Contributions to nephrology
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Continuous renal replacement therapies (CRRTs) are increasingly used in order to maintain normal or near-normal acid-base balance in intensive care unit (ICU) patients. Acid-base balance is greatly influenced by the type of dialysis employed and by the administration route of replacement fluids. In continuous veno-venous hemofiltration, buffer balance depends on losses with ultrafiltrate and gain with replacement fluid, while in techniques such as continuous veno-venous hemodiafiltration, clinicians should balance the role of the dialysate. ⋯ However, the dialysate buffer or electrolyte concentration need always to be balanced with that of the replacement fluids employed. Both fluids should contain electrolytes in concentrations aiming for a physiologic level and taking into account preexisting deficits or excess and all input and losses. Clinicians should be aware that in CRRTs the quality control for sterility, physical properties, individualized prescription and balance control are vitally important.
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There are now powerful compensatory therapies to counteract kidney deficiency and the prognosis of patients with acute renal failure is mainly related to the severity of the initial disease. Renal failure is accompanied by an increase in both severity and duration of the catabolic phase leading to stronger catabolic consequences. The specificity of the metabolic and nutritional disorders in the most severely ill patients is the consequence of three additive phenomena: (1) the metabolic response to stress and to organ dysfunction, (2) the lack of normal kidney function and (3) the interference with the renal treatment (hemodialysis, hemofiltration or both, continuous or intermittent, lactate or bicarbonate buffer, etc.). As in many other diseases of similar severity, adequate nutritional support in acutely ill patients with ARF is of great interest in clinical practice, although the real improvement as a result of this support is still difficult to assess in terms of morbidity or mortality.
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Fortunately with improvements in initial medical resuscitation, such as the avoidance of nephrotoxins, the incidence of acute kidney injury requiring renal support in patients with acute traumatic brain injury remains low. However the incidence of cerebral hemorrhage in patients on chronic dialysis programs appears to be increasing. By carefully adapting renal replacement to minimize cardiovascular instability and reduce the rate of change of serum osmolality, patient survival in this group of critically ill patients is increasing and starting to approach that of patients with traumatic brain injury without kidney injury.
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The questions as to which treatment is the most effective for the replacement of renal function in critically ill patients with acute renal failure and the qualifications needed by nurses to manage the continuous renal replacement therapy (CRRT) device are part of an ongoing debate between nephrologists and intensivists, between nurses of the renal ward and the ICU. ⋯ Initiating and maintaining a CRRT program is a great challenge for the ICU nurse. The possible problems remain within the ICU staff's ability to solve if they follow an education program. If the workload for the nurses is well monitored, extra personnel can be avoided.
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Severity scoring systems were first introduced to intensive care units (ICUs) in 1980. The basis for their development was the intention to provide information on the prognosis of patients, the efficacy of therapeutic interventions, stratification for clinical studies, workload and benchmarking of ICUs. Despite the appearance of several specialized scoring systems, the general mortality prediction systems such as APACHE, SAPS and MPM scores and their constantly improved successors have become the most popular and widely tested models. The newest development in this field is SAPS III which is the first 'global' model using a data set acquired from 307 ICUs from all over the world.