Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation,leading to metforminassociated lactic acidosis(MALA).As diabetes mellitus is a common chronic...Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation,leading to metforminassociated lactic acidosis(MALA).As diabetes mellitus is a common chronic metabolic condition found in critically ill patients,pre-existing metformin use can often be found in critically ill patients admitted to the intensive care unit or the high dependency unit.The aim of this narrative mini review is therefore to update clinicians about MALA,and to provide a practical approach to its diagnosis and treatment.MALA in critically ill patients may be suspected in a patient who has received metformin and who has a high anion gap metabolic acidosis,and confirmed when lactate exceeds 5 mmol/L.Risk factors include those that reduce renal elimination of metformin(renal impairment from any cause,histamine-2 receptor antagonists,ribociclib)and excessive alcohol consumption(as ethanol oxidation consumes nicotinamide adenine dinucleotides that are also required for lactate metabolism).Treatment of MALA involves immediate cessation of metformin,supportive management,treating other concurrent causes of lactic acidosis like sepsis,and treating any coexisting diabetic ketoacidosis.Severe MALA requires extracorporeal removal of metformin with either intermittent hemodialysis or continuous kidney replacement therapy.The optimal time to restart metformin has not been well-studied.It is nonetheless reasonable to first ensure that lactic acidosis has resolved,and then recheck the kidney function post-recovery from critical illness,ensuring that the estimated glomerular filtration rate is 30 mL/min/1.73 m^(2) or better before restarting metformin.展开更多
Among critically ill patients,severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality.Yet,it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the...Among critically ill patients,severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality.Yet,it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease.In addition,management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions,drug-disease interactions,and adverse drug reactions.To help clinicians acquire an up-to-date approach to severe tuberculosis,this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.展开更多
Inhaled corticosteroids(ICS)and intranasal corticosteroids(INS)are the mainstays of treatment for chronic respiratory diseases like asthma,chronic obstructive pulmonary disease,and allergic rhinosinusitis.In addition,...Inhaled corticosteroids(ICS)and intranasal corticosteroids(INS)are the mainstays of treatment for chronic respiratory diseases like asthma,chronic obstructive pulmonary disease,and allergic rhinosinusitis.In addition,these localized forms of steroid therapy are generally considered to have fewer systemic side effects compared to long-term oral corticosteroids.However,concern and controversy remain over the impact of ICS and INS on the incidence and control of diabetes mellitus(DM).Given the widespread use of ICS and INS,even small individual effects on DM could lead to large consequences for the global population.Multiple large observational studies suggest that high dose ICS is associated with increased incident DM and worsened DM control,though the contribution of other risk factors is less certain.In addition,only two studies were done to investigate the association of INS and DM,with both studies demonstrating a short-term association of INS use with hyperglycemia.While more research evaluating the risk of ICS/INS for DM-related adverse events is needed,high doses of ICS/INS should be avoided when possible.The following strategies for ICS/INS dose minimization can be considered:Use of non-pharmacological measures(trigger avoidance,smoking cessation,vaccination to avoid infection),control of comorbid conditions,use of non-ICS-containing medications,intermittent rather than regular ICS dosing,and appropriate de-escalation of high ICS doses.展开更多
The carbon footprint of healthcare is significantly impacted by intensive care units,which has implications for climate change and planetary health.Considering this,it is crucial to implement widespread efforts to pro...The carbon footprint of healthcare is significantly impacted by intensive care units,which has implications for climate change and planetary health.Considering this,it is crucial to implement widespread efforts to promote environmental sustainability in these units.A literature search for publications relevant to environmental sustainability of intensive care units was done using PubMed.This mini-review seeks to equip intensive care unit practitioners and managers with the knowledge necessary to measure and mitigate the carbon cost of healthcare for critically ill patients.It will also provide an overview of the current progress in this field and its future direction.展开更多
