Severe Complications of Herbal Medicines

Herbal medicines are being increasingly used for treatment of variety of disorders. Herbal medicines are generally thought to lack severe side effects. Despite of the general belief, herbal medicines are known to cause serious side effects and toxicities. On the other hand, physicians’ knowledge of herbal medicines and their potential toxicities are generally limited. Neurotoxicity, cardiac toxicity, pulmonary toxicity, hepatotoxicity, and nephrotoxicity are potential severe complications of herbal medicines.


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Sublingual Capnometry: A Non-invasive Measure of Microcirculatory Dysfunction in Sepsis

Sepsis is among the most common reason for admission to intensive care units throughout the world. Sepsis is characterized by a generalized microcirculatory injury, which results in tissue dysoxia. Tissue dysoxia is believed to be the causation of multiorgan dysfunction syndrome (MODS) which commonly complicates the course of sepsis. The expedient detection and correction of tissue dysoxia may limit the development of MODS. The standard oxygenation and hemodynamic variables (blood pressure, arterial oxygenation, cardiac output) which are monitored in critically ill patients are “upstream” markers and provide little information as to the adequacy of tissue oxygenation. Global “downstream” markers of tissue dysoxia such as mixed venous oxygen saturation and blood lactate are insensitive indicators of the extent of the microcirculatory injury in patients with sepsis. Sublingual/buccal mucosal PCO2 is a regional marker of microvascular perfusion and tissue dysoxia that holds great promise for the risk stratifi cation and endpoint of goal-directed resuscitation in patients with sepsis.


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Cardiopulmonary Emergencies in Sarcoidosis

Sarcoidosis is a systemic disease that commonly involves the lungs and the heart. Although rare, lifethreatening cardiopulmonary emergencies can occur. Acute respiratory failure, massive hemoptysis, and cardiac emergencies are described in sarcoidosis. These clinical manifestations can be the first clinical presentation of sarcoidosis. The subject of cardiopulmonary sarcoidosis is reviewed.


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Clevidipine: A Unique Agent for the Critical Care Practitioner

Clevidipine is a new third generation intravenous dihydropyridine calcium channel blocker. It is a specific arterial vasodilator developed for the acute reduction and control of arterial blood pressure in the perioperative period. This drug has an extremely short half life and is rapidly metabolized by tissue and plasma esterases. Clevidipine is a potent arterial vasodilator with very little or no effect of the myocardial contractility and venous capacitance and also minimal side effects. Clevidipine can also theoretically help to protect against organ reperfusion injury. Theoretically, this effect resides in the capacity of this agent to debilitate oxygen free radical-mediated toxicity, cell calcium overload and augment endothelial nitric oxide bioavailability through antioxidative actions. As a result it may diminish the severity of low flow myocardial ischemia and preserve the coronary endothelial function thereby reducing the infarct size. Due to all the characteristics of this parenteral agent it promises to be the drug of choice for the critical care practitioner for the strict control of blood pressure in different clinical scenarios.


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Cardiac troponin I elevation in subarachnoid hemorrhage: Should we worry?

Troponin I can be used as a marker not only for cardiac outcome in patients with SAH; but also as predictive for complications such as DCI, hypotension and pulmonary edema. More over it can be used as a prognostic factor in terms of functionality.


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Hyperglycemia after trauma: Physiologic and tolerable or a possible threat that needs to be corrected?

Admission hyperglycemia is associated with an increased morbidity and mortality in the critically ill trauma population studied by Sung and coworkers. There are a variety of mechanisms involved and attempts to control the glycemic index should become routine in the management of these patients.


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IABP deployment in critical care

The Intra Aortic Balloon Pump (IABP) is an established support in addition to pharmacologic treatment of the failing heart after myocardial infarction, unstable angina, cardiac surgery and percutaneous coronary intervention (PCI). The indication for IABP in acute myocardial infarction expanded to include support of severely ill patient during acute cardiac catheterization and myocardial revascularization both percutaneous and surgical. An international randomized trial, SHould we emergently revascularized Occluded Coronaries for cardiogenic shocK? (SHOCK) reported that cardiogenic shock patients treated with the combination of IABP support followed by early angiography and myocardial revascularization, and/ or thrombolytic therapy had the lowest observed inhospital mortality. The Benchmark Registry revealed plausible IABP economic benefits in total hospital costs; whereas, the potential benefits of careful use of IABP therapy are unlikely to be offset by vascular and hemorrhagic complications. The inference, whether IABP can be appropriate initial therapy at hospitals without revascularization facilities, if followed by prompt transfer to tertiary centers in the developing world, requires careful assessment.


