The Journal of critical illness
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Elderly patients are susceptible to acute renal failure largely because of functional impairment of the kidneys secondary to diseases such as arteriosclerosis, hypertension, and heart failure. Successful prevention of renal failure in the elderly hinges on understanding the age-associated changes in renal anatomy and physiology. To prevent renal failure, rehydrate elderly patients who suffer significant fluid loss to avoid volume depletion. In addition, maintain adequate blood pressure in these patients, consider glomerular filtration rate when determining the dosage of nephrotoxic antibiotics, and administer saline preparation before injecting radiocontrast dyes.
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Tracheotomy can relieve upper airway obstruction, improve pulmonary hygiene, and support long-term mechanical ventilation. Consider performing a tracheotomy whenever the need for more than 14 days of ventilatory support is anticipated. ⋯ Accidental tube displacement within 5 days of surgery is potentially tracheotomy's most lethal early complication. Many late complications can be prevented by careful management and expert nursing support.
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Severe anxiety can disrupt neurohumoral metabolism and lead to agitation and brain failure, which may result in delirium. Predisposing factors include cerebral vascular or endocrine insufficiency, cardiopulmonary decompensation, poor tissue perfusion, multiple medications, and sleep-wake cycle disruption; the stressful ICU environment puts patients especially at risk. Stress-induced noradrenergic hyperactivity can precipitate panic attacks; dopaminergic hyperactivity can lead to delirium (marked by paranoid delusions, visual or auditory hallucinations, and psychomotor agitation). The underlying cause of anxiety must be identified to guide appropriate therapy.
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Gastric tonometry is a noninvasive technique for early detection of splanchnic ischemia. Some studies have found that measurement of intramucosal pH (pHi) is able to predict outcome in critically ill patients. ⋯ Furthermore, accurate pHi measurement requires administration of an H2 blocker 60 to 90 minutes before patients undergo the procedure. Therefore, the role of gastric pHi in guiding therapy remains undefined.
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The initial work-up of a critically ill patient with fever begins with a hunt for an infectious cause. A positive urine culture, or the presence of dysuria or suprapubic tenderness, suggests urinary tract infection. ⋯ Other common causes of fever in the ICU include abdominal abscesses and catheter-related infections; atelectasis has not been shown to cause fever. If the initial work-up fails to establish a cause of postoperative fever, and the fever resolves within 4 days, no further work-up is required.