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Rose and Life: Anaphylaxis Following Rose-Thorn Prick Injury
Neeraj Kumar, Amarjeet Kumar, Sanjeev Kumar
2019, 1:72 (27 September 2019)
We report a case of rose-thorn prick injury in a 60-year-old woman. She presented within hours of exposure to rose-thorn prick and after ruling out all other possible reasons of anaphylaxis. We initiated conservative mode of treatment with moist oxygen inhalation through face mask, nebulized adrenalin, intravenous corticosteroids, antihistaminic, and fluid resuscitation. She was immediately shifted to the intensive care unit in view of any airway obstruction and further hemodynamic monitoring. To the best of our knowledge, this is the first reported case of anaphylactic shock caused by rose-thorn injuries. Hence, to combat these life-threatening situations, proper education and training are given to healthcare personnel's and preparation of pre-filled adrenaline syringes for auto-injection should be kept ready in such places, especially in resuscitation areas.
  11,285 338 -
Pain and its Management in Severe Acute Pancreatitis
Yi Long, Zhengying Jiang, Guixin Wu
2022, 4:9 (22 April 2022)
Pain is common in severe acute pancreatitis (SAP) and is associated with the disease severity and outcomes. The management of pain in SAP may not only relieve pain but also improve outcomes. However, pancreatic pain in SAP involves several complicated mechanisms. Poor understanding about the pain mechanism in SAP and lack of enough high-quality data on pharmacological and nonpharmacological intervention lead to a limited analgesia strategy in patients with SAP mainly managed using nonsteroidal anti-inflammatory drugs and opioids. This makes pain management in SAP challenging and may cause potential harm. This article reviewed the current management of pain in SAP by combining pain mechanisms with animal or clinical studies and proposed an analgesic ladder based on available evidence to improve pain management in patients with SAP.
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Angiotensin in Clinical Practice
Ehsan Ahmadnia, Anna Hall, Marlies Ostermann
2019, 1:7 (3 January 2019)
Interest in the use of angiotensin (AT) (particularly in the context of shock) had been rekindled by recent randomized trial data (notably the AT II for the Treatment of High-Output Shock-3 study). This review article outlines the renin–AT system in health and during sepsis as well as the proposed clinical uses of AT II. The potential for wider application within critical care is also considered.
  5,577 427 1
The Intensity of Renal Replacement Treatment for Acute Kidney Injury: A Systematic Review and Network Meta-Analysis
Hongliang Wang, Haitao Liu, Yue Wang, Hongshuang Tong, Pulin Yu, Shuangshuang Chen, Guiyue Wang, Miao Liu, Yuhang Li, Nana Guo, Changsong Wang, Kaijiang Yu
2019, 1:61 (27 September 2019)
Background: Acute kidney injury (AKI) is a common and serious complication in critically ill patients. Patients who require renal replacement therapy (RRT) face a high mortality rate. Questions concerning the intensity of RRT in AKI patients led us to integrate direct and indirect evidence using a network meta-analysis to determine the optimal intensity and mode. Materials and Methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and Web of Science databases from 1990 to 2017 that included randomized controlled trials (RCTs) comparing different intensities of RRT to treat AKI in adults (18 years or older). Data regarding study characteristics, methods, and outcomes were extracted. We assessed the studies for eligibility, extracted the data, pooled the data, and used the GeMTC package in R to combine direct comparisons with indirect evidence. Results: Ten RCTs including 3354 participants were included in the network meta-analysis. The higher intensity continuous renal replacement treatment (CRRT) (to exceed 35 mL/kg/h) and the higher intensity IRRT (to exceed six times per week) both showed no statistical significance. Further analysis for higher intensity CRRT, lower intensity CRRT, higher intensity IRRT, and lower intensity IRRT also revealed no significance. Conclusions: This meta-analysis showed that increasing the intensity of CRRT to exceed 35 mL/kg/h and six times per week for intermittent RRT (IRRT) did not reduce mortality or the rate of dependence on dialysis among AKI patients.