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Lactate is the ultimate oxidative energy substrate in brain and elsewhere

Now-a-days, the focus on lactate is due to its being an oxidative substrate for energy metabolism in brain (and other tissues), rather than a useless end product of anaerobic glycolysis. Mounting evidence indicates that lactate does play a major role in aerobic energy metabolism in the brain, the heart, skeletal muscle and possibly in any other tissue and organ. Nevertheless, this evidence has challenged the old concept of lactate being an anaerobic waste product and ignited a fierce debate between the supporters of glucose as the major oxidative energy substrate and those who support lactate as a possible alternative to glucose under certain conditions. While researchers working on energy metabolism in skeletal muscle have taken great strides toward bridging between these two extreme positions, accepting lactate role as an oxidative energy substrate, neuroscientists appear to be somewhat more emotional about their differences and less agreeable. In this paper I have employed findings from research on skeletal muscle along with the existing old and new data on cerebral energy metabolism, to postulate that lactate is the only major product of cerebral (and other tissues) glycolysis, whether aerobic or anaerobic, neuronal or astrocytic, under rest or during activation. Accordingly, lactate is a major, if not the only, substrate used by the mitochondrial tricarboxylic acid cycle. If proven true, this hypothesis should provide a better understanding of the biochemistry and physiology of (cerebral) energy metabolism and hold important implications where neuroimaging is concerned.


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Spontaneous breathing during mechanical ventilation in ARDS

The objective of mechanical ventilation used in the management of Acute Respiratory Distress Syndrome (ARDS) is to ensure adequate tissue oxygenation and alveolar ventilation while limiting the patients’ work of breathing and preventing further damage to the lungs. Although the “partial support” ventilation modes were initially developed to assist weaning or liberation from supported ventilation, they have gained increasing popularity as primary ventilation modes, even in patients in with severe acute pulmonary dysfunction. Allowing spontaneous breathing is known to alter both lung mechanics and physiological effects of ventilation, therefore has potential influence on important patho-physiological changes and complications that occur. Spontaneous ventilation has the potential to improve outcomes in ARDS, and therefore is worthy of an intensivist’s attention. A clinical trial of the use of pharmaceutical paralysis suggest a protective effect against worsening respiratory failure by ablating spontaneous breathing in ARDS. Overdistension of alveoli, even at low ventilator driving pressures may be as dangerous as high tidal volume (TV) controlled ventilation and thus naïve use of unrestricted spontaneous breathing techniques may be detrimental. As evidence of both improvement and deterioration exist the hypothesis remains controversial, and warrants a properly conducted randomised trial.


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Is there any need for higher PEEP levels in ARDS patients?

Lung protective ventilation has been shown to reduce mortality in ARDS patients. Current guidelines are focussed on lowering tidal volumes and minimizing mean airway pressures. In this review we discuss possible future improvements to mechanical ventilation; especially the open lung maneuver. We discuss the rationale for the use of higher PEEP levels in ARDS patients, using data from animal and human studies. Finally, guidelines for future strategies and/ or investigations are presented.


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Fluid resuscitation: the good, the bad and the ugly

Fluid resuscitation is one of the most common therapeutic steps in the critically ill. In this brief overview, the goals and potential adverse effects of fluid resuscitation are addressed. The contention is that the value of many of the fluid resuscitation goals in hypovolemic patients has not been unequivocally established, that overhydration is a significant problem and that certain types of fluids can be associated with major adverse effects. Hence, fluid loading should be carefully done and adequately monitored to avoid these effects and to improve survival of patients with hypovolemia and hemodynamic insufficiency.


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Pyrexia in the critically ill

Temperature change is a conserved physiological response to infection. In animal studies cytokine responses associated with body temperature changes have been elucidated. In humans with sepsis, hypothermia appears to be associated with higher TNF-alpha concentrations and has a significantly higher mortality. However, the presence of pyrexia does not appear to influence outcome from infection. The routine use of antipyretic agents remains controversial and studies in patients with viral infections suggest that their use may be associated with an anti-inflammatory effect with prolonged time to viral clearance – and surprisingly, little evidence of improvement in symptoms. In one ICU study it would seem that ibuprofen when used in the sub-group of patients with hypothermia and sepsis is associated with an improvement in outcome.


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Hypoxic tissue damage and the protective effects of therapeutic hypothermia

Several molecules, chemicals and cells are involved in tissue damage during any hypoxic event, such as a cardiac arrest, a respiratory arrest or a cerebrovascular accident. Among them: calcium, protein kinase enzymes, calcium binding proteins, S-100â protein and adhesion molecules such as intracellular adhesion molecule-1 (ICAM-1) are frequently cited in the literature. Controversy exists as to whether these “hypoxic aggressors” can be modified favorably by the use of therapeutic hypothermia. This review focus on the role of these different molecules, chemicals and cells and the protective effect of therapeutic hypothermia.


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Life-threatening hyponatremia in marathon runners: The Varon-Ayus syndrome revisited

Life-threatening hyponatremia can occur when sodium concentration falls to 125 mmol/L or less. Symptoms usually do not depend on the absolute sodium concentration but on the rate of fall. Estimates of mortality in acute hyponatremia are as high as 50%. Marathon runners are at particular risk of developing a syndrome which consists of severe hyponatremia, pulmonary edema and cerebral edema as originally described by Varon and Ayus. This syndrome, if not managed appropriately has a very high morbidity and mortality.


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