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Gude D.,Critical Care | Jha R.,Medwin Hospital
Annals of Cardiac Anaesthesia | Year: 2012

Acute kidney injury (AKI), a recognized complication of cardiac surgery with cardiopulmonary bypass (CPB) is associated with increased morbidity and mortality (15-30%) with approximately 1% of all the affected patients requiring dialysis. Early detection of AKI would enable intervention before occurrence of irreversible injury and might minimize the morbidity and mortality. Recently developed biomarkers of AKI facilitate its earlier discovery and help assessment of its severity and prognosis. In this article, we review the causes of well-known yet inexplicable association between CPB and AKI, the advances in pathophysiologic basis, the diagnostics and the management options. Source


Ventetuolo C.E.,Critical Care | Muratore C.S.,Hasbro Childrens Hospital
American Journal of Respiratory and Critical Care Medicine | Year: 2014

Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults. Copyright © 2014 by the American Thoracic Society. Source


Jokar T.O.,Critical Care
Journal of Trauma and Acute Care Surgery | Year: 2016

INTRODUCTION: Assessment of operative risk in geriatric patients undergoing emergency general surgery (EGS) is challenging. Frailty is an established measure for risk assessment in surgical cases. The aim of our study was to validate a modified 15 variable emergency general surgery specific frailty index (EGSFI). METHODS: We prospectively collected geriatric (age > 65) emergency general surgery patients for 1-year. Post-operative complications were collected. Frailty Index was calculated for 200 patients based on their pre-admission condition using 50-variable modified Rockwood Frailty Index (FI). EGSFI was developed based on the regression model for complications and the most significant factors in the FI. ROC curve analysis was performed to determine cutoff for frail status. We validated our results using 60 patients for predicting complications. RESULTS: A total of 260 patients (200 developing, 60 Validation) were enrolled in this study. Mean age was 71 ± 11 years, and 33% developed complications. Most common complications were pneumonia (12%), UTI (9%), and wound infection (7%). Univariate analysis identified 15 variables significantly associated with complications that were used to develop the EGSFI. A cutoff frailty score of 0.325 was identified using ROC curve analysis for frail status.Sixty-patients (frail: 18, non-frail: 42) were enrolled in the validation cohort. Frail patients were more likely to have post-operative complications (47% vs. 20%, p < 0.001) compared to nonfrail patients. Frail status based on EGSFI was a significant predictor of post-operative complications (OR=7.3, 95%CI = 1.7 – 19.8; p=0.006). Age was not associated with postoperative complications (OR=0.99, 95%CI = 0.92 –1.06; p=0.86). CONCLUSION: The 15-variable validated EGSFI is a simple and reliable bedside tool to determine the frailty status of patients undergoing emergency general surgery. Frail status as determined by Abstract the EGSFI is an independent predictor of post-operative complications and mortality in geriatric emergency general surgery patients. LEVEL OF EVIDENCE: Level II, Prognostic Studies - Investigating the Effect of a Patient Characteristic on the Outcome of Disease © 2016 Lippincott Williams & Wilkins, Inc. Source


Smith G.B.,Bournemouth University | Welch J.,University College London | DeVita M.A.,Critical Care | Hillman K.M.,University of New South Wales | And 2 more authors.
Resuscitation | Year: 2015

In-hospital cardiac arrests (IHCA) occur infrequently and individual staff members working on general wards may only rarely encounter one. Mortality following IHCA is high and the evidence for the benefits of many advanced life support (ALS) interventions is scarce. Nevertheless, regular, often frequent, ALS training is mandatory for many hospital medical staff and nurses. The incidence of pre-cardiac arrest deterioration is much higher than that of cardiac arrests, and there is evidence that intervention prior to cardiac arrest can reduce the incidence of IHCA. This article discusses a proposal to reduce the emphasis on widespread ALS training and to increase education in the recognition and response to pre-arrest clinical deterioration. © 2015 Elsevier Ireland Ltd. Source


Curtin L.B.,Critical Care | Cawley M.J.,University of the Sciences in Philadelphia
Pharmacotherapy | Year: 2012

Phenylephrine, an α1-Adrenergic agonist, and methamphetamine, a prescription drug and substance of abuse, have similar chemical structures and thus have the potential to cross-react in qualitative screening tools such as a urine drug screening (UDS) performed by immunoassay. This cross-reactivity may yield a false-positive result that may affect the provision of care in certain patient populations and clinical situations. We describe a 36-year-old woman with confirmed brain death after a short hospital stay who had an initial UDS that was negative for methamphetamine. The patient was assessed for potential organ donation, which included obtaining a follow-up UDS. A urine sample was obtained after being hospitalized for 36 hours, which tested positive for methamphetamine, with no suspected ingestion of the target substance. Confirmatory laboratory testing indicated that intravenous phenylephrine and its metabolites were the likely cause of the false-positive UDS. However, the patient was not deemed to be a suitable candidate for organ donation, but clear documentation of the reason for denial of organ donation was not available in the patient's medical record. To our knowledge, this is the first case published in the English-language literature that describes the clinical occurrence of apparent immunoassay cross-reactivity of methamphetamine and phenylephrine that resulted in a false-positive UDS for methamphetamine. In addition, this report describes the potential implications of this situation on clinical care, including organ donation acceptance. Toxicology screening in the emergency department and intensive care unit is a tool to assist in the diagnosis of medical conditions, but it may not always be reliable. Therefore, positive immunoassay results that may change the management of a patient's condition should be quickly verified with confirmatory testing to minimize unfavorable consequences. Copyright © 1999-2012 John Wiley & Sons, Inc. Source

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