Critical care : the official journal of the Critical Care Forum
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Acute kidney injury (AKI) after cardiac surgery increases length of hospital stay and in-hospital mortality. A significant number of patients undergoing cardiac surgical procedures require perioperative intra-aortic balloon pump (IABP) support. Use of an IABP has been linked to an increased incidence of perioperative renal dysfunction and death. This might be due to dislodgement of atherosclerotic material in the descending thoracic aorta (DTA). Therefore, we retrospectively studied the correlation between DTA atheroma, AKI and in-hospital mortality. ⋯ Perioperative IABP and DTA atheroma are independent predictors of perioperative AKI and in-hospital mortality. Whether adding an IABP in patients with severe DTA calcification increases their risk of developing AKI and mortality postoperatively cannot be clearly answered in this study. Nevertheless, when IABP and DTA are combined, patients are more likely to develop AKI and to die postoperatively in comparison to patients without IABP and DTA atheroma.
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Computerized tomography is frequently employed in the critically ill, often using intravenous radiocontrast material. Many of these patients have clinical features that are considered risk factors for contrast induced nephropathy, but are simultaneously at risk for renal injury from other factors related to their acute illnesses. The attributable risk for renal dysfunction from radiocontrast exposure has not been well quantified in this population. ⋯ Among established intensive care unit patients declines in glomerular filtration following contrast-enhanced scanning are common, but these changes are far more likely to be attributable to factors other than the contrast exposure itself. The upper bound for the incidence of contrast induced renal injury lasting even three days was 2% in the population studied.
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Currently, the major issue in glycemic control in neurocritical care patients is that tight glycemic control (target range of 80 to 110 mg/dL) using intensive insulin therapy is associated with higher rates of hypoglycemia without an improvement in survival rate. The review by Kramer and colleagues in this issue of Critical Care confirms these data but provides solid evidence about the relationship between hyperglycemia and worsened neurological outcome after acute brain injury. ⋯ In addition, we recommend adequate nutrition before and during insulin infusion, avoidance of insulin as a bolus, and the use of continuous insulin infusion, beginning with low doses with titration to individual sensitivity. Careful and accurate glycemic monitoring is especially important when insulin is infused.
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Editorial Comment
Advancing the science of ventilator-associated pneumonia surveillance.
The landmark Study on the Efficacy of Nosocomial Infection Control definitively demonstrated that infection surveillance and control programs prevent hospital-acquired infections. The rise of public reporting, benchmarking, and pay for performance movements, however, has considerably changed the infection surveillance landscape in the 27 years since this study was published. ⋯ Surveillance definitions need to be revised to enhance objectivity and to ensure that they detect clinically meaningful events associated with compromised outcomes. The US Centers for Disease Control and Prevention recently released modified definitions for ventilator-associated events that have the potential to make safety surveillance for ventilated patients more credible and useful once again.
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There is a plethora of experimental data on the potential therapeutic benefits of recombinant human erythropoietin (rhEPO) and its synthetic derivatives in critical care medicine, in particular in ischemia/reperfusion injury. Most of the recent clinical trials have not shown clear benefits, and, in some patients, EPO-aggravated morbidity and mortality was even reported. Treatment with rhEPO has been successfully used in patients with anemia resulting from chronic kidney disease, but even a subset of this patient population does not adequately respond to rhEPO therapy. The following viewpoint uses rhEPO as an example to highlight the possible pitfalls in current practice using young healthy animals for the evaluation of therapies to treat patients of variable age and underlying chronic co-morbidity.