Critical care clinics
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Erythropoietin (EPO) is a 34kD pleiotropic cytokine that was first identified as being essential for red blood cell (RBC) production. It is now recognized however that EPO is produced by many tissues. ⋯ Large clinical trials in the critically ill failed to demonstrate a role for EPO as an RBC transfusion sparing agent; however, improved clinical outcomes, attributable to EPO role in tissue protection are observed in critically ill trauma patients. Further research to confirm or refute these observations is required.
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Improved survival after critical illness has led to recognition of impaired recovery following critical illness as a major public health problem. A consistent association between critical illness and accelerated bone loss has been described, including changes in bone turnover markers, bone mineral density, and fragility fracture rate. An association between accelerated bone turnover and increased mortality after critical illness is probable. Assessment of the effect of antifracture agents on fracture rate and mortality in the high-risk population of postmenopausal women with prolonged ventilation is warranted.
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Optimal supportive treatment of brain dead potential organ donors maximizes donation and transplant outcomes. Brain death is associated with activation of inflammatory pathways and loss of autoregulatory brain functions that may include hypothalamic-pituitary dysfunction. As well as general supportive care, specific treatment to counter the common sequelae of brain death such as hypotension, hypothermia, and diabetes insipidus is required. In addition, the provision of specific hormonal therapy (thyroid hormone, vasopressin, and steroids) has been proposed but is controversial due to lack of high level evidence to support its efficacy.
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Vasodilatory shock is the most common type of circulatory shock in critically ill patients; sepsis the predominant cause. Steroid use in septic shock gained favor in the 1970s; however, studies of high-dose steroids demonstrated excess morbidity and mortality. ⋯ Two recent trials are likely to reinforce the role of steroids in septic shock and change the recommendation in future clinical practice guidelines. Future work could include elucidating mechanisms of shock reversal, interaction of hydrocortisone with other agents, identifying steroid responsiveness using biochemical or gene signatures, and clarifying the role of fludrocortisone.
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Critical care clinics · Apr 2019
ReviewTherapeutic Opportunities for Hepcidin in Acute Care Medicine.
Iron homeostasis is often disrupted in acute disease with an increase in catalytic free iron leading to the formation of reactive oxygen species and subsequent tissue-specific oxidative damage. This article highlights the potential therapeutic benefit of exogenous hepcidin to prevent and treat iron-induced injury, specifically in the management of infection from enteric gram-negative bacilli or fungi, malaria, sepsis, acute kidney injury, trauma, transfusion, cardiopulmonary bypass surgery, and liver disease.