Critical care : the official journal of the Critical Care Forum
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Because the microcirculation has emerged as an important reanimation target, appropriate methods to monitor the microcirculatory function are crucial. Several teams have now succeeded in crossing this bridge from bench to bedside, but the choice of the tissues of interest remains a debate. The potential accessible vascular beds that doctors could use in reanimation strategies and the relationship of these beds to more relevant microcirculatory ones are important issues to address.
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Editorial Comment
Regional citrate anticoagulation in patients with liver failure - time for a rethink?
Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) has become increasingly attractive in recent years due to its favourable low bleeding risk profile. Its use in liver failure, however, has been limited due to the risk of citrate accumulation and toxicity. ⋯ This study raises interesting prospects with regard to RCA use in liver failure, and we postulate that citrate may have a role as a prognostic marker of metabolic capacity much as in the way of lactate and methacetin. However, further studies are warranted, in particular examining its application in subgroups of liver failure (chronic, acute, hyperacute and subacute), before its use becomes commonplace.
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Regional citrate anticoagulation (RCA) is a valid option in patients at high risk of bleeding who are undergoing continuous renal replacement therapy (CRRT). The aim of this study was to evaluate, in critically ill patients with severe acute kidney injury following cardiac surgery, the efficacy and safety of RCA-continuous veno-venous hemofiltration (CVVH) using a low concentration citrate solution. ⋯ RCA safely prolonged filter life while decreasing CRRT downtime, transfusion rates and supplementation needs for antithrombin III and platelets. In cardiac surgery patients with severe multiple organ dysfunction syndrome, the adoption of a 12 mmol/l citrate solution may provide a suboptimal buffers supply, easily overwhelmed by bicarbonate supplementation.
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Severe sepsis is characterised by intravascular or extravascular infection with microbial agents, systemic inflammation and microcirculatory dysfunction, leading to tissue damage, organ failure and death. The growth factor angiopoietin (Ang-1) has therapeutic potential but recombinant Ang-1 tends to aggregate and has a short half-life in vivo. This study aimed to investigate the acute effects of the more stable Ang-1 variant matrilin-1-angiopoietin-1 (MAT.Ang-1) on the function of the microcirculation in an experimental model of sepsis, and whether any protection by MAT-Ang-1 was associated with modulation of inflammatory cytokines, angiogenic factors or the endothelial nitric oxide synthase (eNOS)-Akt and vascular endothelial (VE)-cadherin pathways. ⋯ Administration of MAT.Ang-1 after the onset of sepsis protects the microcirculation from endotoxemia-induced vascular dysfunction through reducing inflammation but without pro-angiogenic actions, thus representing a novel, potential pharmacotherapeutic agent for the treatment of sepsis.