Acute Kidney Injury and Renal Replacement Therapy: A Review and Update for the Perioperative Physician.

Post-operative acute kidney injury is a devastating complication with significant morbidity and mortality associated with it. The perioperative anesthesiologist is in a unique position to potentially mitigate the risk of postoperative AKI, however, understanding the pathophysiology, risk factors and preventative strategies is paramount. There are also certain clinical scenarios, where renal replacement therapy may be indicated intraoperatively including severe electrolyte abnormalities, metabolic acidosis and massive volume overload. A multidisciplinary approach including the nephrologist, critical care physician, surgeon and anesthesiologist is necessary to determine the optimal management of these critically ill patients.

Psychiatric sequelae and interventions in critically ill trauma survivors.

PURPOSE OF REVIEW: Psychiatric disorders following trauma impact functional recovery in trauma survivors and are a significant source of disability. Although research has traditionally focused on the physical sequelae of trauma, more attention is being directed towards the significant morbidity and mortality associated with the psychologic sequelae of trauma. This review evaluates the existing literature. RECENT FINDINGS: Use of multidisciplinary collaborative programmes in combination with psychiatric treatment and pharmacotherapy may be necessary to improve the care of trauma patients with psychiatric sequelae. Improving identification of vulnerable patients may help in the prevention and treatment of psychiatric disorders and is an area of current research initiatives. SUMMARY: There are few interventions that have demonstrated efficacy in managing the psychiatric sequelae of trauma. The development of strategies to guide early identification of at-risk patients and recommend prevention and treatment may improve the care of trauma survivors.

Predicting mortality in elderly trauma patients: a review of the current literature.

PURPOSE OF REVIEW: Advances in medical care allow patients to live longer, translating into a larger geriatric patient population. Adverse outcomes increase with older age, regardless of injury severity. Age, comorbidities, and physiologic deterioration have been associated with the increased mortality seen in geriatric trauma patients. As such, outcome prediction models are critical to guide clinical decision making and goals of care discussions for this population. The purpose of this review was to evaluate the various outcome prediction models for geriatric trauma patients. RECENT FINDINGS: There are several prediction models used for predicting mortality in elderly trauma patients. The Geriatric Trauma Outcome Score (GTOS) is a validated and accurate predictor of mortality in geriatric trauma patients and performs equally if not better to traditional scores such as the Trauma and Injury Severity Score. However, studies recommend medical comorbidities be included in outcome prediction models for geriatric patients to further improve performance. SUMMARY: The ideal outcome prediction model for geriatric trauma patients has not been identified. The GTOS demonstrates accurate predictive ability in elderly trauma patients. The addition of medical comorbidities as a variable in outcome prediction tools may result in superior performance; however, additional research is warranted.

Impact of a Procalcitonin-Based Protocol on Antibiotic Exposure and Costs in Critically Ill Patients.

To examine the impact before and after adoption of a procalcitonin-based protocol to guide sepsis management has on antibiotic use, care costs, and outcomes of critically ill patients. DESIGN: Before-after study. SETTING: ICU of an academic tertiary care center. PATIENTS: Adults over 18 years old admitted to the ICU from January 1, 2017, to January 31, 2020. INTERVENTIONS: In this before-after study, we compared the use of medications, outcomes, and overall cost before and after the introduction of a procalcitonin-based protocol for evaluation and treatment of sepsis. MEASUREMENTS AND MAIN RESULTS: The final study cohort consisted of 1,793 patients admitted to the ICU, 776 patients pre-procalcitonin and 1,017 patients in the post-procalcitonin period. Patients were not different in the pre-procalcitonin adoption period compared with post-procalcitonin adoption with regard to gender, age (62.0 vs 62.6), race, or comorbidities. Patients admitted during the post-procalcitonin adoption period were less likely to receive the examined broad-spectrum antibiotics (odds ratio, -0.58; CI, -0.99 to -0.17; p < 0.01) than patients during the pre-procalcitonin adoption period. The odds of inhospital death did not differ after procalcitonin adoption when compared with before (0.87; CI, 0.70-1.09; p = 0.234). Total charges for each admission were significantly less in the post-procalcitonin adoption period $3,834.99 compared with pre-procalcitonin adoption $4,429.47 (p < 0.05). Patients post-procalcitonin adoption incurred $1,127.18 per patient less in total charges (-1,127.18; CI, -2,014.74 to -239.62; p = 0.013) after controlling for relevant factors. CONCLUSIONS: In critically ill patients in a large U.S. tertiary care hospital, the adoption of a procalcitonin-based protocol for evaluation and treatment of sepsis may be associated with decreased antibiotic use and significant cost savings, with no change in mortality.