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Shnaiderman‐Torban A, Steinman A, Abu Ahmad W, Kushnir Y, Abells Sutton G, Epstein A, Kelmer G. Preoperative and intraoperative risk factors for post‐anaesthetic pulmonary oedema in horses. EQUINE VET EDUC 2022. [DOI: 10.1111/eve.13646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Anat Shnaiderman‐Torban
- Veterinary Teaching Hospital Koret School of Veterinary Medicine The Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem Rehovot Israel
| | - Amir Steinman
- Veterinary Teaching Hospital Koret School of Veterinary Medicine The Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem Rehovot Israel
| | - Wiessam Abu Ahmad
- Hadassah Braun School of Public Health and Community Medicine The Hebrew University of Jerusalem Israel
| | - Yishai Kushnir
- Veterinary Teaching Hospital Koret School of Veterinary Medicine The Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem Rehovot Israel
| | - Gila Abells Sutton
- Veterinary Teaching Hospital Koret School of Veterinary Medicine The Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem Rehovot Israel
| | - Ana Epstein
- Veterinary Teaching Hospital Koret School of Veterinary Medicine The Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem Rehovot Israel
| | - Gal Kelmer
- Veterinary Teaching Hospital Koret School of Veterinary Medicine The Robert H. Smith Faculty of Agriculture, Food and Environment The Hebrew University of Jerusalem Rehovot Israel
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Meng JB, Jiao YN, Xu XJ, Lai ZZ, Zhang G, Ji CL, Hu MH. Electro-acupuncture attenuates inflammatory responses and intraabdominal pressure in septic patients: A randomized controlled trial. Medicine (Baltimore) 2018; 97:e0555. [PMID: 29703040 PMCID: PMC5944568 DOI: 10.1097/md.0000000000010555] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/04/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND A pathological increase in intraabdominal pressure (IAP) and inflammatory responses have negative effects on splanchnic, respiratory, cardiovascular, renal, and neurological function in septic patients with intestinal dysfunction. Electro-acupuncture (EA) has been evidenced to have a bidirectional neuron-endocrine-immune system regulating effect in patients with intestinal dysfunction. The purpose of current study was to evaluate the effects of EA at "Zusanli" (ST36) and "Shangjuxu" (ST37) on inflammatory responses and IAP in septic patients with intestinal dysfunction manifested syndrome of obstruction of the bowels Qi. METHODS Eighty-two septic patients with intestinal dysfunction manifested syndrome of obstruction of the bowels Qi were randomly assigned to control group (n = 41) and EA group (n = 41). Patients in control group were given conventional therapies including fluid resuscitation, antiinfection, vasoactive agents, mechanical ventilation (MV), supply of enteral nutrition, and glutamine as soon as possible. In addition to conventional therapies, patients in EA group underwent 20-minutes of EA at ST36-ST37 twice a day for 5 days. At baseline, posttreatment 1, 3, and 7 days, serum levels of tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) and IAP levels, were measured, respectively. And days on MV, length of stay in intensive care unit (ICU) and 28 days mortality were recorded. RESULTS The serum levels of TNF-α and IL-1β and IAP levels at posttreatment 1, 3, and 7 days were lower significantly in the EA group compared with the control group (mean [SD]; 61.03 [20.39] vs 79.28 [20.69]; P < .005, mean [SD]; 35.34 [18.75] vs 66.53 [30.43]; P < .005 and mean [SD]; 20.32 [11.30] vs 32.99 [20.62]; P = .001, respectively, TNF-α. Mean [SD]; 14.11 [5.21] vs 16.72 [5.59]; P = .032, mean [SD]; 9.02 [3.62] vs 12.10 [4.13]; P = .001 and mean [SD]; 5.11 [1.79] vs 8.19 [2.99]; P < .005, respectively, IL-1β. Mean [SD]; 14.83 [5.58] vs 17.55 [3.37]; P = .009, mean [SD]; 11.20 [2.57] vs 14.85 [3.01]; P < .005 and mean [SD]; 8.62 [2.55] vs 11.25 [2.72]; P < .005, respectively, IAP). There were no significant differences in the duration of MV, length of stay in ICU, and 28d mortality between the groups. CONCLUSION EA at ST36-ST37 attenuated inflammatory responses through reduction in serum levels of TNF-α and IL-1β and IAP in septic patients with intestinal dysfunction manifested syndrome of obstruction of the bowels Qi.
