Current opinion in critical care
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Sepsis-induced acute kidney injury (SI-AKI) represents the first cause of AKI in ICUs, and renal replacement therapy (RRT) is frequently applied in advanced AKI stages. The debate between 'rescue' indications for RRT start in patients with severe AKI (acidosis, hyperkalemia, uremia, oliguria/anuria, volume overload) and a proactive RRT initiation is still ongoing. In addition, current SI-AKI pathophysiologic theory has identified the toxic effects of soluble middle-molecules released during sepsis and inflammation (pathogen and damaged associated molecular patterns).The purpose of the present review is to summarize the recent literature on RRT for patients with SI-AKI. Supportive or replacement measures for severe stages of renal dysfunction and blood purification techniques for sepsis syndrome will be reviewed. ⋯ In the present review, the recent insights and results from large randomized and nonrandomized trials in the area of RRT applied both as supportive measures for kidney failure and blood purification techniques are described.
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Curr Opin Crit Care · Dec 2018
ReviewAn update on membranes and cartridges for extracorporeal blood purification in sepsis and septic shock.
This review aims to summarize the most recent advances on different membranes and cartridges used for extracorporeal blood purification in critically ill patients with sepsis or septic shock. ⋯ None of the discussed specific membranes or cartridges can currently be recommended as sole adjunctive treatment in sepsis and septic shock. Any available technique should be timely initiated and adapted to the patient's status. Sickest patients seem to benefit more from blood purification. Patient selection is thus of crucial importance and may be optimized by focusing on disease severity and degree of organ failure. Measurement of endotoxin activity and plasma procalcitonin levels can support the selection process but ideal cutoff values need to be defined. Well-designed prospective randomized clinical trials assessing or comparing the various available membranes and cartridges are eagerly awaited.
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Curr Opin Crit Care · Dec 2018
ReviewContinuous renal replacement therapy during extracorporeal membrane oxygenation: why, when and how?
The use of extracorporeal membrane oxygenation (ECMO) is increasing rapidly. Patients on ECMO have a high risk of developing acute kidney injury (AKI) and needing renal replacement therapy (RRT). The aim of this review is to describe different strategies of combining RRT and ECMO and to outline their advantages and drawbacks. ⋯ In patients on ECMO, CRRT can be provided via an integrated approach or independently via parallel systems. An in-depth understanding of the advantages and drawbacks of the different techniques is required.
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Curr Opin Crit Care · Dec 2018
ReviewMajor surgery and the immune system: from pathophysiology to treatment.
The purpose of this review is to provide an overview of the immune response to major surgery, and the ways in which it may be modulated to improve postoperative outcomes. ⋯ The immune system is critical to the host response to tissue injury occurring due to surgery. However, the physiological processes required to resolve the surgical insult can also contribute to sequelae such as cognitive decline, pneumonia and acute kidney injury. Our understanding of the immune pathogenesis underlying these complications is improving, leading to interest in the development of immunomodulatory therapies, which aim to permit host defence whilst ameliorating postoperative complications.
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Curr Opin Crit Care · Dec 2018
ReviewHow to optimize critical care resources in surgical patients: intensive care without physical borders.
Timely identification of surgery patients at risk of postoperative complications is important to improve the care process, including critical care. This review discusses epidemiology and impact of postoperative complications; prediction scores used to identify surgical patients at risk of complications, and the role of critical care in the postoperative management. It also discusses how critical care may change, with respect to admission to the ICU. ⋯ To optimize critical care resources for surgery patients at high risk of postoperative complications, the care process should not only include critical care and monitoring in ICUs, but also strict monitoring in the ward. Prediction scores could help to timely identify patients at risk. More intense care (monitoring) outside the ICU could improve outcome. This concept of critical care without borders could be implemented in the near future to optimize the local resources and improve patient safety. Predict more, do less in ICUs, and more in the ward.