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Pragmatic Studies for Acute Kidney Injury: Fluid Resuscitation in the Peri-Acute Kidney Injury Period
Raghavan Murugan, Haibo Qiu, Thomas Rimmele, Jianguo Li, Zhiyong Peng, Kaijiang Yu, John A Kellum, Claudio Ronco
2019, 1:52 (27 September 2019)
How fluid resuscitation clinical trials should be conducted for either prevention or treatment of acute kidney injury among patients admitted to the intensive care unit is unclear. In 2017, a group of experts in fluid resuscitation and acute kidney injury met at the Acute Disease Quality Initiative (ADQI) XIX consensus conference on “Pragmatic Studies for AKI”, Wuhan, China and developed a research framework. In this report, we summarize the consensus recommendations on the topic of fluid resuscitation in the peri-AKI period based on existing clinical evidence. We also discuss the gaps in our knowledge and identify future research questions. Finally, we examine the feasibility of conducting a pragmatic fluid resuscitation trial to improve outcomes from acute kidney injury.
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Is there a Role for Systematic Tools to Improve the Clinical Management of Patients with Acute Kidney Injury? Consensus Report of Acute Disease Quality Initiative XIX
Marlies Ostermann, Xiumin Xi, Jean-Louis Vincent, Raymond K Hsu
2019, 1:57 (27 September 2019)
Acute kidney injury (AKI) occurs in approximately 20% of hospitalized patients and is associated with increased morbidity and mortality. The care of hospitalized patients with AKI has been shown to be variable in clinical practices. Systematic tools including checklists, care bundles and medical algorithms have been developed and implemented to improve the care and outcomes of AKI patients. However, whether these systematic tools can improve the quality of care and outcomes of AKI patients is still unknown. The committee of the 19th Acute Disease Quality Initiative (ADQI) conference dedicated a workgroup with the task of developing a study protocol to investigate this question. A comprehensive literature search was performed using PubMed and Embase. Key questions and feasibility of potential study proposals were discussed during the conference. Then a two-step Delphi process was used to reach consensus regarding several aspects of the study protocol. The group suggested that patient risk assessment be included in the study protocol and the choice of systematic tool be depending on different clinical contexts. The group also proposed a two-phase study with the use of oliguria and systematic tool to investigate the quality of care and outcomes of AKI patients. Consensus was reached on a study protocol regarding the efficacy of using systematic tools to improve clinical management and outcomes of AKI patients.
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Ethics and End-of-Life Care
Jozef Kesecioglu
2019, 1:45 (27 September 2019)
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Management of Simultaneously Occurring Multiple Massive Intracerebral Hemorrhages
Luis Rafael Moscote-Salazar, Tariq Janjua, Amit Agrawal, Guru Dutta Satyarthee, Willem Guillermo Calderon-Miranda
2019, 1:69 (27 September 2019)
Occurrence of simultaneous multiple intracerebral hemorrhages (ICHs) in different arterial territories is an uncommon presentation. We report the cases of concurrent ocular and ICHs. The rarity of these lesions leads to delay in the diagnosis. Further lack of clear management guidelines for these pathologies makes further delay in the institution of appropriate therapy. In addition, the pathogenesis, diagnosis, and management along with pertinent literature are also reviewed.
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D Vitamin, Coronavirus, and Neurological Injuries
William Andres Florez Perdomo, Harold Enrique Vásquez Ucros, Luis Rafael Moscote-Salazar
2020, 2:64 (31 December 2020)
  4,631 159 2
Pragmatic Studies for Acute Kidney Injury in China: Renal Replacement Therapy for Acute Kidney Injury and Sepsis Consensus Report of Acute Disease Quality Initiative XIX
John R Prowle, Bin Du, Changsong Wang, Martin Gallagher
2019, 1:48 (27 September 2019)
In this article, we report consensus of 19th Acute Disease Quality Initiative (ADQI) conference and pragmatic trial proposals on renal replacement therapy (RRT) for acute kidney injury (AKI)and sepsis. The committee develop a list of key questions for the pragmatic trials. Then a systematic literature search was performed using PubMed and Embase. Finally the group summarized the proposed trials using PICO(Patient, Intervention, Comparator, Outcome). The groups recommended the first step would be a prospective observational study to document the current clinical practice of RRT in ICUs. Then the second stage would be to develop a quality improvement (QI) tools to improve and standardize the RRT practice in ICUs. The committee also proposed the primary outcome and secondary outcomes of the trial. Consensus had been reached for the pragmatic trial of RRT for AKI and sepsis in Chinese ICUs.