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Affiliation(s)
- Jian-biao Meng
- Intensive Care Unit, Tongde Hospital of Zhejiang Province
| | - Yan-na Jiao
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiu-juan Xu
- Intensive Care Unit, Tongde Hospital of Zhejiang Province
| | - Zhi-zhen Lai
- Intensive Care Unit, Tongde Hospital of Zhejiang Province
| | - Geng Zhang
- Intensive Care Unit, Tongde Hospital of Zhejiang Province
| | - Chun-lian Ji
- Intensive Care Unit, Tongde Hospital of Zhejiang Province
| | - Ma-hong Hu
- Intensive Care Unit, Tongde Hospital of Zhejiang Province
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Braha B, Mahmutaj D, Maxhuni M, Neziri B, Krasniqi S. Correlation of Procalcitonin and C-Reactive Protein with Intra-Abdominal Hypertension in Intra-Abdominal Infections: Their Predictive Role in the Progress of the Disease. Open Access Maced J Med Sci 2018; 6:479-484. [PMID: 29610604 PMCID: PMC5874369 DOI: 10.3889/oamjms.2018.112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 01/17/2023] Open
Abstract
AIM To analyse the correlation of procalcitonin (PCT) and C-reactive protein (CRP) values with increased intra-abdominal pressure and to evaluate their predictive role in the progression of Intra-abdominal infections. MATERIALS AND METHODS A non-randomized prospective study conducted in the group of 80 patients. We have measured the PCT, CRP and intra-abdominal pressure (IAP). RESULTS According to IAH grades (G), there was a significant difference of PCT values: G I 3.6 ± 5.1 ng/ml, G II 10.9 ± 22.6 ng/ml, G III 15.2 ± 30.2 ng/ml (p = 0.045) until: CRP values were increased in all IAH groups but without distinction between the groups: GI 183 ± 64.5, GII 196 ± 90.2, GIII 224 ± 96.3 (p = 0.17). According to the severity of the infection, we yielded increased values of PCT, IAP and CRP in septic shock, severe sepsis and SIRS/sepsis resulting in significant differences of PCT and IAP. CONCLUSION Based on the results of our research, we conclude that the correlation of PCT values with IAH grades is quite significant while the CRP results remain high in IAH but without significant difference between the different grades of IAH.
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Affiliation(s)
- Bedri Braha
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Dafina Mahmutaj
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Mehmet Maxhuni
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Burim Neziri
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
| | - Shaip Krasniqi
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
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Kim TJ, Yeh YT, Zobair K. Impending abdominal compartment syndrome from a giant ovarian cyst torsion. ANZ J Surg 2017; 89:E164-E165. [PMID: 28922702 DOI: 10.1111/ans.14147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 06/03/2017] [Accepted: 06/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Tae-Jun Kim
- Department of Surgery, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Yu-Ting Yeh
- Department of Surgery, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Karishma Zobair
- Department of Surgery, Blacktown Hospital, Sydney, New South Wales, Australia
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Qin Q, Xia Y, Cao Y. Clinical study of a new Modified Early Warning System scoring system for rapidly evaluating shock in adults. J Crit Care 2016; 37:50-55. [PMID: 27626832 DOI: 10.1016/j.jcrc.2016.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 08/17/2016] [Accepted: 08/28/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Shock, the most common severe emergency syndrome, has a complicated etiopathogenesis, is difficult to identify, progresses quickly, and is dangerous. Early identification and intervention play determining roles in the final outcomes of shock patients, but no specific scoring system for shock has been established to date. METHODS We collected 292 shock patients and analyzed the correlation between 28-day prognosis and the Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II), Modified Early Warning System (MEWS), and Sequential Organ Failure Assessment scoring systems. According to the previous result, we established a new MEWS scoring system based on the conventional MEWS, which also included age and transcutaneous oxygen saturation. Some of the items with a strong correlation with the 28-day prognosis were selected to establish the new MEWS scoring system. We then evaluated the predictive efficacy of the new MEWS scoring system on 28-day prognosis and the correlation with other scoring systems. RESULTS Some indexes, including age, transcutaneous oxygen saturation, arterial blood pH and blood lactic acid, serum sodium, serum potassium, HCO3, and red blood cells deposited, differed significantly between the nonsurviving and surviving groups (P<.05). The area under the curve (AUC) of the APACHE II, MEWS, shock index, and Sequential Organ Failure Assessment scoring systems for 28-day prognosis indicated a critical predictive efficacy. Receiver operating characteristic curves indicated that the MEWS AUC was 0.614, new MEWS AUC was 0.696, and APACHE II AUC was 0.785, suggesting superiority of the new MEWS to the conventional MEWS but inferiority to the APACHE II. Interestingly, the correlation efficient of the traditional MEWS and the new MEWS was 0.81. The correlation efficient of these scoring systems with other indexes, including lactic acid and hemoglobin, was less than 0.3. CONCLUSIONS The new MEWS scoring system could be an independent indicator to reflect shock severity. It has higher predictive efficacy in septic shock, especially for 28-day prognosis.
