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Poisoning : Kinetics to Therapeutics

Objectives This chapter will: 1. Review the fundamentals of pharmacokinetics and toxicology. 2. Present an overview of therapeutic management of poisoning by conventional and extracorporeal circulatory methods. 3. Describe the role of supportive treatments. Accidental or premeditated ingestion of poisons is a significant health problem worldwide and is a frequent cause of admission to emergency departments and intensive care units (ICUs). Reflecting the necessarily urgent nature…

Plasmapheresis in Acute Intoxication and Poisoning

Objectives This chapter will: 1. Review the possible mechanisms of action of plasmapheresis in poisoning and drug overdose. 2. Describe the pharmacokinetic factors that affect the elimination of poisons and drugs by plasmapheresis. 3. Explain the limitations of published studies on the efficacy of plasmapheresis in poisoning and drug overdose. 4. Review published data on the efficacy of plasmapheresis for specific poisons Plasmapheresis is widely accepted…

Extracorporeal Therapies in Acute Intoxication and Poisoning

Objectives This chapter will: 1. Present the indications for extracorporeal therapies in the treatment of acute poisoning. 2. Describe principles of drug removal and how they apply to selection of modality. 3. Describe the utility and complications of combining chelating agents to improve clearance of heavy metals. 4. Discuss clinical presentation and treatment (including extracorporeal therapy) with regard to specific intoxicants. Management of the poisoned patient…

Drugs and Antidotes in Acute Intoxication

Objectives This chapter will: 1. Provide an overview of drugs and antidotes in acute intoxication. 2. Highlight clinical pitfalls in the management of toxicity. 3. Identify the clinically significant toxidromes. 4. Describe the effects of sodium and potassium channel blockers. 5. Present a review of specific poisons and antidotes. 6. Review poisons that have significant effects on the kidney. Deliberate self-poisoning, accidental poisoning, and recreational drug…

Principles of Antibiotic Prescription in Intensive Care Unit Patients and Patients With Acute Renal Failure

Objectives This chapter will: 1. Review basic principles of antibiotic prescribing. 2. Discuss the implications of the emergence of multi–drug-resistant organisms. 3. Review the mechanisms for antibiotic resistance. Intensive care units (ICUs) are unique because they provide confined accommodations for the critically ill patient, where antibiotic use is extremely common. They are often the center of infections; it is estimated that 37% to 51.2% of all…

Critical Care Viral Infections

Objectives This chapter will: 1. Describe the diagnosis and treatment of viral influenza. 2. Explain the evaluation and management of viral meningoencephalitis. 3. Describe the initial approach to viral hepatitis. Viral infections in the intensive care unit (ICU) have gained a higher profile recently. This is due, in part, to novel and emerging pathogens, an aging population, and increased numbers of immunocompromised hosts, but most of…

Management of Infection in Patients With Kidney Transplant

Objectives This chapter will: 1. Recognize risk for and manifestations of common opportunistic infections in renal transplant recipients admitted to the intensive care unit. 2. Describe appropriate evaluation and treatment for infections in renal transplant recipients admitted to the intensive care unit. Chronic kidney disease (CKD) is pervasive throughout the world, resulting in increased need for renal transplantation. Unfortunately, current donor pools (live or cadaveric) cannot…

Blood Purification for Sepsis

Objectives This chapter will: 1. Introduce the concept of blood purification. 2. Explain the mechanisms of blood purification in sepsis. 3. Evaluate the commonly used blood purification technologies. 4. Discuss the limitations and future directions of blood purification technologies. Extracorporeal blood purification (EBP) is a treatment in which a patient's blood is passed through a device (e.g., membrane, sorbent) in which solute (waste products, toxins) and…

Renal Replacement Therapy for Septic Acute Kidney Injury

Objectives This chapter will: 1. Highlight the very high mortality rates of patients who receive renal replacement therapy for septic acute kidney injury. 2. Appraise renal replacement modes, clearance techniques, doses, and optimal time to commence treatment in septic acute kidney injury. Epidemiologic studies conducted across multiple hospitals in numerous countries have identified that depending on case mix, 30% to 60% of patients in an intensive…

Principles of Antimicrobial Prescription in Intensive Care Unit Patients With Acute Kidney Injury

Objective This chapter will: 1. Identify antimicrobial- and patient-specific factors that may influence antimicrobial dosing in critically ill patients. Description of Antimicrobial Prescribing Practices in the Intensive Care Unit Antimicrobials are listed consistently in the top 10 drugs prescribed annually in the intensive care unit (ICU), with 70% of patients receiving at least one antimicrobial agent during their stay. Approximately one third of patients receive antimicrobials…

