Best practice & research. Clinical anaesthesiology
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Acute renal failure (ARF) is a common problem in intensive care medicine. Even modest degrees of ARF not requiring dialysis treatment increase the risk of death approximately fivefold. Despite the widespread appreciation of the role of nephrotoxic drugs in their contribution to ARF, these drugs continue to have an ongoing aetiological role. ⋯ Tubular injury initiated by toxins often results from a combination of acute renal vasoconstriction and direct cellular toxicity due to intracellular accumulation of the toxin, or, alternatively, may be mediated immunologically in case of interstitial nephritis. Patients with reduced renal functional reserve, cardiovascular co-morbidity, diabetes mellitus, and advanced age are at increased risk. Awareness of the range of toxins on the one hand and simple measures such as adequate pre-hydration of the patient and drug monitoring on the other hand may be sufficient to avoid drug-induced ARF or minimize its clinical severity in susceptible patients.
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Best Pract Res Clin Anaesthesiol · Mar 2004
ReviewPrevention of perioperative acute renal failure: what works?
Perioperative acute renal failure (ARF) is associated with increased morbidity and mortality. Patients undergoing cardiac, vascular and major abdominal surgery and those with pre-operative renal insufficiency are at increased risk for developing post-operative ARF. The aetiologies of perioperative ARF are multi-factorial. ⋯ Various pharmacological agents have been used to optimize renal perfusion and tubular function. Unfortunately, none has been shown to be effective in randomized placebo-controlled trials. In this chapter, we discuss the prophylactic use of fluids, vasoactive drugs, diuretics and other agents, as well as modification of surgical techniques to reduce the incidence of perioperative ARF.
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Best Pract Res Clin Anaesthesiol · Mar 2004
ReviewVascular access for dialysis in the intensive care unit.
Management of the vascular access (VA) for renal replacement therapy (RRT) in acute renal failure (ARF) patients is faced with a twofold problem: first, the creation of an angio-access that is adequate for RRT in the acute setting; second, the preservation of the patient's vascular network in order not to preclude further use of the vessel in the event of evolution to chronic renal failure. Central venous catheters are the preferred VA for RRT in the intensive care setting. Semi-rigid double-lumen polyurethane catheters may be considered for short-time use (up to 2-3 weeks). ⋯ Catheter handling and care should comply with best practice guidelines and should be part of a continuous quality improvement programme in order to reduce catheter-related morbidity. Preservation of the upper limb vascular network of the patient consists of sparing the native vessels (artery and vein) of the patient and preserving the functionality of the permanent VA in chronic renal failure patient. This 'lifeline' of chronic renal failure patients may be maintained by preventing inflammation, infection and thrombosis of the superficial vessels of the arm and forearm of patient.
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Best Pract Res Clin Anaesthesiol · Mar 2004
ReviewPerioperative management of patients with chronic kidney disease or ESRD.
The perioperative management of patients with chronic kidney disease (CKD) or dialysis-dependent end-stage renal disease (ESRD) is complicated by both the underlying renal dysfunction, with associated disturbances of fluid and electrolyte homeostasis and altered drug clearance, and the presence of associated co-morbid conditions, including diabetes mellitus, chronic hypertension and cardiovascular and cerebrovascular disease. The impact of CKD on fluid and electrolyte management, haematological and cardiovascular complications and drug management in the perioperative period are reviewed. Special issues related to the management of haemodialysis and peritoneal dialysis patients in the perioperative period are also reviewed.
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Mechanical ventilation is a standard component of intensive care unit management of critically ill patients and is widely used for respiratory support. Recent animal and clinical studies have shown that positive pressure ventilation can worsen pre-existing lung injury and produce ventilator-induced lung injury, which has been linked with the development of systemic inflammation and multi-system organ dysfunction, including renal failure. ⋯ Interestingly, recent data are emerging which suggest that renal dysfunction also has a direct, adverse effect on pulmonary function. This chapter reviews the information in these areas and provides a framework for future investigation in this field.