04 May 10
Posted in Anesthesia, Critical Care at 0:10 by Laci
By P Reddy, A Mooradian
Int J Clin Pract 2009;63:1494-1508
Hyponatraemia is a commonly encountered electrolyte abnormality in hospitalised patients and is associated with significant morbidity and mortality. The fact that most cases of hyponatraemia are the result of water imbalance rather than sodium imbalance underscores the role of antidiuretic hormone (ADH) in the pathophysiology. Hyponatraemia can be classified according to the measured plasma osmolality as isotonic, hypertonic or hypotonic. Hyponatraemia with a normal plasma osmolality usually indicates pseudohyponatraemia, while hyponatraemia because of a high plasma osmolality is typically caused by hyperglycaemia. After excluding isotonic and hypertonic causes, hypotonic hyponatraemia is further classified according to the volume status of the patient as hypovolaemic, hypervolaemic or euvolaemic. Hypovolaemic hyponatraemia is accompanied by extracellular fluid (ECF) volume deficit, while hypervolaemic hyponatraemia manifests with ECF volume expansion. The syndrome of inappropriate ADH (SIADH) should be suspected in any patient with euvolaemic hyponatraemia with a urine osmolality above 100 mOsm/kg and urine sodium concentration above 40 mEq/l. In the management of any hyponatraemia regardless of the patient’s volume status, it is advised to restrict free water and hypotonic fluid intake. Hypertonic saline and vasopressin antagonists can be used to correct symptomatic hyponatraemia. The rate of correction is dependent upon the duration, degree of hyponatraemia and the presence or absence of symptoms. Symptomatic acute hyponatraemia (< 48 h) is a medical emergency requiring rapid correction to prevent the worsening of brain oedema. In asymptomatic patients with chronic hyponatraemia (> 48 h or unknown duration), fluid restriction and close monitoring alone are sufficient, while a slow correction by 0.5 mEq/l/h may be attempted in symptomatic patients. Excessive rapid correction should be avoided in both acute and chronic hyponatraemia, because it can lead to irreversible neurological complications including central osmotic demyelination.
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03 Apr 10
Posted in Critical Care, Infection at 1:00 by Laci
By T Dellit, R Owens, J McGowan, D Gerding, R Weinstein, J Burke et al
Clinical Infectious Diseases 2007;44:159–177
This document presents guidelines for developing institutional programs to enhance antimicrobial stewardship, an activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy. The multifaceted nature of antimicrobial stewardship has led to collaborative review and support of these recommendations by the following organizations: American Academy of Pediatrics, American Society of Health‐System Pharmacists, Infectious Diseases Society for Obstetrics and Gynecology, Pediatric Infectious Diseases Society, Society for Hospital Medicine, and Society of Infectious Diseases Pharmacists. The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridium difficile), and the emergence of resistance. Thus, the appropriate use of antimicrobials is an essential part of patient safety and deserves careful oversight and guidance. Given the association between antimicrobial use and the selection of resistant pathogens, the frequency of inappropriate antimicrobial use is often used as a surrogate marker for the avoidable impact on antimicrobial resistance. The combination of effective antimicrobial stewardship with a comprehensive infection control program has been shown to limit the emergence and transmission of antimicrobial‐resistant bacteria. A secondary goal of antimicrobial stewardship is to reduce health care costs without adversely impacting quality of care.
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30 Mar 10
Posted in Critical Care, Infection at 21:47 by Laci
By P George and A Morris
Critical Care 2010;14:205
You are director of a large multi-disciplinary ICU. You have recently read that hospital-wide antibiotic stewardship programs have the potential to improve the quality and safety of care, and to reduce the emergence of multi-drug resistant organisms and overall costs. You are considering starting one of these programs in your ICU, but are concerned about the associated infrastructure costs. You are debating whether it is worth bringing the concept forward to your hospital’s administration to consider investing in.
Statement for debate
Antibiotic stewardship programs improve patient outcomes and cost-effectiveness in critically ill patients in the ICU.
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23 Mar 10
Posted in Critical Care, Lactate at 1:04 by Laci
By A Nichol, M Egi, V Pettila, R Bellomo, C French, G Hart et al
Critical Care 2010, 14:R25
Higher lactate concentrations within the normal reference range (“relative hyperlactatemia”) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death.
Methods
Retrospective observational study of prospectively obtained intensive care database of 7155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission (LacADM), maximal (LacMAX) and time-weighted (LacTW) lactate levels and hospital outcome in all patients and in those patients whose LacADM (n=3964), LacMAX (n=2511) and LacTW (n=4584) lactate was under 2 mmol.L-1 (relative hyperlactatemia).
Results
We obtained 172,723 lactate measurements. Higher LacADM and LacTW concentration within the reference range was independently associated with increased hospital mortality (LacADM: odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3-3.5, P=0.01; LacTW OR 3.7, 95% CI 1.9-7.00, P<0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L-1. Furthermore, in patients whose lactate never exceeded 2 mmol.L-1, higher LacTW remained strongly associated with higher hospital mortality (LacTW OR 4.8, 95% CI 1.8-12.4, P<0.001).
Conclusions
In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations >0.75 mmol.L-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed.
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