Acta Clin Belg
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Patients with sepsis often receive large amounts of fluids and the presence of capillary leak, trauma or bleeding results in ongoing fluid resuscitation. This increases interstitial and intestinal edema and finally leads to intra-abdominal hypertension (IAH), which in turn impedes lymphatic drainage. Patients with IAH often develop secondary respiratory failure needing mechanical ventilation with high intrathoracic pressure or PEEP that might further alter lymphatic drainage. This review will try to convince the reader of the importance of the lymphatics in septic patients with IAH. ⋯ Although often overlooked the role of lymphatic flow is complex but very important to determine not only the fluid balance in the lung but also in the peripheral organs. Different pathologies and treatments can markedly influence the pathophysiology of the lymphatics with dramatic effects on endorgan function.
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Gastrointestinal failure (GIF) has been postulated as the motor of multiple organ dysfunction syndrome (MODS) but is not commonly included among other organ failures in scoring systems identifying MODS. ⋯ There is no consensus on definition of GIF and different medical specialties have different approaches. Development of a proper definition of GIF is warranted.
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Comparative Study
Acute kidney injury, length of stay, and costs in patients hospitalized in the intensive care unit.
Acute kidney injury (AKI) in patients hospitalized in the intensive care unit (ICU) results in increased morbidity, mortality, and as a consequence, higher health-care costs. The bad prognosis associated with this condition and limited health-care budgets both have raised the issue of how much therapy should be dedicated to ICU patients with AKI. As no universally-agreed standardized definition for AKI is available, wide ranges of incidence are reported and precise estimates of its associated excess of costs are, therefore, difficult to explore. ⋯ Moreover, among survivors, even greater requirements of in-hospital and post-hospitalization care was noted. Notwithstanding the high health-economic burden, full supportive intensive care treatment is justified in this particular cohort of patients. Major efforts are highly required in terms of public health prevention initiatives and the early recognition and timely management of AKI, in ICU hospitalized patients in particular.
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Increased intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) is a cause of organ dysfunction in critically ill patients and is independently associated with mortality. The kidneys seem to be especially vulnerable to IAH induced dysfunction and renal failure is one of the most consistently described organ dysfunctions associated with IAH. The aim of this paper is to review the historical background, awareness, definitions, pathophysiologic implications and treatment options for IAP induced renal failure. ⋯ IAH can cause renal dysfunction. Therefore, IAP measurements should be considered in our daily practice and preventive measures should be taken to avoid (deterioration of) renal failure in patients with IAH. Decompression may have a beneficial effect in patients with established IAH and renal failure.
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Cardiovascular dysfunction and failure are commonly encountered in the patient with intra-abdominal hypertension or abdominal compartment syndrome. Accurate assessment and optimization of preload, contractility, and afterload, in conjunction with appropriate goal-directed resuscitation and abdominal decompression when indicated, are essential to restoring end-organ perfusion and maximizing patient survival. The validity of traditional hemodynamic resuscitation endpoints, such as pulmonary artery occlusion pressure and central venous pressure, must be reconsidered in the patient with intra-abdominal hypertension as these pressure-based estimates of intravascular volume have significant limitations in patients with elevated intra-abdominal pressure. ⋯ Volumetric monitoring techniques have been proven to be superior to traditional intra-cardiac filling pressures in directing the appropriate resuscitation of this patient population. Calculation of the "abdominal perfusion pressure", defined as mean arterial pressure minus intra-abdominal pressure, has been shown to be a beneficial resuscitation endpoint as it assesses not only the severity of the patient's intra-abdominal hypertension, but also the adequacy of abdominal blood flow. Application of a goal-directed resuscitation strategy, including abdominal decompression when indicated, improves cardiac function, reverses end-organ failure, and minimizes intra-abdominal hypertension-related patient morbidity and mortality.