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Affiliation(s)
- Qin Qin
- Department of Emergency, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yiqin Xia
- Department of Emergency, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yu Cao
- Department of Emergency, West China Hospital of Sichuan University, Chengdu 610041, China.
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Golden D, Corbett J, Forni LG. Peri-operative renal dysfunction: prevention and management. Anaesthesia 2016; 71 Suppl 1:51-7. [PMID: 26620147 DOI: 10.1111/anae.13313] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
Postoperative increases in serum creatinine concentration, by amounts historically viewed as trivial, are associated with increased morbidity and mortality. Acute kidney injury is common, affecting one in five patients admitted with acute medical disease and up to four in five patients admitted to intensive care, of whom one in two have had operations. This review is focused principally on the identification of patients at risk of acute kidney injury and the prevention of injury. In the main, there are no interventions that directly treat the damaged kidney. The management of acute kidney injury is based on correction of dehydration, hypotension, and urinary tract obstruction, stopping nephrotoxic drugs, giving antibiotics for bacterial infection, and commencing renal replacement therapy if necessary.
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Affiliation(s)
- D Golden
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - J Corbett
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - L G Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK.,Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Faculty of Health Care Sciences, University of Surrey, Guildford, Surrey, UK
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Correa-Martín L, Párraga E, Sánchez-Margallo FM, Latorre R, López-Albors O, Wise R, Malbrain MLNG, Castellanos G. Mechanical Intestinal Obstruction in a Porcine Model: Effects of Intra-Abdominal Hypertension. A Preliminary Study. PLoS One 2016; 11:e0148058. [PMID: 26849559 PMCID: PMC4744005 DOI: 10.1371/journal.pone.0148058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 12/03/2015] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Mechanical intestinal obstruction is a disorder associated with intra-abdominal hypertension and abdominal compartment syndrome. As the large intestine intraluminal and intra-abdominal pressures are increased, so the patient's risk for intestinal ischaemia. Previous studies have focused on hypoperfusion and bacterial translocation without considering the concomitant effect of intra-abdominal hypertension. The objective of this study was to design and evaluate a mechanical intestinal obstruction model in pigs similar to the human pathophysiology. MATERIALS AND METHODS Fifteen pigs were divided into three groups: a control group (n = 5) and two groups of 5 pigs with intra-abdominal hypertension induced by mechanical intestinal obstruction. The intra-abdominal pressures of 20 mmHg were maintained for 2 and 5 hours respectively. Hemodynamic, respiratory and gastric intramucosal pH values, as well as blood tests were recorded every 30 min. RESULTS Significant differences between the control and mechanical intestinal obstruction groups were noted. The mean arterial pressure, cardiac index, dynamic pulmonary compliance and abdominal perfusion pressure decreased. The systemic vascular resistance index, central venous pressure, pulse pressure variation, airway resistance and lactate increased within 2 hours from starting intra-abdominal hypertension (p<0.05). In addition, we observed increased values for the peak and plateau airway pressures, and low values of gastric intramucosal pH in the mechanical intestinal obstruction groups that were significant after 3 hours. CONCLUSION The mechanical intestinal obstruction model appears to adequately simulate the pathophysiology of intestinal obstruction that occurs in humans. Monitoring abdominal perfusion pressure, dynamic pulmonary compliance, gastric intramucosal pH and lactate values may provide insight in predicting the effects on endorgan function in patients with mechanical intestinal obstruction.
