Colloid Osmotic Pressure

Colloid osmotic pressure measurement is easy and cannot be derived by reference to protein measurements Its measurement may have a role in predicting prognosis although this is disputed. A low colloid osmotic pressure may influence the choice of resuscitation fluid since crystalloids would depress colloid osmotic pressure further. However, colloids tend to maintain rather than raise colloid osmotic pressure. One of the most important reasons to measure colloid osmotic pressure in critically ill patients is to prevent an excessive rise in patients on renal replacement therapy. Such a rise will prolong the recovery of renal failure.


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PMN and Lymphocyte Apoptosis in the Critically Ill: Different Means, Similar Outcome

Accidental traumatic injury remains the fifth leading cause of death in America Behind heart disease, cancer, stroke and lung disease. Frequently, patients that survive the initial injury and do not succumb to major central nervous system or internal organ damage during the first day develop inflammatory complications, which result in morbidity and mortality due to multiple organ failure/dysfunction. These complications include non-septic inflammation of damaged tissue/organs, the adult respiratory distress syndrome (ARDS), and sepsis. While apoptosis, or programmed cell death, was initially understood as a mechanism by which cells of the immune system are cleared as a means of natural cell turnover or resolution of an inflammatory response, dysregulated apoptosis can be detrimental to the organism. Here we will briefly summarize data from both experimental animal models and critically ill patients that address (1) the suppression of neutrophil apoptosis in the critically ill, (2) the increase of lymphocyte (B and T cell) apoptosis, which leads to immunosuppression, (3) inflammatory mediators, such as cytokines, which appear to play predominant roles in neutrophil and lymphocyte apoptosis, and (4) the importance of the Bcl-2 familty in the regulation of apoptosis in the critically ill. These data clearly demonstrate the complexity of the apoptotic response and, thus, justify the need to increase our understanding of apoptosis in the critically ill. Such information will provide us with new insights, and possibly offer better therapeutic targets for the management of these devastating conditions.


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Cytopathic Dysoxia Revisited

Most patients in septic shock die from the ensuing multi-organ dysfunction syndrome (MODS) rather than the acute inflammatory process per se. How systemic inflammation produces MODS remains unknown and many conundrums exist. It has been traditionally ascribed to tissue hypoxia secondary to microvascular shunting of blood away from nutrient capillaries. However, cell death, the expected corollary, is surprisingly absent in these failed organs despite gross biochemical and functional abnormality. With increasing severity of sepsis, tissue oxygen extraction falls with a decrease (relative or absolute) in tissue oxygen consumption. Nevertheless, tissue oxygen tensions rise, suggesting cellular availability but decreased utilisation, i.e. dysoxia. As mitochondrial oxygen consumption accounts for around 90% of total body oxygen utilisation, mitochondrial dysfunction leading to bioenergetic failure is a reasonable postulate to account for the biochemical and physiological perturbations witnessed in the septic patient. Importantly, nitric oxide and other reactive species, released in vast excess in sepsis, are potent inhibitors of mitochondrial oxidative phosphorylation. We review the increasing body of evidence derived from cell, animal and patient studies that implicate dysoxia as an important mechanism underlying the pathophysiology of multi-organ dysfunction.


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The Management of Head Trauma in Children

In the United States, head trauma is a major cause of death and disability in children. There are significant epidemiological, anatomical and physiological differences in pediatric patients, which make them susceptible to additional complications and permanent brain injury. This article presents an over view of the initial assessment and management of pediatric head trauma in the acute care setting.


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Oxidative Stress and Cardiovascular Dysfunction in Sepsis

A state of severe oxidative stress and cardiovascular dysfunction are both associated with the dysregulated immuno-inflammatory response encountered in sepsis. The hemodynamic changes seen are typically a reduction in vascular tone and myocardial depression, accompanied by a preserved or increased cardiac output. Inflammatory mediators (including cytokines, endothelial-derived factors, and reactive oxygen species), regulated by nuclear factor kappa B, appear to have an integral role in mediating this cardiovascular dysfunction. This review gives a background to the oxidative stress encountered in sepsis, together with an overview of the proposed mechanisms underlying the cardiovascular dysfunction in sepsis and the role which reactive oxygen species and oxidative stress appear to have in its pathogenesis. The results of endogenous antioxidant repletion and synthetic antioxidant administration in sepsis and their effects on the cardiovascular dysfunction seen are reviewed. The role of more direct superoxide anion inhibition is also highlighted.