  4,214 479 -
Multimodal Monitoring Technologies for Pathophysiology and Management of Traumatic Brain Injury
Yujie Chen, Qianwei Chen, Jian Sun, Lijun Zhang, Liang Tan, Hua Feng
2019, 1:12 (3 January 2019)
Despite decades of efforts, severe traumatic brain injury (TBI) is still the leading cause for mortality and immobility of children and young adults worldwide and is a great burden to the health-care system. After injury, the oxygen supply is conventionally considered the monitoring parameter in a neurosurgical Intensive Care Unit. However, the overall mortality rate has only slightly improved since the late twentieth century. Evolving evidence suggests that dysfunction of oxygen utilization might be the underlying pathophysiology of secondary brain injury, which should also be a key parameter for multimodal monitoring and management after severe TBI. In this review, we summarize the current and advanced understanding of multimodal monitoring for severe TBI along with novel noninvasive technologies in this field. By continuously monitoring patients with severe TBI, the use of multimodal monitoring technologies including (but not limited to) computed tomography, cerebral microdialysis, near-infrared spectroscopy, magnetic resonance spectroscopy, high-performance liquid chromatography, and magnetic induction phase shift method will be crucial for observing disease changes such as intracranial pressure and brain tissue oxygen partial pressure as well as developing potential therapeutic strategies after severe TBI.
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The Doctors in ICU Need to Know the Basics of Coagulopathy
Ziwei Hu, He Miao, Xiaochun Ma, Renyu Ding
2021, 2:69 (25 June 2021)
Coagulopathy is common in critically ill patients. Under pathogenic factors, the homeostasis of coagulation, anticoagulation, and fibrinolytic system is disrupted, causing a series of cascade reactions that ultimately lead to coagulopathy. The pathophysiology of coagulopathy markedly varies according to the etiology. For sepsis-induced coagulopathy, inflammation interacts with coagulation. This process involves various cells, including endothelial cells, neutrophils, and platelets. Thrombocytopenia, as a common coagulopathy disorder among intensive care unit (ICU) patients, is indicative of poor outcome, and its differential diagnosis is crucial. However, the standardized diagnostic criteria for disseminated intravascular coagulation are yet to be established, and the existing ones have limitations. Therefore, we used PubMed to search literature related to “thrombocytopenia,” “sepsis,” “coagulopathy,” “disseminated intravascular coagulation,” and “coagulation biomarkers” and expected ICU doctors to fully understand knowledgeable of the pathophysiology of Coagulopathy. The traditional coagulation indicators can be combined with novel coagulation-related biomarkers for the accurate diagnosis and treatment of coagulopathy.
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Combining Therapy of Octreotide and Glucocorticoid in the Treatment of a Lung Adenocarcinoma Patient with Acute Respiratory Distress Syndrome
Xue-Zhong Xing, Hai-Jun Wang, Shi-Ning Qu, Chu-Lin Huang
2019, 1:4 (3 January 2019)
A 63-year-old male who was diagnosed with adenocarcinoma of the right lower lobe presented with 1 week of fever, cough, and progressive dyspnea and admitted to the Intensive Care Unit (ICU). After intubation, physical examination revealed copious, light bloody sputum and diffuse crackles and rales on lung auscultation. The patient was diagnosed as Stage IV adenocarcinoma, septic shock (lung infection), and acute respiratory distress syndrome. His oxygenation failed to improve despite sedation, restrictive fluid therapy, and methylprednisolone, antimicrobials therapy, protective ventilation, plasma supplement, and anticoagulation. Respiratory secretions suctioned from her endotracheal tube averaged 1.0 L daily. On day 2 after admission, octreotide was infused to control sputum volume. The patient's respiratory secretions decreased significantly, and on day 8, the ventilator mode was changed to pressure support ventilation, and the patient was extubated and dismissed from ICU.
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Timing for Initiating Renal Replacement Therapy in Patients with Acute Kidney Injury: Late is Better?
Kaijiang Yu
2022, 4:2 (18 January 2022)
  3,869 479 -
Using Clinical Decision Support Systems for Acute Kidney Injury Pragmatic Trials
Kianoush Kashani, Nooshin Dalili, Rickey E Carter, John A Kellum, Ravindra L Mehta
2019, 1:28 (3 January 2019)
Following the initial introduction of clinical decision support systems (CDSS) into the clinical practice in the 1970s, the complexity and performance quality of CDSSs have increased. The current literature on the efficacy and effectiveness of such systems shows conflicting results. While some studies show a clear benefit in quality-of-care improvement, others fail to replicate these outcomes. Heterogeneity of studies and the complexity of CDSS characteristics drive these conflicting conclusions. The lower cost and the easier implementation of pragmatic clinical trials provide an excellent platform to prove the effectiveness of CDSS in the real-world scenarios. To achieve better results, a series of explanatory trials are needed to identify the most effective CDSS in controlled settings. Therefore, utilization of both explanatory and pragmatic trial designs is necessary to evaluate the safety and efficacy of CDSS on the care of patients with acute kidney injury (AKI) in the acute setting. In this review, the authors provide an overview of the literature on critical care-related CDSS, its characteristics and dimensions, differences between pragmatic and explanatory trials, and potential proposals for both trial designs for AKI.
