Current drug targets
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Current drug targets · Sep 2009
ReviewUse of corticosteroids in critically ill septic patients : a review of mechanisms of adrenal insufficiency in sepsis and treatment.
Adrenal insufficiency has being reported with increased frequency in critical ill patients with sepsis and other inflammatory states. Its incidence varies widely depending on the criteria used to define it and the patient population studied. Increased glucocorticoid action is essential in the stress response to acute injury and even minor degrees of adrenal insufficiency can be fatal. ⋯ Whether exogenous corticosteroid support may be beneficial in critical illness is still matter of debate: most international guidelines recommend that the decision to treat patients with corticosteroids should be based on clinical criteria (low blood pressure poorly responsive to vasopressor despite adequate fluid resuscitation) rather than on tests of the hypothalamic-pituitary-adrenal axis alone. As regards specifically the role of steroids in the treatment of sepsis and septic shock, at present there are no strong evidence-based recommendations. More studies are needed to reach consensus about several issues: which is the best target population, whether a cosyntropin test should be used to guide treatment, whether fludrocortisones should be given along with hydrocortisone, and how long treatment should continue.
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Statins are widely prescribed cholesterol lowering agents that exert their effects by inhibiting 3-hydroxy-3methylglutaryl co-enzyme A reductase. With their modulatory effects on the atherogenic lipid profile, the role of statin therapy is expanding amidst the growing obesity epidemic. The cholesterol lowering effects of statin therapy remains central in the long term management of coronary artery disease and cerebrovascular disease. ⋯ Clinical research into plaque histology, vulnerable high risk plaques and plaque rupture has improved our insight into the pathophysiology of these acute vascular events. Non lipid lowering effects of statin, the so called pleitrophic effects, have become the focal point of investigation. This review discusses recent experimental and clinical evidence supporting the role of statin in perioperative medicine.
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It has been estimated that nosocomial fever occurs in approximately one-third of hospitalized patients. The incidence is even higher in critically-ill patients in whom both infectious and noninfectious etiologies of fever are common. ⋯ There is widespread acceptance that in most if not all critically ill neurologic patients fever should be treated but still it is not clear if fever per se in nonneurologic critically ill patients should be treated too. We review physical and pharmacological methods presently utilized to treat fever in critically ill patients.
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Current drug targets · Sep 2009
ReviewBeta-Blockers in the perioperative period: are there indications other than prevention of cardiac ischemia?
Beta-blocker therapy is accepted to reduce perioperative cardiovascular complications. Moreover, beta-blockers have potentially beneficial effects other than prevention of cardiac events. ⋯ Beta-blockers are also useful in stabilizing hemodynamics during electroconvulsive therapy, intubation and emergency periods. Physicians need to bear in mind the benefits of beta-blockers for purposes other than preventing cardiac events when applied in the perioperative period, and should be familiar with the pharmacodynamics and effective dosages of these agents.
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Current drug targets · Sep 2009
Reducing the risk of major elective non-cardiac surgery: is there a role for levosimendan in the preoperative optimization of cardiac function?
Patients with heart failure undergoing non-cardiac surgery still have an unacceptably high morbidity and mortality. Compromised myocardial physiologic reserves in combination with extensive surgery and anesthesia appear to play a crucial role in determining high perioperative morbidity and mortality. Nevertheless, several other mechanisms and pathways such as metabolic factors, ischemia-reperfusion conditions, neurohormonal activation, inflammation and oxidative stress contribute to the adverse outcome. ⋯ At the cellular level in the heart, kidney, lung, liver as well as the gut, levosimendan exerts protective preconditioning effects secondary to activation of adenosine triphosphate (ATP)-sensitive potassium channels. Taking into account these multiple but complementary mechanisms, levosimendan appears to be a suitable agent for preoperative optimization of cardiac functions in heart failure patients undergoing major elective surgery. Nevertheless, large-scale trials are needed before final conclusions can be drawn on the use of levosimendan in this indication.