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Daptomycin
Published in M. Lindsay Grayson, Sara E. Cosgrove, Suzanne M. Crowe, M. Lindsay Grayson, William Hope, James S. McCarthy, John Mills, Johan W. Mouton, David L. Paterson, Kucers’ The Use of Antibiotics, 2017
Anouk E. Muller, Inge C. Gyssens
Several studies have been performed with patients during continuous renal replacement therapy. Corti et al. (2013) described nine critically ill patients and reviewed the literature. Dosing recommendations varied in this special population; because of the limited data available, therapeutic drug monitoring was recommended. On the other hand, Preiswerk et al. (2013) retrospectively reviewed seven cases of continuous renal replacement therapy and also concluded that the recommended dose should be at least 6 mg/kg/day, but possibly 8 mg/kg/day for critically ill patients. They also recommended therapeutic drug monitoring to prevent underdosing. A summary of these studies is provided in Table 45.3.
Acute Renal Dysfunction
Published in Stephen M. Cohn, Matthew O. Dolich, Kenji Inaba, Acute Care Surgery and Trauma, 2016
David Bennett, Meghan E. Sise, Catherine S. Forster, Matthew O’Rourke, Katherine Xu, Jonathan Barasch
Acute renal dysfunction is a common complication of hospitalized patients that is associated with significant morbidity and mortality. Multiple classification systems have been developed, including risk, injury, failure, loss, end-stage renal disease (RIFLE), Acute Kidney Injury Network, and more recently, the Kidney Disease: Improving Global Outcomes (KDIGO). These classification systems are thought to identify acute kidney injury (AKI) and allow for severity grading based on changes in the level of serum creatinine (sCr) and urine output. However, there are significant limitations to the use of sCr. These limitations are highlighted by the recent discovery of serum and urinary biomarkers, as well as kidney-specific genes, expressed soon after kidney injury, which are changing that paradigm in which we view AKI. At present, there are multiple forms of kidney stress and damage that are known to raise sCr in hospitalized patients including prerenal, intrinsic renal, and postrenal causes. Sepsis, hypovolemia, chronic kidney disease, major trauma, and surgery all confer significantly increased risk of the most severe form of azotemia, called intrinsic AKI. Unfortunately, medical therapies to limit or reverse the intrinsic forms of AKI have thus far eluded researchers, and while the judicious use of fluids is appropriate in volume-depleted prerenal patients with renal failure, they may be dangerous in patients with renal failure of the edematous states such as heart failure. Neither the timing of renal replacement therapy nor its modality or intensity has been consistently shown to impact mortality or renal recovery. Intermittent hemodialysis is used for hemo-dynamically stable patients, whereas continuous renal replacement therapy is typically used for patients who are unstable or in shock. Peritoneal dialysis has fallen out of favor for the treatment of AKI, albeit a useful modality for chronic kidney disease.
Necrotizing Soft Tissue Infections
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
These patients are usually critically ill and require ICU admission. They often present in septic shock aggravated by dehydration, with renal failure, and sometimes may suffer toxic shock syndrome as well. The usual measures of aggressive crystalloid resuscitation, early culture and empiric antibiotics, and source control by aggressive operative debridement are paramount. While a complete initial debridement is the desired goal, the patient may not tolerate this and require second and additional returns to the operating room once they are hopefully more stable. However, if the patient fails to stabilize in the initial postoperative period, requiring ongoing resuscitation and pressors, the assumption should be made that there is progression of disease, and early return to the OR for more aggressive debridement is critically important. Even in the cases where the initial debridement is thought to be complete, the necrosis may continue to spread beyond the boundaries of the resection postoperatively, and a second look should be mandatory. Debridements should continue on a daily basis until the surgeon is satisfied that there is no further necrotic progression. Once the tissues are clean without further evidence of disease, vacuum wound dressings may be placed to minimize wound size and facilitate wound healing and closure. If renal failure or dysfunction result, continuous renal replacement therapy may be required early in the course; patients are often too labile to tolerate hemodialysis. Pressors may be required to maintain blood pressure and perfusion in accordance with the latest SCCM guidelines. The 2018 update to the 2016 Surviving Sepsis guidelines advocates even earlier establishment of the previous bundles to a 1-hour time frame: measurement of lactate, blood cultures, broad spectrum antibiotics, crystalloid infusion, and vasopressors to restore blood pressure and perfusion. Nutritional support is key to recovery, with caloric and protein requirements that can be similar to those of burn patients in severe cases. IVIG may be of value as an adjunctive measure in patients with Type II (Group a Streptococcal) NSTIs and concomitant toxic shock syndrome. The evidence for this is not strong, but there are some indications it may be beneficial in these patients. Hyperbaric oxygen therapy remains unproven and incurs significant additional burdens on the patient and care teams, and its use should not delay the mainstays of treatment.
