Current opinion in critical care
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Curr Opin Crit Care · Dec 2012
ReviewProtocoled resuscitation and the prevention of acute kidney injury.
Acute kidney injury (AKI) occurrence in critically ill patients is common and is associated with a substantial increase in morbidity and mortality. The scope of this review is to summarize the most recent evidence-based knowledge for prevention of AKI. ⋯ Key components of optimal AKI prevention include maintenance of renal perfusion and avoidance of precipitating factors. Adequate renal blood flow maintenance is the first strategy to employ not only to assure renal oxygenation, but also to prevent nephrotoxic drugs-associated AKI. Many potential therapies and interventions are on the horizon, but most of the future research will need to focus more on a step-wise, protocoled, kidney-oriented approach, than on single treatments.
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Recent high-profile campaigns have endeavoured to improve the quality of critical care provision. Within other specialities, integrated care pathways (ICPs) have been advocated as an effective means of improving practice. We review the published research regarding their efficacy and potential role in critical care. ⋯ ICPs show promise as a mechanism for improving efficiency and care quality in specific circumstances. However, little research specific to critical care has been undertaken and it may be challenging to protocolize the multisystem care required in many critical illnesses. Although further evaluation is required to find the most appropriate way of incorporating ICPs into critical care, we commend their thoughtful adoption.
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Trauma-induced coagulopathy is a frequent complication in severely injured patients. To correct coagulopathy and restore haemostasis, these patients have traditionally been treated with fresh frozen plasma, but in the last decade, there has been a shift from empirical therapy to targeted therapy with coagulation factor concentrates and other haemostatic agents. This review highlights emerging therapeutic options and controversial topics. ⋯ Current evidence in trauma resuscitation indicates a potential role for coagulation factor concentrates and other haemostatic agents in correcting trauma-induced coagulopathy. Despite a shift towards such transfusion strategy, there remains a shortage of data to support this approach.
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Curr Opin Crit Care · Dec 2012
ReviewFluid overload in AKI: epiphenomenon or putative effect on mortality?
The incidence of acute kidney injury (AKI) is increasing dramatically, and despite advances in dialytic therapy and critical care, there has been little improvement in associated morbidity and mortality. Recently, several articles have suggested that fluid overload in patients with AKI is associated with an increased risk of death. ⋯ On the basis of the current literature, the relative contributions of the direct effects of fluid overload versus the association of fluid overload with other patient characteristics associated with adverse outcome (e.g. sepsis) remain unknown. Additional human studies, including randomized controlled trials, are warranted to further clarify these issues.
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Transfusion paradigms and protocols have evolved at a rapid pace in the last few years to ameliorate the adverse effects of trauma-induced coagulopathy (TIC). This has occurred despite fragmented and inadequate knowledge of the underlying pathophysiology that they are supposed to treat. This review will collate and assimilate the most recent data about TIC in order to present our state-of-the-art understanding of this condition. ⋯ Further improvement in the outcome from trauma-haemorrhage is possible with more refined and tailored haemostatic resuscitation. Achieving this will depend upon a better understanding of the haemostatic defects that develop after injury.