Illness-induced hyperglycemia impairs neutrophil function,increases pro-inflammatory cytokines,inhibits fibrinolysis,and promotes cellular damage.In turn,these mechanisms lead to pneumonia and surgical site infections...Illness-induced hyperglycemia impairs neutrophil function,increases pro-inflammatory cytokines,inhibits fibrinolysis,and promotes cellular damage.In turn,these mechanisms lead to pneumonia and surgical site infections,prolonged mechanical ventilation,prolonged hospitalization,and increased mortality.For optimal glucose control,blood glucose measurements need to be done accurately,frequently,and promptly.When choosing glycemic targets,one should keep the glycemic variability<4 mmol/L and avoid targeting a lower limit of blood glucose<4.4 mmol/L.The upper limit of blood glucose should be set according to casemix and the quality of glucose control.A lower glycemic target range(i.e.,blood glucose 4.5-7.8 mmol/L)would be favored for patients without diabetes mellitus,with traumatic brain injury,or who are at risk of surgical site infection.To avoid harm from hypoglycemia,strict adherence to glycemic control protocols and timely glucose measurements are required.In contrast,a higher glycemic target range(i.e.,blood glucose 7.8-10 mmol/L)would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus.These targets may be modified if technical advances for blood glucose measurement and control can be achieved.展开更多
Acute respiratory distress syndrome(ARDS)-related acute cor pulmonale(ACP)is found in 8%-50%of all patients with ARDS,and is associated with adverse hemodynamic and survival outcomes.ARDS-related ACP is an echocardiog...Acute respiratory distress syndrome(ARDS)-related acute cor pulmonale(ACP)is found in 8%-50%of all patients with ARDS,and is associated with adverse hemodynamic and survival outcomes.ARDS-related ACP is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia,which connote simultaneous diastolic(volume)and systolic(pressure)overload respectively.Risk factors include pneumonia,hypercapnia,hypoxemia,high airway pressures and concomitant pulmonary disease.Current evidence suggests that ARDS-related ACP is amenable to multimodal treatments including ventilator adjustment(aiming for arterial partial pressure of carbon dioxide<60 mmHg,plateau pressure<27 cmH2O,driving pressure<17 cmH2O),prone positioning,fluid balance optimization and pharmacotherapy.Further research is required to elucidate the optimal frequency and duration of routine bedside echocardiography screening for ARDS-related ACP,to more clearly delineate the diagnostic role of transthoracic echocardiography relative to transesophageal echocardiography,and to validate current and novel therapies.展开更多
Point-of-care ultrasonography(POCUS)for managing critically ill patients is increasingly performed by intensivists or emergency physicians.Results of needs surveys among intensivists reveal emphasis on basic cardiac,l...Point-of-care ultrasonography(POCUS)for managing critically ill patients is increasingly performed by intensivists or emergency physicians.Results of needs surveys among intensivists reveal emphasis on basic cardiac,lung and abdominal ultrasound,which are the commonest POCUS modalities in the intensive care unit.We therefore aim to describe the key diagnostic features of basic cardiac,lung and abdominal ultrasound as practised by intensivists or emergency physicians in terms of accuracy(sensitivity,specificity),clinical utility and limitations.We also aim to explore POCUS protocols that integrate basic cardiac,lung and abdominal ultrasound,and highlight areas for future research.展开更多
文摘Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation,leading to metforminassociated lactic acidosis(MALA).As diabetes mellitus is a common chronic metabolic condition found in critically ill patients,pre-existing metformin use can often be found in critically ill patients admitted to the intensive care unit or the high dependency unit.The aim of this narrative mini review is therefore to update clinicians about MALA,and to provide a practical approach to its diagnosis and treatment.MALA in critically ill patients may be suspected in a patient who has received metformin and who has a high anion gap metabolic acidosis,and confirmed when lactate exceeds 5 mmol/L.Risk factors include those that reduce renal elimination of metformin(renal impairment from any cause,histamine-2 receptor antagonists,ribociclib)and excessive alcohol consumption(as ethanol oxidation consumes nicotinamide adenine dinucleotides that are also required for lactate metabolism).Treatment of MALA involves immediate cessation of metformin,supportive management,treating other concurrent causes of lactic acidosis like sepsis,and treating any coexisting diabetic ketoacidosis.Severe MALA requires extracorporeal removal of metformin with either intermittent hemodialysis or continuous kidney replacement therapy.The optimal time to restart metformin has not been well-studied.It is nonetheless reasonable to first ensure that lactic acidosis has resolved,and then recheck the kidney function post-recovery from critical illness,ensuring that the estimated glomerular filtration rate is 30 mL/min/1.73 m^(2) or better before restarting metformin.
文摘Among critically ill patients,severe pulmonary and extrapulmonary tuberculosis has high morbidity and mortality.Yet,it is a diagnostic challenge given its nonspecific clinical symptoms and signs in early stages of the disease.In addition,management of severe pulmonary and extrapulmonary tuberculosis is complicated given the high risk of drug-drug interactions,drug-disease interactions,and adverse drug reactions.To help clinicians acquire an up-to-date approach to severe tuberculosis,this paper will provide a narrative review of contemporary diagnosis and management of severe pulmonary and extrapulmonary tuberculosis in critically ill patients.