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Affiliation(s)
- L. Correa-Martín
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre (JUMISC), Cáceres, Spain
| | - E. Párraga
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - F. M. Sánchez-Margallo
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre (JUMISC), Cáceres, Spain
| | - R. Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - O. López-Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - R. Wise
- Critical Care Unit, Edendale Hospital, Pietermaritzburg, South Africa, and Department of Anaesthetics and Critical Care, Perioperative Research Group, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - M. L. N. G. Malbrain
- Medical and surgical ICU and high care Burn Unit, Ziekenhuis Netwerk Antwerpen, Antwerpen, Belgium
| | - G. Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
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Murtaza G, Pal KI, Jajja MRN, Nawaz Z, Koondhar R, Nasim S. Intra abdominal hypertension; incidence, prevalence and outcomes in a mixed intensive care unit: Prospective cohort study. Int J Surg 2015; 19:67-71. [DOI: 10.1016/j.ijsu.2015.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 04/23/2015] [Accepted: 05/07/2015] [Indexed: 01/01/2023]
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Abstract
We report a case of a false-positive focused abdominal sonography in trauma (FAST) examination in a persistently hypotensive pediatric trauma patient, performed 12 hours after the trauma, suspected to be caused by massive fluid resuscitation leading to ascites. While a positive FAST in a hypotensive trauma patient usually indicates hemoperitoneum, this case illustrates that the timing of the FAST examination relative to the injury, as well as clinical evolution including the volume of fluid resuscitation, need to be considered when interpreting the results of serial and/or late FAST examinations.
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Leng Y, Zhang K, Fan J, Yi M, Ge Q, Chen L, Zhang L, Yao G. Effect of acute, slightly increased intra-abdominal pressure on intestinal permeability and oxidative stress in a rat model. PLoS One 2014; 9:e109350. [PMID: 25295715 PMCID: PMC4190173 DOI: 10.1371/journal.pone.0109350] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 09/10/2014] [Indexed: 12/16/2022] Open
Abstract
Introduction Intra-abdominal hypertension (IAH) is known as a common, serious complication in critically ill patients. Bacterial translocation and permeability changes are considered the pathophysiological bases for IAH-induced enterogenic endotoxemia and subsequent multiorgan failure. Nevertheless, the effects of slightly elevated intra-abdominal pressures (IAPs) on the intestinal mucosa and the associated mechanisms remain unclear. Methods To investigate the acute effects of different nitrogen pneumoperitoneum grades on colonic mucosa, male Sprague-Dawley rats were assigned to six groups with different IAPs (0 [control], 4, 8, 12, 16, and 20 mmHg, n = 6/group). During 90 min of exposure, we dynamically monitored the heart rate and noninvasive hemodynamic parameters. After gradual decompression, arterial blood gas analyses were conducted. Thereafter, structural injuries to the colonic mucosa were identified using light microscopy. Colon permeability was determined using the expression of tight junction proteins, combined with fluorescein isothiocyanate dextran (FD-4) absorption. The pro-oxidant-antioxidant balance was determined based on the levels of malondialdehyde (MDA) and antioxidant enzymes. Results IAH significantly affected the histological scores of the colonic mucosa, tight junction protein expression, mucosal permeability, and pro-oxidant-antioxidant balance. Interestingly, elevations of IAP that were lower than the threshold for IAH also showed a similar, undesirable effect. In the 8 mmHg group, mild hyponatremia, hypocalcemia, and hypoxemia occurred, accompanied by reduced blood and abdominal perfusion pressures. Mild microscopic inflammatory infiltration and increased MDA levels were also detected. Moreover, an 8-mm Hg IAP markedly inhibited the expression of tight junction proteins, although no significant differences in FD-4 permeability were observed between the 0- and 8-mmHg groups. Conclusions Acute exposure to slightly elevated IAP may result in adverse effects on intestinal permeability and the pro-oxidant-antioxidant balance. Therefore, in patients with critical illnesses, IAP should be dynamically monitored and corrected, as soon as possible, to prevent intestinal mucosal injury and subsequent gut-derived sepsis.