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Energy, Trace Element And Vitamin Requirements in Major Burns

Nutritional management of patients with severe burn injuries remains a challenge for the clinician. Energy requirements are increased for prolonged periods of time. Substrate flux is accelerated. Catabolism is strongly enhanced, resulting in the loss of lean body mass: full nutritional support is unable to reverse this process. Increasing protein and carbohydrate intakes above respectively 1.3 g/kg/d and 4 mg/kg/min has no proven metabolic benefit. On the contrary, high intakes of carbohydrates and prolonged hypernutrition result in increased de novo lipogenesis, with the risk of developing liver complications like fatty liver infiltration. Strategies to reduce energy expenditure have been developed including early surgery, warm environment, pharmacological treatments (beta-blockade). Trace element and vitamin needs are also strongly increased. The micronutrients have particularly important antioxidant functions after major burns: they contribute to the reduction of lipid peroxidation, to the immune defence, and are essential in most anabolic pathways. There are strongly increased requirements for copper, selenium, zinc, alpha-tocopherol and ascorbic acid. The optimal route for nutrition is the gut, gastric and postpyloric accesses being possible. Enteral nutrition should be used first, and started during the first 24 hours of injury, but parenteral nutrition should not be excluded in patients intolerant to this feeding mode.


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Resuscitation in The Bible

The Bible is occasionally cited as the source of written descriptions of the earliest instances of resuscitation. A number of accounts of recovery from death are found in the Bible. Two Old Testament episodes that appear to describe resuscitation are related in the books of Kings, and involve the Hebrew prophets Elijah and Elisha. The story of Elisha, Elijah’s successor as Prophet of Israel, is the one most frequently cited in medical articles as representing the earliest documented case of mouth-to-mouth resuscitation. The opinions of biblical and medical scholars differ on this point. Another episode that may represent resuscitation is told in the New Testament, and regards an action by the Apostle Paul. Within a century of this episode, the investigations of Galen marked the dawning of a new era in medical inquiry that was ultimately to lay the scientific foundations of resuscitation. However, episodes from the Bible had already served to display the possibility that resuscitation could be achieved.


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Ventilator – Associated Pneumonia: Pathophysiology, Diagnosis, and Treatment

Ventilator Associated Pneumonia (VAP) is a common and important problem in the ICU. It affects approximately 25 % of ICU patients. With the rise of mechanical ventilation throughout the world its occurrence will only increase. Mortality from VAP is in the range of 30-70%. With early diagnosis and treatment the mortality may be decreased. In this review we will discuss the pathophysiology, diagnosis and treatment of VAP. Through proper education and diagnosis we may be able to decrease the incidence of VAP and thereby decrease the complications of this very common problem.


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Loop Diuretics in Acute Oliguric and Pre-renal States

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

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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Effectiveness Study of rHuEPO in the ICU

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

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

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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Acid-Base Disturbance Analysis: Comparison of the Traditional and Stewart Approaches

Introduction: The new approach to acid-base balance which initially proposed by Stewart in 1978 was success to provide a new insight which more easy to understand what is the cause, the mechanism and the degree of acid-base disturbance. The purpose of the present study was to compare two different methods of analysis acid-base disturbance in patients admitted to Pediatric Intensive Care Unit (PICU). Methods: The study was performed in 43 patients admitted to the pediatric intensive care unit of Cipto Mangunkusumo Hospital, Jakarta. Sodium, potassium, chloride, albumin, lactate and arterial blood gases were measured. All samples were taken from artery in every patient. The anion gap (AG) was calculated using the Narins method (1977), the corrected anion gap (AGcorr) using the Moviat method (2003), the strong ion gap (SIG) using Kellum method (1995) and the base excess unmeasured anions (BEUA) using the Fencl-Stewart method simplifi ed by Story (2003). Results: The presence of unmeasured ions identifi ed by signifi cantly abnormal BEUA was poorly identifi ed by SBE. Of the 43 patients included in the study, 18 (41.9%) had a different interpretation of acid-base balance when the Fencl-Stewart method was used compared to using SBE. There was good correlation between SIG and AG (r =0.831), and there was excellent correlation between SIG and AGcorr (r =0.991). Conclusions: In the condition of electrolyte unbalance and hypoalbuminemia the Stewart approach is better than the traditional approach. Nevertheless, the calculation of SIG is more timeconsuming, therefore the corrected anion gap (AGcorr) was suggested to use in clinical practice as a combination with SBE.


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Extra-Pulmonary Sarcoidosis: Neurosarcoidosis - Case Presentation and Literature Review

More than a century after the description of sarcoidosis, the disease remains not well understood. Sarcoidosis is an infl ammatory disease of unknown etiology characterized by noncaseating granulomas with multiple organs affected. The epidemiology reveals lung involvement in 90- 95% of the patients and just 5-13% incidence of neurological involvement. We present an unusual case of a patient with medulla oblongata and retroperitoneal sarcoidosis with no other organ involvement. In addition to the case presentation and extensive up-to-date literature review on extrapulmonary sarcoidosis, we describe the diffi culties in making the diagnosis and the challenge in differentiating sarcoidosis from other illnesses such as tuberculosis.


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