Urinary catheter monitoring of intra-abdominal pressure after major abdominal surgery, a cost-benefit analysis
Published in Journal of Medical Economics, 2022
John P. Ney, Vanessa Moll, Edward J. Kimball
However, we do capture hospital costs by translation of two important utilization outcomes that have clear associations with IAP-ICU length of stay and AKI requiring renal replacement therapy. Each ICU day costs over $5,000 without including costs of mechanical ventilation, based on the study by Dasta et a18 and inflated to 2020 costs, with substantial variation that only increases with more procedures and services applied to the patient. Renal replacement therapy, categorized here as continuous renal replacement therapy, is characterized in the model as an aggregate amount representing all acute ICU-related continuous dialysis costs reported by Ethgen et al.19 and again inflated to 2020 values. In both cases, the Monte Carlo simulation allows for substantial rightward skew to account for variation that is likely to be much higher in some users. While our base case shows the mean per-patient saving is substantial, exceeding the cost of a day of ICU care with mechanical ventilation for each patient monitored, the potential cost savings were >$40,000 per person in some MCS iterations (Figure 4).
Defining the role of peritoneal dialysis in management of congestive heart failure
Published in Expert Review of Cardiovascular Therapy, 2019
Amir Kazory, Joanne M. Bargman
Peritoneal dialysis (PD) is a home-based renal replacement therapy with a large capacity for customization to the patient’s clinical needs and lifestyle. Currently, it is the only form of continuous renal replacement therapy that can be performed in the outpatient setting. In PD, the hyperosmolar or hyperoncotic dialysate is introduced into the peritoneal cavity via a permanent abdominal catheter. An osmotic gradient between the dialysate solution and the capillary blood drives peritoneal ultrafiltration (i.e. water extraction) and convective solute removal, while diffusive forces result in additional solute extraction, including the removal of sodium. In the United States, two types of dialysis solutions are currently available for inducing convective forces: dextrose-based solutions and those containing icodextrin (discussed below). At the end of the dwell, the dialysis fluid that contains the solutes and waste products (e.g. sodium, potassium, and urea) is drained, followed by infusion of fresh dialysate to start a new exchange cycle. The volume of ultrafiltration depends on a number of parameters including the concentration of glucose solution used for each exchange, the length of the dwell, and the individual patient’s peritoneal membrane permeability characteristics. PD regimens are highly flexible; patients can adjust their ultrafiltration goal on a daily basis according to their target weight and volume status.
The landscape of renal replacement therapy in Veterans Affairs Medical Center intensive care units
Published in Renal Failure, 2021
Chandan Vangala, Maulin Shah, Natasha N. Dave, Layth Al Attar, Sankar D. Navaneethan, Venkat Ramanathan, Susan Crowley, Wolfgang C. Winkelmayer
The Veterans Health Administration is the largest integrated healthcare system in the United States. Using the Veterans Affairs (VA) internal Dialysis Facility Directory, we sent surveys regarding renal replacement therapy practices in the intensive care unit to the dialysis directors of each VA facility that provided VA-staffed inpatient hemodialysis. With 76 responses out of total of 87 facilities, we described prolonged and continuous renal replacement therapy with regards to basic aspects of treatment, such as modality, equipment, solutions, anticoagulation, staffing, and access. This report helps educate on the heterogeneity of treatment and what principal common denominators could serve as potential quality measures to improve the delivery of care.