Loop Diuretics in Acute Oliguric and Pre-renal States

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Oliguria is common in critically ill patients, the most common cause being a reduction of the effective intravascular volume. Oliguric patients are almost universally treated with escalating doses of loop diuretics in the hope of increasing urine output. However, in the setting of a reduced effective intravascular volume loop diuretics cause a marked fall in glomerular filtration rate with an acute decline in renal function. In this paper we demonstrate that there is no scientific rationale or clinical evidence to support the use of loop diuretics in patients with oliguria and pre-renal azotemia, prophylactically in patients at risk of developing acute renal failure and in patients with established acute renal failure.

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Henderson-Hasselbalch vs Stewart: Another Acid-Base Controversy

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The Henderson-Hasselbalch approach to acid-base physiology and disorders has been the dominant approach for the last 100 years. Over the last 20 years there has been considerable interest in a different approach developed by Peter Stewart. At the center of the controversy around the Stewart approach is replacing the role of bicarbonate with the strong-ion-difference and total weak-acid concentration.The Stewart approach, however, appears to better describe the nature and complexity of the clinical acid-base disorders of the critically ill. The old and the new maybe partially reconciled by combining Stewart’s approach with base-excess. This combination appears to have considerable clinical utility.

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Assessement of Change in Body Water By Multiple Frequency Bioelectrical Impedance in Patients Undergoing Cardiopulmonary Bypass

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Objective: To evaluate the relationship between changes in body bioelectrical impedance (BI) at 1, 50, 100 kHz and fluid balance, as an index of body water changes, in patients undergoing cardiopulmonary bypass.
Design: Descriptive, correlative.
Setting: Intensive Care Unit of a cardiac center Patients: Twenty male patients, before and after elective coronary artery bypass graft surgery with cardiopulmonary bypass.
Interventions: None.
Measurements: Whole body bioelectrical impedance using multiple frequency bioelectrical impedance (Dietosystem, Italy) at multiple frequencies (1, 50, 100 kHz) was conducted preoperatively and three times during the 24 hour postoperative period. The volume of body water compartment was calculated using Guricci’s formula. The calculated fluid balances uncorrected for insensible water losses were measured from fluid intake and output.
Findings: In 24 hours after surgery calculated total body water (TBW), extracellular water (ECW), and intracellular water (ICW) increased by 16.0%, 20.7%, and 13.0%, respectively, but the values were within desirable ranges. There was no correlation between TBW changes measured by MFBIA and calculated fluid balance.
Conclusions: The current study indicates that changes of body water compartment occur during 24 hours after CABG. Calculated ICW increases within 24 hours after CABG.

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SCCM’s Patient and Family Web site

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This Web site will link you to a variety of resources and brochures that may help you understand the ICU environment and the work that occurs there.

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Effectiveness Study of rHuEPO in the ICU

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Purpose: To evaluate the clinical outcomes and resource use in ICU patients receiving rHuEPO in a naturalistic setting.
Methods: A retrospective, case-matched (1:2 ratio) study compared patients receiving rHuEPO to a control group. Patients admitted between January 2000 and July 2002 with an ICU length of stay (LOS) ¡Ý3 days were identifi ed by an electronic data repository. Patients, who received rHuEPO prior to ICU admission, had chronic renal failure or were <18 years of age were excluded. Patients were matched by age (¡À5 years), sex, admission year and ICU type. Collected data included patient demographics, admission date, ICU and hospital mortality and LOS, mechanical ventilation days, serum creatinine concentration, hemoglobin concentration, number of blood transfusions, and ICU resource use. Results: rHuEPO-treated patients (n=391) were matched with 782 controls. Patients receiving rHuEPO had higher Simplifi ed Acute Physiology Scores II (46.2 vs 38.8; p <0.001) and received signifi cantly more blood transfusions than control patients (19 vs 6; p <0.001). After adjusting for severity of illness in a linear regression model, rHuEPO was signifi cantly associated with increased blood transfusions and higher mortality risk. Patients receiving rHuEPO had signifi cantly longer hospital and ICU LOS, mechanical ventilation duration, and higher hospital and ICU mortality rate and hospital resource use (p <0.001). Conclusions: In this real-world retrospective analysis, critically ill patients treated with rHuEPO did not experience clinical benefi ts; however, patients were sicker and received rHuEPO late in their ICU stay. Monitoring prescribing patterns and patient selection of rHuEPO treatment in critically ill patients in clinical practice is recommended to optimize rHuEPO use and outcomes.