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Affiliation(s)
- Yuxin Leng
- Department of Intensive Care Unit, Peking University Third Hospital, Haidian District, Beijing, P.R. China
- * E-mail: (YL); (GY)
| | - Kuo Zhang
- Laboratory Animal Center, Peking University Health Science Center, Haidian District, Beijing, P.R. China
| | - Jie Fan
- Department of Intensive Care Unit, Peking University Third Hospital, Haidian District, Beijing, P.R. China
| | - Min Yi
- Department of Intensive Care Unit, Peking University Third Hospital, Haidian District, Beijing, P.R. China
| | - Qinggang Ge
- Department of Intensive Care Unit, Peking University Third Hospital, Haidian District, Beijing, P.R. China
| | - Li Chen
- Department of Central Laboratory, Peking University Third Hospital, Haidian District, Beijing, P.R. China
| | - Lu Zhang
- Department of Gastroenterology, Peking University Third Hospital, Haidian District, Beijing, P.R. China
| | - Gaiqi Yao
- Department of Intensive Care Unit, Peking University Third Hospital, Haidian District, Beijing, P.R. China
- * E-mail: (YL); (GY)
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Zanello M, Vincenzi M, Di Mauro L, Gualdani S. Gut and sepsis: Victim of circumstance or prime mover. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Intra-abdominal hypertension falsely elevates the pulmonary artery pressure. Volumetric pulmonary artery catheter monitoring is an optionfor estimating preload in this condition. Treatment of intra-abdominal hypertension begins with medical therapy but once abdominal compartment syndrome develops it requires decompressive laparotomy for definitive management. Pulmonary hypertension reduces cardiac function which may be improved with inotropes that simultaneously reduce pulmonary artery pressure. Oxygenation may be improved with elevated PEEP and FiO(2).
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Current world literature. Curr Opin Anaesthesiol 2012; 25:629-38. [PMID: 22955173 DOI: 10.1097/aco.0b013e328358c68a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chenitz KB, Lane-Fall MB. Decreased urine output and acute kidney injury in the postanesthesia care unit. Anesthesiol Clin 2012; 30:513-26. [PMID: 22989592 DOI: 10.1016/j.anclin.2012.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Decreased urine output and acute kidney injury (also known as acute renal failure) are among the most important complications that may develop in the postanesthetic period. In this article, the authors present definitions of decreased urine output, oliguria, and acute kidney injury. They review the epidemiology, pathophysiology, and prevention of postoperative acute kidney injury. Finally, the article offers approaches to diagnosis and management of the postsurgical patient with decreased urine output or acute kidney injury.
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Affiliation(s)
- Kara Beth Chenitz
- Renal, Electrolyte and Hypertension Division, Department of Internal Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 1 Founders Building, Philadelphia, PA 19104, USA
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