Catálogo de publicaciones - libros

Patients with liver cirrhosis and ascites often develop renal failure, even in its acute form. As of all forms of acute renal failure, prerenal failure (42%) and acute tubular necrosis (38%) are the most common, with hepatorenal syndrome (HRS) being somewhat less frequent (20%) []. The prevalence of HRS in patients affected by hepatic cirrhosis with ascites is in effect 18% after one year, rising to 39% at 5 years []. In almost half the cases of HRS, one or more precipitating factors may be identified, including: bacterial infections (57%), gastrointestinal hemorrhage (36%), and therapeutic paracentesis (7%) [].

Severe sepsis is associated with acute renal failure in approximately 23% of patients, while septic shock is complicated by acute renal failure in 51% of patients []. Acute renal failure associated with sepsis has a mortality as high as 70–80% []. Much of the hemodynamic and inflammatory events which accompany sepsis are related to endotoxemia. The study of the renal effects of endotoxemia have, therefore, provided substantial insights into the mechanisms mediating acute renal injury during sepsis.

One of the most challenging problems of nephrology and intensive care medicine is the treatment of acute renal failure. Due to its increased incidience and changing patterns, mortality rates remain high despite the advent of modern means of renal replacement therapy []–[]. However, increasing the dose of renal replacement therapy may provide substantial benefits, particularly in patients with intermediate levels of illness severity [, ]. To achieve this high dialysis dose, there is renewed interest in prolonged or extended dialysis modalities for critically ill patients with acute renal failure in the intensive care unit (ICU).

During continuous renal replacement therapy (CRRT), anticoagulation of the extra-corporeal circuit is generally required in order to prevent clotting of the circuit, to preserve filter performance, optimize circuit survival and prevent loss of blood due to circuit clotting.

Severe sepsis and multiple organ failure (MOF) represent significant challenges in critical care. Despite all the developments achieved in infectious diseases, organ substitution and critical care, the mortality rates from these conditions remain unacceptably high. The pathophysiology of severe sepsis and MOF is only partially understood. Circulating pro-inflammatory and anti-inflammatory mediators appear to participate in the complex cascade of events which leads to deranged microcirculatory function with consequent MOF as detailed in the peak concentration hypothesis []. The cytokines and other pro-inflammatory mediators in the systemic circulation, where major biological effects take place, determine vasopermeability, hypotension and shock. At the same time, the monocytes of the septic patient seem to be hyporesponsive to inflammatory stimuli to a certain extent. Due to the short half-life of cytokines and other mediators spilled over into the circulation, it is extremely difficult to approach the problem at the right moment with the right pharmacological agent. For these reasons, the peak concentration hypothesis suggests that continuous renal replacement therapies due to their continuity and non-specific capacity of removal might be beneficial in cutting the concentration peaks of inflammatory molecules [].

The concept of sleep has evolved from that of the first philosophers such as Democritus, who defined it as “a small group of atoms leaving the body” to its present definition as “a readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility”. The invention of the human electroencephalogram (EEG) by Hangs Berger in 1929 [] and the consequent development of polysomnography by Rechtschaffen and Kales in 1968 [] played a key role in the progress of sleep science. Nowadays, polysomnography is an essential tool for sleep studies. This field of research has grown rapidly in ambulatory patients. Nevertheless, probably due to the complexity of sleep exploration and the wide use of sedation in the intensive care unit (ICU), the incidence of sleep disorders in ICU patients has historically been underestimated. Sedation can carry the patient from a state of superficial artificial sleep to pharmacological coma, while physiological sleep is a state of rapidly reversible unconsciousness. Differentiation between sleep and sedation is, therefore, the first essential point.

The intensive care unit (ICU) is perceived by patients and families as a hostile environment: with analgesic requests not yielding the expected pain relief, sleep deprivation and disruption, anxiety, isolation, pain and lack of information often being reported []–[]. Using patient questionnaires and sleep monitoring, numerous studies have demonstrated that exposure to the ICU environment consistently results in reduced sleep efficiency, reduced restorative sleep, and increased sleep fragmentation. Common aspects of the ICU, such as sleep disturbances and deprivation, induce additional stress in critical care patients and may impair immunity and cause increased catabolism –.

In recent years, evidence has started to emerge of the impact on patients of their experiences while they were critically ill on an intensive care unit (ICU). Numerous studies in the past had shown that patients’ recall for their time on the ICU was often fragmentary and that a significant number of patients reported remembering delusional memories, such as hallucinations and nightmares []–[]. However, the effect of such distorted memories on the patients’ psychological health during their recovery had, until recently, not been examined. It is only with the advent of critical care follow-up that the struggle that some patients have coming to terms with their memories for ICU has become clear .

Obesity is a growing epidemic and holds significant health and economic consequences []–[]. It has been shown to dramatically increase the risk of other diseases including type II diabetes, serious cardiovascular and pulmonary conditions such as coronary artery disease, and stroke. In addition, obesity directly correlates with mortality and can decrease life expectancy by nearly two decades []. The economic ramifications of obesity are also profound [, ]. One study reported that $93 billion of health care expenditure in the USA was allocated to obesity-related illnesses. Between the periods of 1987 and 2001, there was a 27% rise in inflation-adjusted per capita spending for obesity-correlated disease in the USA . While first originating in the USA as a medical epidemic, obesity has also risen sharply in other parts of the world, including Europe, Russia and Latin America. In the last fifteen years, the prevalence of obesity has tripled in England and Wales and has risen by 20% in Eastern Europe [, ]. The International Obesity Task Force considers obesity to be a global epidemic, and estimates 300 million people around the world are obese []. The significance of obesity in health care cannot be overemphasized — obesity has dictated the way in which health care providers manage and strategize their treatment to this unique patient population.

Patient safety has become an increasingly important topic of discussion in health care organizations all over the world. The publication of the report by the Institute of Medicine in the United States [] triggered awareness of the importance of safer practices in health care, among both health care professionals and the public. In 1990, Rubins and Moskowitz [] reported that 14% of studied patients experienced complications during their ICU stay; the hospital mortality rate in these patients increased to 67% (versus 27% in patients without complications, p < 0.0001). Giraud et al. [] observed iatrogenic complications in 31% of adults admitted to the intensive care unit (ICU), and the patients with a major complication had a twofold increase in mortality risk. Stambouly et al. [] reported on a prospective study on complications in a pediatric ICU (PICU); complications occurred in 8% of the admissions. The authors observed that any complication increased PICU stay from 2 to 12 days (p < 0.0001). They also found an increased mortality risk for patients experiencing any complication (0.010 to 0.022). Another study on the impact of adverse events in the PICU reported that infectious complications gave rise to approximately a $50,000 increase in total costs and an increased length of stay of 15.6 days. In another context, Zhan and Miller [] reported on the effect of medical injuries during hospitalization using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs). The impact of these injuries was highly variable; postoperative sepsis increased length of stay to 11 days, total costs by $57,727 and mortality to 22% (p < 0.001).