Acta Clin Belg
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Acute kidney injury (AKI) is a serious complication in critically-ill patients and portends a high mortality. The incidence of AKI continues to increase and is often underestimated. The intriguing question to both the intensivists and nephrologists is whether the kidney is an innocent bystander in the process of multi-organ systems failure or whether the kidney is initiating various complex metabolic and humoral pathways affecting distant organs contributing to the overall mortality. ⋯ Volume overload and acid-base derangements typical of renal dysfunction have serious consequences in the duration and weaning of mechanical ventilation. Recent animal studies suggest that acutely ischaemic kidneys may induce both functional and transcriptional changes in the lung, independent of uraemia. In this review, we have attempted to discuss various physiological derangements and their clinical effects, in the setting of AKI.
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Review
ICU management of the patient with intra-abdominal hypertension: what to do, when and to whom?
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are increasingly recognised to be a contributing cause of organ dysfunction and mortality in critically ill patients. The number of publications describing and researching this phenomenon is increasing exponentially but there are still very limited data about treatment and outcome. ⋯ This paper describes current insights on management of IAP induced organ dysfunction and lists the most widely used and published non-invasive techniques to decrease IAP with their limitations and pitfalls.
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Cardiovascular dysfunction and failure are commonly encountered in the patient with intra-abdominal hypertension or abdominal compartment syndrome. Accurate assessment and optimization of preload, contractility, and afterload, in conjunction with appropriate goal-directed resuscitation and abdominal decompression when indicated, are essential to restoring end-organ perfusion and maximizing patient survival. The validity of traditional hemodynamic resuscitation endpoints, such as pulmonary artery occlusion pressure and central venous pressure, must be reconsidered in the patient with intra-abdominal hypertension as these pressure-based estimates of intravascular volume have significant limitations in patients with elevated intra-abdominal pressure. ⋯ Volumetric monitoring techniques have been proven to be superior to traditional intra-cardiac filling pressures in directing the appropriate resuscitation of this patient population. Calculation of the "abdominal perfusion pressure", defined as mean arterial pressure minus intra-abdominal pressure, has been shown to be a beneficial resuscitation endpoint as it assesses not only the severity of the patient's intra-abdominal hypertension, but also the adequacy of abdominal blood flow. Application of a goal-directed resuscitation strategy, including abdominal decompression when indicated, improves cardiac function, reverses end-organ failure, and minimizes intra-abdominal hypertension-related patient morbidity and mortality.
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Comparative Study
Acute kidney injury, length of stay, and costs in patients hospitalized in the intensive care unit.
Acute kidney injury (AKI) in patients hospitalized in the intensive care unit (ICU) results in increased morbidity, mortality, and as a consequence, higher health-care costs. The bad prognosis associated with this condition and limited health-care budgets both have raised the issue of how much therapy should be dedicated to ICU patients with AKI. As no universally-agreed standardized definition for AKI is available, wide ranges of incidence are reported and precise estimates of its associated excess of costs are, therefore, difficult to explore. ⋯ Moreover, among survivors, even greater requirements of in-hospital and post-hospitalization care was noted. Notwithstanding the high health-economic burden, full supportive intensive care treatment is justified in this particular cohort of patients. Major efforts are highly required in terms of public health prevention initiatives and the early recognition and timely management of AKI, in ICU hospitalized patients in particular.
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Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations. ⋯ ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.