Current opinion in critical care
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The evaluation and management of acute renal failure in the ICU patient remains a formidable task because of the complexity of this condition. Clinical and physiologic assessment and complementing laboratory and imaging tests are currently insufficient to differ between true renal parenchymal damage (acute tubular necrosis; it is important to realize that this term does not necessarily imply widespread injury, because whole organ dysfunction in humans has often been associated with very limited parenchymal cellular necrosis) and prerenal azotemia (decreased renal blood flow with altered glomerular hemodynamics and subsequently diminished glomerular filtration, without significant epithelial cell injury). Moreover, tubular damage and altered glomerular hemodynamics may coexist or lead to each other, and their relative contribution to the evolving renal dysfunction has not been unequivocally established. ⋯ Because of the difficulties in analyzing the pathophysiology in humans, clinicians continue to rely largely on animal models to guide understanding and rationale for the identification of therapeutic targets. Data from such animal studies are complemented by studies in isolated perfused kidneys, isolated tubules, and tubular epithelial cell cultures. In this report, we summarize some concepts of acute tubular necrosis that have evolved as a result of these studies, evaluate available animal models, and underscore controversies regarding experimental acute tubular necrosis.
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Curr Opin Crit Care · Oct 2002
ReviewOutcome of cardiac surgery patients with complicated intensive care unit stay.
Risk stratification has become an essential element in the practice of cardiac surgery. Several studies have identified preoperative risk factors for adverse outcome. However, outcome is mostly defined by 30-day mortality and morbidity. ⋯ By reviewing the recent data reported in the literature, we can identify a number of preoperative predictive factors for complicated ICU stay, including advanced age, chronic obstructive pulmonary disease, preoperative low ejection fraction, previous myocardial infarction, reoperation, renal failure, combined surgery (coronary artery bypass grafting plus valve surgery), low hematocrit, and neurologic impairment. Short- and long-term outcomes are dependent on the type of postoperative complication. Unfortunately, data regarding the long-term outcome in these situations are very scarce.
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The autonomic nervous system plays an integral role in homeostasis. Autonomic modulation can frequently be altered in critically ill patients. ⋯ The hypothesis that depressed HRV may occur over a broad range of critical illness and injury and may be inversely correlated with disease severity and outcome has been tested in the last decade. In this article, we review recent literature concerning assessment of HRV in patients with critical illness or injury, as well as the potential clinical implications and limitations of HRV assessment in this area.
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An estimated 750,000 cases of severe sepsis occur annually in the United States, and the mortality rate is about 30%. As a condition that disproportionately affects the elderly and is related to invasive and immunosuppressive healthcare, increases in the frequency of sepsis are anticipated. The complex pathophysiology of sepsis encompasses the interplay of pro- and anti-inflammatory mediators, activated circulating and resident inflammatory cells, disrupted coagulation, endothelial activation and injury, vasodilatation and vascular hyporesponsiveness to vasoactive mediators, cardiac dysfunction, and cellular dysoxia. Current management of severe sepsis includes eradication of infection through source control and antimicrobial therapy, aggressive and targeted shock resuscitation that includes fluid administration, correction of anemia, vasopressor support, modest inotropic therapy, infusion of human recombinant activated protein C to selected patients, and compulsive supportive care to manage organ dysfunction and to avoid complications.