Curr Opin Crit Care · Dec 2015
ReviewThrombotic thrombocytopenic purpura: from diagnosis to therapy.
Thrombotic thrombocytopenic purpura (TTP) is a rare but challenging disease for intensive care specialists. Patients with acute TTP frequently require admission to the intensive care unit because of organ dysfunctions due to the disease or because of the risk of sudden aggravation at the onset of the disease. This review aims at describing recent evolutions in the diagnosis and for the management of TTP for the use of intensive care specialists. ⋯ The classification of thrombotic microangiopathies has evolved from a clinical to a pathophysiological definition. TTP is characterized by a severe ADAMTS13 deficiency that can be documented in vitro, along with anti-ADAMTS13 antibodies in most adult cases. Plasmapheresis and immunosuppressive therapy with steroids remain the standard of care for acute inaugural TTP. Anti-CD20 monoclonal antibody rituximab is safe and indicated in relapsing and/or refractory TTP. Its indication in inaugural TTP remains to be evaluated but is nevertheless recommended by experts. Novel therapies for TTP are still in preclinical phases.
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The review focuses on severe acute vaso-occlusive manifestations of sickle cell disease leading adult patients to the ICU. ⋯ Acute vaso-occlusive episodes are characterized by an unpredictable course that needs for vigilance for everyone, and justifies ICU or intermediate care unit admission to allow close monitoring, and supportive treatment in a timely fashion.
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Curr Opin Crit Care · Dec 2015
ReviewImproving acute kidney injury diagnostics using predictive analytics.
Acute kidney injury (AKI) is a multifactorial syndrome affecting an alarming proportion of hospitalized patients. Although early recognition may expedite management, the ability to identify patients at-risk and those suffering real-time injury is inconsistent. The review will summarize the recent reports describing advancements in the area of AKI epidemiology, specifically focusing on risk scoring and predictive analytics. ⋯ Integrating a high-functioning clinical information system with risk stratification methodology and novel biomarker yields a predictive analytic model for AKI diagnostics.
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Curr Opin Crit Care · Dec 2015
ReviewAutomated/integrated real-time clinical decision support in acute kidney injury.
Health information technology advancements have resulted in recent increased sophistication of the electronic health record, whereby patient demographic, physiological, and laboratory data can be extracted real-time and integrated into clinical decision support (CDS). ⋯ Early, real-time identification and notification to healthcare providers of patients at risk for, or with, acute or chronic kidney disease can drive simple interventions to reduce harm. Similarly, screening patients at risk for AKI with these platforms to alert research personnel will lead to improve study subject recruitment. However, sole reliance on electronic health record generated alerts without active healthcare team integration and assessment represents a major barrier to the realization of the potential of CDS to improve healthcare quality and outcomes.
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Shock occurs because of a failure to deliver adequate oxygen to meet the metabolic demands of the body resulting in metabolic acidosis, inflammation, and coagulopathy. Resuscitation is the process of treating shock in an attempt to restore normal physiology. Various hemodynamic, metabolic, and regional endpoints have been described to evaluate the degree of shock and guide resuscitation efforts. We will briefly describe these endpoints, and propose damage control resuscitation as an additional endpoint. ⋯ Numerous endpoints are available; however, no single endpoint is universally applicable. Damage control resuscitation strategies have demonstrated improved survival, hemostasis, and less early death from exsanguination, suggesting that hemorrhage control should be an additional endpoint in resuscitation.