  3,987 354 2
Translational Critical Care Medicine: Integrating State-of-the-Art Knowledge between Bench and Bedside
Xiaofeng Jia, Zhiyong Peng
2019, 1:2 (3 January 2019)
  3,887 406 -
Neuromonitoring in Malignant Middle Cerebral Artery Infarction: A Review of Literature
Songyu Chen, Ke Wang, Chengcheng Zhou, Sajan Pandey, Liang Gao
2019, 1:20 (3 January 2019)
Malignant middle cerebral artery infarction is a devastating subtype of ischemic stroke, which carries a significant mortality rate (up to 80%) despite of conservative treatment. On the other hand, surgical decompressive procedure is the only established therapy to rescue the adverse effects of malignant edema and thus improve outcome. Accordingly, the early recognition of a possible malignant course as well as prediction of outcome is crucial for clinical decision-making. Numerous neuromonitoring techniques have been applied to address this issue. In theory, these techniques have the potential to present the information needed to guide targeted and timely intervention before irreversible damage takes place. However, the results were heterogeneous yet conflicting. We examined and summarized the recent evidence in this review, which may shed light on current trends.
  3,821 326 -
The Short- and Long-Term Burden of Acute Kidney Injury
Jonah G Powell-Tuck, Jorge Cerda, Marlies Ostermann
2019, 1:35 (3 January 2019)
Acute kidney injury (AKI) is a common complication of acute illness and carries a significant risk of mortality and morbidity, resulting in high health-care-associated costs. The incidence of AKI appears to be rising, making it ever more important to understand its acute and chronic consequences. In this review, we explore the evolving epidemiology of AKI, describe the impact of AKI on other organs, and discuss the short- and long-term effects of AKI on mortality and morbidity and its economic burden.
  3,752 346 1
Liberal Versus Conservative Fluid Therapy in COVID-19 Patients: What is the Best Strategy for the Treatment of Critically ill Patients?
José de Jesus Bohorquez-Rivero, Ezequiel García-Ballestas, Tariq M Janjua, Luis Rafael Moscote-Salazar
2022, 4:1 (6 January 2022)
  3,618 445 -
Indices of Tissue Perfusion: Triggers of Targets of Resuscitation?
Daniel De Backer, Marie Van Hove, Pierre Foulon, Joe Kadou, Gregoire Michiels, Simone Giglioli
2020, 2:1 (31 December 2020)
Circulatory shock is characterized by a decrease in oxygen delivery to the tissues associated with impairment in oxygen metabolism and tissue hypoxia. Clinical and biological signs of impaired tissue perfusion and tissue hypoxia are used as bedside to detect circulatory failure and trigger resuscitation procedures. The most popular signs of tissue hypoperfusion include mean arterial pressure, capillary refill time and mottling score, central venous oxygen saturation (ScvO2), veno-arterial difference in PCO2 (PvaCO2), microcirculation assessment, and lactate. Both the severity and duration of the alterations in any of these variables are associated with a poor outcome so that it sounds logical to trigger therapy based on these. Using these variables as target for therapy is much more complex. Some of the limits for using some of these variables as targets include an incertitude about the target to reach (should we aim at normalizing or improving the variable, and by how much?) and the time lag between resolution of impaired tissue perfusion/hypoxia and normalization of the variable. The ideal target variable should have a well-defined end point and a rapid response time. Interestingly, hemodynamic resuscitation targeting these variables gave variable results. In this review, we will discuss the interest and limitations of the above-mentioned indices of tissue perfusion and hypoxia as trigger as well as end point of resuscitation in critically ill patients.
