Prevention of acute kidney injury and protection of renal function in the intensive care unit

Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest using vasopressors in vasodilatory hypotension, specific vasodilators under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention

Avaliação da lidocaína tópica como pré-medicação para a endoscopia digestiva alta em crianças Evaluation of topical lidocaine spray as premedication to upper gastrointestinal endoscopy in children

OBJETIVO: Avaliar a eficácia da lidocaína spray tópica como droga adjuvante na sedação e analgesia de crianças e adolescentes para endoscopia digestiva. MÉTODOS: Foram incluídos 80 pacientes (49 femininos e 31 masculinos, idade média 12±3 anos), 40 no grupo placebo e 40 no grupo lidocaína. Os pacientes foram alocados aleatoriamente e um paciente de cada grupo foi excluído. Lidocaína a 10% ou placebo (ácido tânico 0,5%) aerossol (dois jatos) foram aplicados na orofaringe antes da infusão de propofol. Os pacientes foram monitorizados durante o procedimento e após, sendo respondido questionário para avaliar odinofagia e a pré-medicação. O desfecho primário foi a dose de propofol empregada, enquanto os desfechos secundários foram incidência de complicações, tempo de sala e duração do procedimento. RESULTADOS: Não houve diferenças entre os grupos quanto à idade, sexo e indicação da endoscopia. A dose de propofol empregada não foi diferente nos dois grupos (grupo placebo 3,1±1,1 e grupo lidocaína 2,9±1,3mg/kg; p=0,69), mesmo quando considerada a dose bruta (p=0,33). No entanto, o tempo de sala médio foi maior no grupo placebo do que no lidocaína (23±7 versus 20±5 minutos; IC95% da diferença: 0,47-5,89 minutos, p=0,02). Não houve diferenças entre os grupos quanto à duração do procedimento, incidência de complicações e aceitação pelo paciente. CONCLUSÕES: O emprego de medicação tópica anestésica em endoscopia reduz o tempo de sala sem aumentar a incidência de efeitos adversos (NCT00521703).<br>OBJECTIVE: This study aims to evaluate the efficacy of topical lidocaine as an adjuvant drug to sedatives in children and adolescents undergoing digestive endoscopies. METHODS: 80 patients (49 females and 31 males, 12±3 years old) were randomly allocated into placebo (n=40) or lidocaine group (n=40). One patient was excluded from each group after allocation. Two puffs of either 10% lidocaine or placebo (tannic acid 0.5%) were sprayed into the oropharynx before the infusion of propofol. Patients were monitored during the procedure and answered a questionnaire after the procedure to evaluate sore throat and the medicine used as pre-medication. The primary outcome measure was propofol dose. Time spent in the procedure room, in the procedure and the incidence of complications were secondary outcome measures. RESULTS: Demographic data (age, sex and endoscopy indication) were evenly distributed in each group. The dose of propofol was not different between patients and controls (placebo group 3.1±1.1 and lidocaine group 2.9±1.3mg/kg; p=0.69), even considering the total dose (p=0.33). The time spent in the procedure room was longer for the placebo group than for the lidocaine group (23±7 versus 20±5 minutes; 95%CI of the difference: 0.47-5.89 minutes, p=0.02). There was no difference between groups regarding procedure duration, complications incidence and tolerability. CONCLUSIONS: Topic anesthetic medication reduces the time spent in the procedure room without increasing the incidence of side effects (NCT00521703)