Current opinion in critical care
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Acute renal failure is a serious condition that affects as many as 20% of ICU patients. The most common causes of acute renal failure in the ICU patient are severe sepsis and septic shock. The mortality of acute renal failure in septic critically ill patients remains high despite our increasing ability to support vital organs. This is partly the result of our poor understanding of the pathogenesis of sepsis-induced renal dysfunction. Accordingly, a review of our current understanding of the pathogenesis of septic acute renal failure is timely and relevant. ⋯ This review suggests that, on the evidence available, septic acute renal failure is more likely to be an immune or toxic state rather than simply a hemodynamic condition. The authors speculate that future insights into its pathogenesis might lead to a paradigm shift away from the concept of acute tubular necrosis, which has never been convincingly shown in sepsis, to that of acute tubular apoptosis.
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Curr Opin Crit Care · Dec 2003
ReviewCommunication with family members of patients dying in the intensive care unit.
In intensive care units the patient is usually unconscious and/or incompetent so that the relationship shifts to the family. Interactions between caregivers and families usually follow one of three models. In the first model, a family representative receives information from the caregivers but does not participate in decisions or physical care. ⋯ In the third model, the family members communicate their own wishes, provide physical care to the patient, and participate in medical decision-making. After a description of the studies that measured the quality of information provided to ICU families and by discussing the extent to which respecting the principle of patient autonomy is feasible in the ICU, we will review the literature on studies that identified specific needs of families of dying patients and specific challenges faced by intensivists as they seek to inform the families of dying patients. The need for family-centered care and for a better communication within the patient-family-caregiver trio is also highlighted.
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Curr Opin Crit Care · Dec 2003
Review Comparative StudyDialysis strategies in critically ill acute renal failure patients.
Acute renal failure requiring dialysis is a frequent complication in critically ill patients, with a high morbidity and mortality. Until now, no evidence-based guidelines on the optimal treatment of acute renal failure on the ICU are available. This article reviews recent publications that shed light on several specific topics, like optimal treatment modality, dose of dialysis, type of dialysis membrane, and new developments such as slow extended daily dialysis. ⋯ Adequate dialysis is needed to reduce mortality related to acute renal failure in ICU patients. This necessitates an approach that is completely different from that in chronic renal failure.
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As the elderly population expands and adopts increasingly more active lifestyles, trauma and critical care practitioners will be faced with providing care for greater numbers of severely injured patients. However, because of their associated preexisting medical conditions and poor relative physiologic reserve, geriatric patients have higher mortality rates and poorer long-term functional outcomes than their younger counterparts. A thorough understanding of the causes for these disparate outcomes is critical if successful strategies and treatments for this unique patient population are to be developed. ⋯ Ironically, the field of geriatric trauma is still in its infancy. Given the relation between advanced age, associated preexisting medical conditions, and poor physiologic reserve, a poor outcome may be inevitable by the time the geriatric patient presents for medical attention. Greater emphasis should therefore be placed on injury prevention efforts in this patient population. There is a dire need for well-designed prospective studies in geriatric trauma.
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Curr Opin Crit Care · Oct 2003
ReviewIntraabdominal sepsis: newer interventional and antimicrobial therapies for infected necrotizing pancreatitis.
Recent advances in interventional techniques and antimicrobial therapy have significantly affected the morbidity and mortality of infected pancreatic necrosis. This review describes elements of this progress. ⋯ These findings recommend the practice of routine antibacterial prophylaxis with systemic agents. Patients receiving such treatment should be monitored for colonization by yeast; surveillance cultures do not appear to be necessary because these critically ill patients have an inflammatory disease and frequently experience temperature elevations warranting cultures to rule out infection. If infection is documented by aspiration or intervention, aggressive antimicrobial therapy directed at organisms identified by Gram stain should be started. Classes of antimicrobial agents other than those used for prophylaxis should be used.