Seminars in dialysis
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Pulmonary artery catheterization has been a routine part of care for critically ill patients over the past 25 years. Primary hemodynamic data regarding cardiac output and pulmonary pressures can be utilized to make diagnoses and guide therapy. Tissue oxygen delivery and utilization allow inferences about the efficiency of the cardiopulmonary system and the impact of disease and medical therapies on tissue metabolism. ⋯ Optimizing renal perfusion and minimizing pulmonary congestion with precise volume titration are common reasons for performing pulmonary artery catheterization in the intensive care unit. Despite being reassuring to clinicians that hemodynamic therapy is optimal, multiple data from well conducted clinical studies have not demonstrated outcome benefits to patients related to pulmonary artery catheterization. Less invasive techniques to obtain data regarding hemodynamic function are now entering the clinical arena and are being actively investigated.
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Seminars in dialysis · Nov 2006
ReviewRenal replacement therapy in the treatment of acute renal failure-intermittent and continuous.
Renal replacement therapy (RRT) is increasingly used in intensive care as acute renal failure (ARF) is a common and constantly increasing complication in this setting. Different forms of RRT such as intermittent hemodialysis, continuous hemofiltration, or hybrid forms, which combine advantages of both, are available and will be discussed in this article. As a general survival benefit for neither method has been demonstrated, it is the task of the nephrologist or intensivist to choose the RRT strategy that is most advantageous for each individual patient. ⋯ An adequate dose of RRT seems to result in improved survival in patients with ARF. However, clear guidelines on the dose of RRT and the timing of initiation are still lacking. Moreover, it will be discussed whether patients with sepsis and septic shock benefit from early RRT initiation, the use of increased RRT doses, and increased removal of inflammatory mediators by RRT.
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Critically ill patients are anemic early in their intensive care unit (ICU) course. As a consequence of this anemia they receive a large number of red blood cell (RBC) transfusions. ⋯ It is clear that most critically ill patients can tolerate hemoglobin levels as low as 7 g/dl and therefore a more conservative approach to RBC transfusion is warranted. Strategies to minimize loss of blood and increase the production of RBCs are also important in the management of all critically ill patients.
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Seminars in dialysis · Nov 2006
Acid-base disturbances in the intensive care unit: metabolic acidosis.
This article will discuss metabolic acidosis and, to a lesser extent, metabolic alkalosis in the ICU setting. A classification and clinical approach will be the focus.
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The appropriate and timely evaluation and treatment of patients with severely elevated blood pressure is essential to avoid serious adverse outcomes. Most importantly, the distinction between a hypertensive emergency (crisis) and urgency needs to be made. A sudden elevation in systolic (SBP) and/or diastolic blood pressure (DBP) that is associated with acute end organ damage (cardiovascular, cerebrovascular, or renal) is defined as a hypertensive crisis or emergency. ⋯ In patients with a hypertensive emergency, blood pressure control should be attained as expeditiously as possible with parenteral medications to prevent ongoing and potentially permanent end organ damage. In contrast, with hypertensive urgency, blood pressure control can be achieved with the use of oral medications within 24-48 hours. This paper reviews the management of hypertensive emergencies.