[Ajuste de fármacos y nutrición en terapias de reemplazo renal continuo]

Del 6 al 23% de los pacientes con lesión renal aguda (LRA) en unidades de cuidados intensivos (UCI) requieren apoyo renal, siendo la terapia continua una modalidad de alta frecuencia de uso en el paciente críticamente enfermo. Si bien el objetivo general de las terapias de reemplazo renal continuo (TRRC) es restablecer el equilibrio hídrico y ácido-base, junto con la eliminación de toxinas urémicas e inflamatorias relacionadas con la pérdida de depuración renal y la disfunción multiorgánica; reconocemos como efecto colateral la depuración (K) no deseado de moléculas y sustancias deseadas en la recuperación del paciente crítico, como pueden ser antimicrobianos y nutrientes. La sepsis es la causa más frecuente de LRA en la UCI y en este contexto la terapia antimicrobiana adecuadamente seleccionada y a la dosis correcta es la médica terapéutica más importante. De la misma manera, es indispensable garantizar el adecuado apoyo nutricional en este grupo poblacional. Proponemos en esta revisión una aproximación teórica y práctica para seleccionar el tratamiento farmacológico de antimicrobianos y el apoyo nutricional en el paciente en TRRC.

Six to 23% of patients with acute kidney injury (AKI) in intensive care units (ICU) require renal support. Continuous renal replacement therapies (CRRT) have become the modality of choice in critical care. Although the aim of CRRT is to restore the water and acid-base balance, together with the removal of uremic and inflammatory toxins related to the loss of renal clearance and multi-organ dysfunction; we recognize as a side effect the unwanted clearance of molecules and substances desired for the recovery of the critically ill patient such as antimicrobials and nutrients. Sepsis is the most frequent cause of AKI in the ICU and, in this context, the appropriate selection of antimicrobial therapy, and at the correct dose, is one of the most important decisions; it is also essential to guarantee the adequate nutritional support in this population. We propose in this review a theoretical and practical approach to address the pharmacological management of antimicrobials and nutritional support in the patient in CRRT.

Intracorporeal orthotopic neobladder formation: Why not to do it?

There has been growing  interest in intracorporeal techniques to urinary diversion during cystectomy in the modern area. There is little high-quality evidence that this technique is superior to  extracorporeal diversion in patients who are obtaining  an orthotopic intracorporeal neobladder urinary diversion. This study describes the proposed advantages and  disadvantages of intracorporeal orthotopic neobladder urinary diversion and expert opinion on preference.  METHODS: We reviewed the literature for all studies  discussing the outcomes and advantages of intracorporeal orthotopic neobladder urinary diversion, including those comparing the intracorporeal and extracorporeal approach. The studies were reviewed and these findings were summarized based on categories of the proposed advantages and disadvantages of the intracorporeal approach. We provided an assessment of the claims made in favor of the intracorporeal approach and discussed advantages of the extracorporeal approach that may persuade even the most experienced robotic surgeons to lean away from the former.  RESULTS AND CONCLUSIONS: Herein we review the studies that propose advantages of the intracorporeal diversion, as well as the studies that do not demonstrate any advantage to this approach. Some of the proposedadvantages addressed include decreased stricture rate, lower complications and shorter hospitalization. Furthermore, we address the issues of the steep learningcurve and the impact on resident education. We conclude that the proposed benefits of an intracorporeal approach to urinary diversion are not substantiated and it is the preference of the authors to primarily perform extracorporeal urinary diversions.