Current opinion in critical care
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Acute renal failure is a serious condition that affects as many as 20% of ICU patients. The most common causes of acute renal failure in the ICU patient are severe sepsis and septic shock. The mortality of acute renal failure in septic critically ill patients remains high despite our increasing ability to support vital organs. This is partly the result of our poor understanding of the pathogenesis of sepsis-induced renal dysfunction. Accordingly, a review of our current understanding of the pathogenesis of septic acute renal failure is timely and relevant. ⋯ This review suggests that, on the evidence available, septic acute renal failure is more likely to be an immune or toxic state rather than simply a hemodynamic condition. The authors speculate that future insights into its pathogenesis might lead to a paradigm shift away from the concept of acute tubular necrosis, which has never been convincingly shown in sepsis, to that of acute tubular apoptosis.
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Curr Opin Crit Care · Dec 2003
ReviewCommunication with family members of patients dying in the intensive care unit.
In intensive care units the patient is usually unconscious and/or incompetent so that the relationship shifts to the family. Interactions between caregivers and families usually follow one of three models. In the first model, a family representative receives information from the caregivers but does not participate in decisions or physical care. ⋯ In the third model, the family members communicate their own wishes, provide physical care to the patient, and participate in medical decision-making. After a description of the studies that measured the quality of information provided to ICU families and by discussing the extent to which respecting the principle of patient autonomy is feasible in the ICU, we will review the literature on studies that identified specific needs of families of dying patients and specific challenges faced by intensivists as they seek to inform the families of dying patients. The need for family-centered care and for a better communication within the patient-family-caregiver trio is also highlighted.
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Curr Opin Crit Care · Dec 2003
ReviewAcid-base and electrolyte analysis in critically ill patients: are we ready for the new millennium?
Disorders of acid-base and electrolytes are commonly seen in critically ill patients. The presence of these disorders typically signals the development of an underlying pathology. These disturbances can be severe and are often associated with worse outcome. Indeed, metabolic acidosis is one of the ways we quantify organ failure. Although acid-base and electrolyte disorders may be a result of the underlying pathophysiology (eg, renal failure, respiratory failure, shock), they may also result from the way in which we manage critically ill patients. ⋯ By adopting a physical-chemical approach to acid-base analysis we are gaining insight to the complexities of acid-base disorders and how their treatments may affect outcome.
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The subject of research ethics and informed consent in the ICU has recently received unprecedented attention during the past year, the reasons for which are reviewed herein. ⋯ Clinical trials should compare new therapies with "standard" ones if a standard of care exists. Surrogate consent is required for research involving most critically ill subjects, and state laws in the United States and national statutes in Europe should reflect this requirement. Conflicts of interest should be identified at both the individual and the institutional levels. Institutional review boards should focus on ethical issues after conflicts of interest are evaluated. Making the investigator-subject relationship transparent should help protect subjects.
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Curr Opin Crit Care · Dec 2003
Review Comparative StudyDialysis strategies in critically ill acute renal failure patients.
Acute renal failure requiring dialysis is a frequent complication in critically ill patients, with a high morbidity and mortality. Until now, no evidence-based guidelines on the optimal treatment of acute renal failure on the ICU are available. This article reviews recent publications that shed light on several specific topics, like optimal treatment modality, dose of dialysis, type of dialysis membrane, and new developments such as slow extended daily dialysis. ⋯ Adequate dialysis is needed to reduce mortality related to acute renal failure in ICU patients. This necessitates an approach that is completely different from that in chronic renal failure.