Current opinion in critical care
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Withdrawal of life-sustaining medical treatment (LSMT) is under scrutiny as next-of-kin challenge medical decision-making in the courts and established end-of-life pathways are withdrawn in the face of public criticism. With persistent lobbying for medically assisted dying as the other side of the coin, and professional advice that doctors distance themselves from this activity, the fine line between defensible palliative care and hastening a death needs to be unambiguously defined, particularly with additional confounders such as transplantation initiatives. ⋯ The process and, therefore, the timing of dying is open to manipulation by intensivists, families, other hospital physicians, courts of law and extraneous influences such as organ donation. Intensivists faced with these challenging processes need to consider some key principles to help them navigate the management of dying. They need to demonstrate transparency in order to engender trust, be responsive to the dynamically evolving needs of patient and family, avoid ambiguity, show consistency and predictability and, finally, they need to conform with society's expectations and professional standards to achieve defensibility for their actions. Adherence to these principles is likely to minimize conflict, maximize patient benefit, maintain public confidence and avoid professional jeopardy.
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Septic shock is one of the most common and life-threatening conditions afflicting critically ill patients. Intravenous volume resuscitation is considered an initial and very important step in management. The most suitable fluid for volume expansion during septic shock remains unclear. In this review, we focus on the benefits and adverse effects of the most commonly used intravenous fluids in critically ill septic patients. ⋯ Crystalloids should still be considered as the first-choice drug for volume resuscitation in patients with septic shock. Colloids such as albumin can be considered in some clinical settings. HES should be avoided. Balanced crystalloids might have an important role to play in the management of septic shock.
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Curr Opin Crit Care · Dec 2013
ReviewTherapeutic targeting of the mitochondrial dysfunction in septic acute kidney injury.
Acute kidney injury (AKI) is a common and serious complication of severe sepsis. No targeted therapies exist for sepsis-associated AKI, suggesting a pressing need for elucidation of the underlying pathogenic mechanisms. ⋯ Recent findings from human and experimental septic AKI studies strongly implicate the mitochondrion as an important target for sublethal kidney injury. Stimulating the natural pathways through which mitochondrial function is normally recovered following sepsis represents a promising strategy for the development of novel therapies.