文摘Inhaled corticosteroids(ICS)and intranasal corticosteroids(INS)are the mainstays of treatment for chronic respiratory diseases like asthma,chronic obstructive pulmonary disease,and allergic rhinosinusitis.In addition,these localized forms of steroid therapy are generally considered to have fewer systemic side effects compared to long-term oral corticosteroids.However,concern and controversy remain over the impact of ICS and INS on the incidence and control of diabetes mellitus(DM).Given the widespread use of ICS and INS,even small individual effects on DM could lead to large consequences for the global population.Multiple large observational studies suggest that high dose ICS is associated with increased incident DM and worsened DM control,though the contribution of other risk factors is less certain.In addition,only two studies were done to investigate the association of INS and DM,with both studies demonstrating a short-term association of INS use with hyperglycemia.While more research evaluating the risk of ICS/INS for DM-related adverse events is needed,high doses of ICS/INS should be avoided when possible.The following strategies for ICS/INS dose minimization can be considered:Use of non-pharmacological measures(trigger avoidance,smoking cessation,vaccination to avoid infection),control of comorbid conditions,use of non-ICS-containing medications,intermittent rather than regular ICS dosing,and appropriate de-escalation of high ICS doses.
文摘The carbon footprint of healthcare is significantly impacted by intensive care units,which has implications for climate change and planetary health.Considering this,it is crucial to implement widespread efforts to promote environmental sustainability in these units.A literature search for publications relevant to environmental sustainability of intensive care units was done using PubMed.This mini-review seeks to equip intensive care unit practitioners and managers with the knowledge necessary to measure and mitigate the carbon cost of healthcare for critically ill patients.It will also provide an overview of the current progress in this field and its future direction.
文摘Illness-induced hyperglycemia impairs neutrophil function,increases pro-inflammatory cytokines,inhibits fibrinolysis,and promotes cellular damage.In turn,these mechanisms lead to pneumonia and surgical site infections,prolonged mechanical ventilation,prolonged hospitalization,and increased mortality.For optimal glucose control,blood glucose measurements need to be done accurately,frequently,and promptly.When choosing glycemic targets,one should keep the glycemic variability<4 mmol/L and avoid targeting a lower limit of blood glucose<4.4 mmol/L.The upper limit of blood glucose should be set according to casemix and the quality of glucose control.A lower glycemic target range(i.e.,blood glucose 4.5-7.8 mmol/L)would be favored for patients without diabetes mellitus,with traumatic brain injury,or who are at risk of surgical site infection.To avoid harm from hypoglycemia,strict adherence to glycemic control protocols and timely glucose measurements are required.In contrast,a higher glycemic target range(i.e.,blood glucose 7.8-10 mmol/L)would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus.These targets may be modified if technical advances for blood glucose measurement and control can be achieved.
文摘Acute respiratory distress syndrome(ARDS)-related acute cor pulmonale(ACP)is found in 8%-50%of all patients with ARDS,and is associated with adverse hemodynamic and survival outcomes.ARDS-related ACP is an echocardiographic diagnosis marked by combined right ventricular dilatation and septal dyskinesia,which connote simultaneous diastolic(volume)and systolic(pressure)overload respectively.Risk factors include pneumonia,hypercapnia,hypoxemia,high airway pressures and concomitant pulmonary disease.Current evidence suggests that ARDS-related ACP is amenable to multimodal treatments including ventilator adjustment(aiming for arterial partial pressure of carbon dioxide<60 mmHg,plateau pressure<27 cmH2O,driving pressure<17 cmH2O),prone positioning,fluid balance optimization and pharmacotherapy.Further research is required to elucidate the optimal frequency and duration of routine bedside echocardiography screening for ARDS-related ACP,to more clearly delineate the diagnostic role of transthoracic echocardiography relative to transesophageal echocardiography,and to validate current and novel therapies.
文摘Point-of-care ultrasonography(POCUS)for managing critically ill patients is increasingly performed by intensivists or emergency physicians.Results of needs surveys among intensivists reveal emphasis on basic cardiac,lung and abdominal ultrasound,which are the commonest POCUS modalities in the intensive care unit.We therefore aim to describe the key diagnostic features of basic cardiac,lung and abdominal ultrasound as practised by intensivists or emergency physicians in terms of accuracy(sensitivity,specificity),clinical utility and limitations.We also aim to explore POCUS protocols that integrate basic cardiac,lung and abdominal ultrasound,and highlight areas for future research.