Recommendations for Sepsis Management

Objective This chapter will: 1. Present key evidence pertaining to the treatment of sepsis. Infection is a common occurrence in the intensive care unit (ICU), as a reason for ICU admission and when acquired in the ICU, and results in significant morbidity and mortality. In the United States the annual incidence of infection-induced organ dysfunction is estimated to be more than 750,000 cases a year, resulting…

Sepsis-Induced Acute Kidney Injury

Objectives This chapter will: 1. Review the epidemiology of sepsis-induced acute kidney injury. 2. Discuss the evidence supporting novel mechanisms leading to acute kidney injury in the setting of sepsis. 3. Review novel approaches to the diagnosis of sepsis-induced acute kidney injury. 4. Review current and potential therapies in the context of novel mechanisms of disease. Sepsis is the most common cause of acute kidney injury…

Endothelial Dysfunction of the Kidney in Sepsis

Objectives This chapter will: 1. Describe the role of the endothelium dysfunction during sepsis and its interplay with the local environment. 2. Explain how endothelium damage translates into a loss of kidney function: sepsis-induced acute kidney injury. 3. Summarize the therapies targeting renal endothelial cells in sepsis-induced acute kidney injury. Endothelial dysfunction and microcirculation impairment are recognized hallmarks of sepsis-related organ failure. Many experimental and clinical…

Coagulation Abnormalities in Sepsis

Objectives This chapter will: 1. Review the normal process of coagulation and describe the sepsis-induced coagulation abnormalities. 2. Delineate the interaction between coagulation and inflammation during sepsis. 3. Outline the pathogenesis of sepsis-associated coagulopathy and discuss relevant factors associated with its diagnosis, clinical presentation, associated outcomes, and management. Sepsis now is defined as a life-threatening organ dysfunction resulting from a dysregulated host response to infection. The…

Complement and Its Consequences in Sepsis

Objectives This chapter will: 1. Describe products of complement activation during sepsis. 2. Demonstrate protective effects of blocking antibodies to C5a, together with its structural details, in the setting of sepsis. 3. Explain pathophysiologic events related to complement activation that develop during sepsis and acute lung injury, and protection against tissue damage and lethality in C5aR knockout mice or blockage of C5a receptors. Robust activation of…

Sepsis and Septic Shock

Objective This chapter will: 1. Provide an overview of newly developed definitions for sepsis and septic shock 2. Summarize the manner in which the clinical criteria were derived and validated using clinical data in an evidence-based manner 3. Identify the need for additional validation, especially in under-resourced populations, and in a prospective manner. The development of acute kidney injury (AKI) is a frequent complication in critically…

Tropical Infections Causing Acute Kidney Injury

Objectives This chapter will: 1. Provide an overview of tropical areas and tropical infections causing acute kidney injury (AKI). 2. Describe epidemiology, clinical features, pathogenesis, and management of common tropical infections causing AKI, including leptospirosis, malaria, dengue, and hantavirus infection. 3. Explain the role of renal support in limited resource areas, including tropical areas. 4. Provide an example of long-term outcomes of AKI patients who recover…

Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome

Objectives This chapter will: 1. Discuss the pathophysiology, diagnosis, and treatment of spontaneous bacterial peritonitis. 2. Discuss prevention of acute kidney injury and hepatorenal syndrome in patients with spontaneous bacterial peritonitis. 3. Discuss the management of hepatorenal syndrome in the setting of spontaneous bacterial peritonitis. Patients with cirrhosis and ascites have a high risk of developing bacterial infections and sepsis compared with the general population, and…

Adaptive Immunity and Critical Illness

Objectives This chapter will: 1. Outline the activation of the innate and adaptive immune system in response to invading pathogens. 2. Define characteristics of the adaptive immune response and its interplay with the innate immune response in septic, ischemic, and nephrotoxic acute kidney injury. 3. Describe mechanisms of resolution of inflammation and progression to chronic kidney disease. Immune System: an Overview The primary force that has…

Innate Immunity and the Kidney

Objectives This chapter will: 1. Briefly review essential features of innate immunity as the first line of defense against microbial invaders. 2. Describe the mechanisms by which the innate immune system rapidly recognizes danger to host viability induced by either infectious or noninfectious tissue injury. 3. Detail the role of innate immune functions that enable specific elements of the adaptive immune system to become activated and…