Critical care clinics
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Critical care clinics · Apr 2019
ReviewClassic and Nonclassic Renin-Angiotensin Systems in the Critically Ill.
Classic and nonclassic renin-angiotensin systems (RAS) are 2 sides of an ubiquitous endocrine/paracrine cascade regulating blood pressure and homeostasis. Angiotensin II and angiotensin-converting enzyme (ACE) levels are associated with severity of disease in the critically ill, and are central to the physiology and the pathogenesis of circulatory shock. ⋯ The tissue-based RAS has paracrine effects dissociated from those of the circulating RAS. Exogenous angiotensin II or ACE2 may improve the outcome of septic shock and acute respiratory distress syndrome, respectively.
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The Renaissance of glucose-lowering therapies has arrived with multiple agents that lower blood glucose and demonstrate cardiovascular and renal benefits in people with type 2 diabetes. This article summarizes these new classes of therapies, including the sodium glucose co-transporter-2 inhibitors, glucagon-like peptide-1 agonists, and dipeptidyl peptidase-4 inhibitors. ⋯ As more options become available to treat type 2 diabetes, clinicians need to be aware of the advantages of each class of medications, beyond their glycemic lowering effects. The safety profiles are summarized in this article.
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Low-dose hydrocortisone reduces the dose of vasopressors and hospital length of stay; it may also decrease the rate of hospital-acquired pneumonia and time on ventilator. No major side effect was reported, but glycemia and natremia should be monitored. ⋯ Erythropoietin did not enhance neurologic outcome of traumatic brain-injured patients; such treatment, however, could reduce the mortality in subgroups of patients. This review focuses mainly on glucocorticoids, which are the most extensively investigated treatments in hormone therapy.
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Critical care clinics · Apr 2019
ReviewDiabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone in Critically Ill Patients.
Diabetes insipidus and the syndrome of inappropriate antidiuretic hormone secretion lie at opposite ends of the spectrum of disordered renal handling of water. Whereas renal retention of water insidiously causes hypotonic hyponatremia in syndrome of inappropriate antidiuretic hormone secretion, diabetes insipidus may lead to free water loss, hypernatremia, and volume depletion. ⋯ Moreover, pathologies causing polyuria and hyponatremia in patients in intensive care may be multiple, making diagnosis challenging. We provide an approach to the diagnosis and management of these conditions in intensive care patients.
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The Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3) trial demonstrated the vasopressor effects and catecholamine-sparing properties of angiotensin II. As a result, the Food and Drug Administration has approved angiotensin II for the treatment of vasodilatory shock. This review details the goals of treatment of vasodilatory shock in addition to the history, current use, and recent research regarding the use of angiotensin II. An illustrative case of the use of angiotensin II is also incorporated for understanding the clinical utility of the drug.