  3,652 366 1
Monitoring Respiratory Drive and Effort during Mechanical Ventilation
Irene Telias, Megan Abbott, Laurent Brochard
2021, 3:13 (16 November 2021)
During assisted mechanical ventilation, the respiratory system is exposed to the positive pressure from the ventilator and the negative pressure generated by the respiratory muscles. Both excessively high and low respiratory drive and effort can injure the respiratory muscles and lungs resulting in worse patient's outcomes. Monitoring respiratory drive and inspiratory effort are key to prevent harm by adjusting sedation and ventilation to meet safe targets of respiratory drive and inspiratory effort. Based on physiological studies and observational data, it is currently recommended to target an intermediate range of drive and effort in most patients, however, these targets need to be validated prospective and adjusted for different patient populations. The gold standard for measuring inspiratory effort requires the insertion of an esophageal catheter and additional equipment. However, recently, several noninvasive techniques using end-expiratory or end-inspiratory occlusions on the ventilator have been validated to estimate respiratory drive and effort allowing clinicians to monitor drive and effort easily at the bedside. In this narrative review, we discuss potential beneficial and deleterious consequences of breathing effort during assisted ventilation, available monitoring techniques, and propose a structured approach for bedside implementation.
  3,154 430 -
Desmopressin in Critically Ill Neurosurgical Patients: An Overview
Angie Ching-Gonzalez, Christian Meza-Valle, Karen Muñoz-Báez, Juan Medrano-Carreazo, Amit Agrawal, Rakesh Mishra, Adesh Shrivastava, Tariq Janjua, Luis Rafael Moscote-Salazar
2020, 2:23 (31 December 2020)
Severely ill neurosurgical patients are those who present with pathologies of the nervous system associated with either a high mortality or that which leaves significant sequelae in those who survive. Desmopressin is a synthetic analog of the antidiuretic hormone that is stored in neurohypophysis. Its function is to decrease urinary volume by increasing reabsorption of water in the convoluted tubules and nephron collectors, additionally increasing the expression of coagulation factor VII and the von Willebrand factor. For this reason, its usefulness in the management of various pathologies has been tested, from coagulopathies to posttraumatic and postsurgical diabetes insipidus. It contributes in improving hyponatremia and in maintaining the balance of fluids and electrolytes in traumatic brain injury and subarachnoid hemorrhage (SAH) patients. It has been additionally studied for its role in the risk of rebleeding in SAH patients and in those with coagulopathies, where its implicated mechanism of action is through platelet anti-aggregation.
  3,361 190 1
Fluid Overload and Acute Kidney Injury, Chicken or Eggs?
Hong Bo, Andrew M Harrison, Yan Kang, Xuelian Liao
2020, 1:81 (28 October 2020)
Fluid overload is one of the main complications associated with intravenous fluid therapy. Weight-based fluid accumulation is often calculated for fluid balance status in most researches. Fluid overload was defined as more than a 10% increase in body weight relative to baseline. There are many evidences that fluid overload is associated with an increased risk of acute kidney injury (AKI) and mortality. This review focuses on the pathophysiological link between fluid overload and AKI. Disruption of endothelial glycocalyx induced by fluid overload plays an important role in AKI. In addition, the compositions of the fluids (some colloids and chloride-rich fluids) may also contribute to kidney injury. On the other side, fluid overload is more obvious and the outcome in patients with AKI or with more critical illness. Therefore, the relationship between fluid overload and AKI should be fully understood and carefully managed.
  3,187 260 -
Preface of Journal of Translational Critical Care Medicine
Kaijiang Yu, Zhiyong Peng
2019, 1:1 (3 January 2019)
  3,080 355 -
Neurotoxicity Associated with Cefepime: An Update to Neurocritical Care: A Narrative Review
Luis Rafael Moscote-Salazar, Amrita Ghosh, Ranabir Pal, Sumit Raj, Md Moshiur Rahman, Amit Agrawal
2020, 2:28 (31 December 2020)
Neurotoxicity has been an adverse effect described for almost all B-lactams; since its launch in 1994, there are numerous reports of patients treated with cefepime, covering a wide spectrum of clinical manifestations ranging from delirium to a nonconvulsive status epilepticus (NCSE), being the most of them reported in patients with decreased renal function, but also in patients with preserved renal function. We attempted to illustrate the clinical spectrum of cefepime neurotoxicity in relation to neurocritical care. We identified 13 publications describing neurotoxicity following cefepime administration from PubMed using search terms were cefepime, neurotoxicity, seizures, delirium, encephalopathy, NCSE, myoclonus, confusion, aphasia, agitation, coma, disability, and death. Two reviewers independently assessed identified articles for eligibility and used for this review writing. Most reports occur in elderly patients, although cases have been described in children and newborns. In general, patients recover soon after stopping beta-lactams or after reducing the dose or replacing them with another antibiotic; however, there is a likelihood of recurrence of symptoms after reintroducing Cefepime again at a dose low.
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