Minerva anestesiologica
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Minerva anestesiologica · Jun 2010
ReviewBiomarkers of acute kidney injury in anesthesia, intensive care and major surgery: from the bench to clinical research to clinical practice.
Acute kidney injury (AKI) is common after major surgery and reportedly occurs in approximately 36% of ICU patients (RIFLE Risk/Injury/ Failure categories). It is associated with increased mortality, greater cost, and prolonged Intensive Care Unit (ICU) and hospital stay, despite attempts to develop therapies to prevent or attenuate AKI, which have had limited success. One major reason for this lack of success may be the result of delayed implementation due to the inability to detect AKI early. ⋯ They can be used to evaluate the effect of new techniques and therapies on kidney function, as safety markers to monitor toxicity and as measures of treatment effect. For example, NGAL and cystatin C have been used in a safety monitoring trial of hydroxyethylstarch therapy and to detect AKI early, during or immediately after cardiac surgery. Clinical use beyond research settings is rapidly expanding.
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Minerva anestesiologica · Jun 2010
Review Meta AnalysisProne positioning improves survival in severe ARDS: a pathophysiologic review and individual patient meta-analysis.
Prone positioning has been used for over 30 years in the management of patients with acute respiratory distress syndrome (ARDS). This maneuver has consistently proven capable of improving oxygenation in patients with acute respiratory failure. Several mechanisms can explain this observation, including possible intervening net recruitment and more homogeneously distributed alveolar inflation. ⋯ The available randomized clinical trials, however, have failed to demonstrate that prone positioning improves the outcomes of patients with ARDS overall. In contrast, the individual patient meta-analysis of the four major clinical trials available clearly shows that with prone positioning, the absolute mortality of severely hypoxemic ARDS patients may be reduced by approximately 10%. On the other hand, all data suggest that long-term prone positioning may expose patients with less severe ARDS to unnecessary complications.
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The aim of this study was to describe the role of glucocorticoids in immune modulation during critical illness and to review clinical trials and recent meta-analyses of glucocorticoids in early and late acute respiratory distress syndrome (ARDS). Selected reviews of publications, clinical trials, and meta-analyses were considered for the study. Activation of the adrenal axis is an important component of the compensatory anti-inflammatory response to critical illness. ⋯ In conclusion, short-duration, high-dose glucocorticoid therapy is not effective in preventing ARDS and may be harmful. Lower doses for persistent ARDS improve lung function and shorten the duration of mechanical ventilation but the impact on long-term mortality is unclear. Additional trials are needed to determine if corticosteroids improve important clinical outcomes before they can be recommended for the routine use of patients with unresolved ARDS.
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Minerva anestesiologica · Jun 2010
Risk factors for inadequate emergence after anesthesia: emergence delirium and hypoactive emergence.
Inadequate emergence after anesthesia in the adult patient may be distinguished by the patients' activity level into two subtypes: emergence delirium and hypoactive emergence. The aim of this study was to determine the incidence of inadequate emergence in its different forms, to identify causative factors and to examine the possible influence on postoperative length of stay in the recovery room and in the hospital. ⋯ Inadequate emergence after anesthesia is a frequent complication. Preventable risk factors for emergence delirium were induction of anesthesia with etomidate, premedication with benzodiazepines and higher postoperative pain scores. Hypoactive emergence was less frequent than emergence delirium and was associated with a longer postoperative hospital stay.