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37th Critical Care Congress

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http://www.sccm.org/SCCM/Annual+Congress/Program/

The 37th Critical Care Congress will offer educational sessions on a wide variety of relevant and timely topics that all members of the multiprofessional team will find vital to their practice. The 2008 Congress curriculum will be packed with world-renowned speakers, interactive workshops, thought-provoking panel discussions, stimulating educational sessions, and the opportunity to earn continuing education credits.

At the conclusion of the 37th Critical Care Congress, participants should be able to:

*Recognize recent advances in drug design and development and the relevance to critical illness
*Apply patient care to current and cutting edge information regarding specific therapeutic interventions for the critically ill or injured
*Review, in the context of the intensivist-led, multiprofessional team, new knowledge and strategies to optimize the care and outcomes of the critical care patient

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EXPERIENCE CHEST 2007

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Chicago, Illinois

http://www.chestnet.org/CHEST/program/index.php

CHEST 2007 will offer clinical updates in pulmonology, critical care, cardiothoracic surgery, sleep medicine, and related areas. The learning opportunities will be ideal for:

* Advanced Practice Nurses
* Anesthesiologists
* Cardiologists
* Cardiothoracic Surgeons
* Critical Care Physicians
* Fellows-in-Training
* Hospitalists
* ICU Medical Directors
* Internists
* Pediatric Pulmonologists
* Physician Assistants
* Pulmonologists
* Registered Nurses
* Respiratory Therapists
* Sleep Medicine Physicians

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Critical Care of the Liver Transplant ICU Patients: A Pittsburgh “Point of View”

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The purpose of this review is to summarize the advances in critical care management of the liver transplant ICU patients (patients with end stage liver disease, before and after orthotopic liver transplant). The review is based on search of Medline literature, with a focus on liver failure patients and critical care issues around liver transplantation. Starzl Transplantation Institute at the University of Pittsburgh Medical Center is one of the global leaders in the treatment of end stage liver disease (ESLD). This review is in part based on our work in the 28-bed liver transplant ICU at Montefi ore Hospital, University of Pittsburgh Medical Center, in Pittsburgh, PA. Over the past few years, our understanding of the several important pathophysiologic markers of end stage liver disease has been signifi cantly improved. For example, we do now much better understand hyperdynamic circulation of liver failure, hepatorenal syndrome and its consequences, the role of TIPSS (transjugular intrahepatic portosystemic shunt) and adrenal insuffi ciency in liver failure patients. The management and prophylaxis of variceal bleeding and subacute bacterial peritonitis (SBP), has been successfully standardized. These and other advances in understanding of ESLD pathophysiology and its clinical results, have certainly contributed to more promising outcomes in the ICU management of these complex patients.

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Abdominal Sarcoidosis

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Abdominal sarcoidosis is an uncommon form of sarcoidosis. The clinical presentation of esophageal, gastric, small bowel, colon, appendicular, spleen, pancreas, and abdominal aortic sarcoidosis are discussed in this review. The differential diagnosis of abdominal sarcoidosis is extensive. Other granulomatous diseases including tuberculosis, fungal infections, parasitic diseases, infl ammatory bowel disease, and Whipple’s disease should be excluded before making the diagnosis of gastrointestinal sarcoidosis. Corticosteroid therapy is the mainstay of medical therapy in abdominal sarcoidosis. Second line agents such as methotrexate are also discussed. Surgical intervention may be necessary in patients with bowel obstruction, perforation, or massive hemorrhage. The authors also provide their experience regarding preoperative pulmonary evaluation of patients with pulmonary sarcoidosis undergoing surgery.

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Significantly Raised Brain Natriuretic Peptide in a Young Patient with Dengue Fever without Heart and Renal Failure

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Objective: This is the fi rst case report of association of raised brain natriuretic peptide (BNP) in patients with dengue fever (DF). BNP is raised in patients with heart failure. It can also be elevated in renal failure and subarachnoid haemorrhage in the absence of heart failure. Raised BNP has never been described in patients with DF. Clinical features: We describe a young patient with DF who complained of sudden onset breathlessness on day 3 of admission. She was found to have right sided crepitations. Myocardial screen was done which was negative but BNP was 3555 pg/ml. Her SpO2 and arterial blood gas while breathing room air was normal. There was no elevated jugular venous pressure, pedal edema or laboratory evidence of heart failure. There was no renal impairment or systemic infl ammatory response syndrome. A transthoracic 2-dimensional echocardiography was normal. Treatment: Patient was treated with intravenous fl uids and oral clarithromycin for 5 days. Outcome: Patient was discharged on day 8 of admission. She was well but follow-up BNP was high but on downward trend. She refused any further invasive investigations for heart. Conclusions: BNP may be raised in patient with DF without heart failure. The exact pathogenesis of raised BNP in DF is unclear.

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