Explore NYSORA knowledge base for free:
Explore NYSORA knowledge base for free:
In intensive care units (ICUs) worldwide, the use of diuretics is nearly universal among patients requiring management of fluid overload. Despite their frequent use, a wide range of questions remains regarding the most suitable diuretic agents, optimal dosing strategies, and the physiological consequences of their administration. A 2025 narrative review published in the British Journal of Anaesthesia synthesizes the current knowledge of renal physiology, drug mechanisms, and clinical indications of diuretics in critically ill patients. The review highlights practical insights into how diuretics can be used more effectively while identifying areas where further evidence is required. This comprehensive summary addresses both the pharmacodynamic principles and the nuanced clinical applications of diuretic therapy, providing a structured framework for decision-making in ICU fluid management. Renal physiology as the foundation for diuretic strategy Effective use of diuretics in critical care hinges on a sound understanding of renal function. The nephron, the kidney’s functional unit, reabsorbs over 99% of the filtered water and solutes, primarily in the proximal tubule and loop of Henle. Different classes of diuretics target distinct nephron segments to interrupt sodium and water reabsorption. Crucial physiological processes involved include: Tubular transport mechanisms, such as the Na⁺-H⁺ exchanger and the NKCC co-transporter, are essential for sodium and bicarbonate reabsorption. Tubuloglomerular feedback is mediated by the macula densa, which regulates glomerular filtration rate (GFR) in response to tubular solute load. Hormonal regulation through the renin–angiotensin–aldosterone system (RAAS) affects sodium reabsorption and fluid balance in the distal nephron. In the context of critical illness, factors such as capillary leak, altered renal perfusion, and systemic inflammation often disrupt these regulatory mechanisms, thereby complicating fluid management. Loop diuretics: clinical utility and considerations Loop diuretics, particularly furosemide, are the cornerstone of diuretic therapy in the intensive care unit (ICU) due to their potency in inducing natriuresis and […]
July 15, 2025
In a landmark move published in JAMA in May 2025, the Association for the Advancement of Blood and Biotherapies (AABB) and the International Collaboration for Transfusion Medicine Guidelines (ICTMG) unveiled updated international clinical guidelines on platelet transfusion. Backed by a robust panel of global experts and patient partners, these guidelines emphasize a conservative, or restrictive, approach to platelet transfusion to minimize harm, conserve resources, and enhance clinical outcomes. Why restrictive transfusion strategies matter Platelet transfusions are lifesaving in specific clinical contexts, particularly for patients with thrombocytopenia (low platelet counts) or platelet dysfunction. However, the procedure is not without risks. Platelets are biologically active and prone to causing immune and non-immune adverse events more frequently than red blood cell transfusions. Key considerations: Short shelf life: Platelets have a shelf life of 5–7 days, making supply chains highly vulnerable. High demand: Unlike red blood cell use, platelet use has not declined in recent years. Adverse effects: These include allergic reactions, febrile nonhemolytic reactions, and life-threatening events like TRALI and TACO. Resource strain: Platelet collection and storage are costly, requiring tight coordination. By advocating for a restrictive strategy, the 2025 guidelines aim to reduce unnecessary transfusions, improve safety, and optimize the use of limited blood products. Major findings from the evidence review The guideline development was grounded in the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology, which assessed 21 randomized clinical trials (RCTs) and 13 observational studies spanning several decades and diverse patient populations. Overall results show: No increase in mortality with restrictive strategies. Minimal difference in grade 3–4 bleeding. Reduced exposure to transfusion-related harms. Who should get transfused and when? These are backed by moderate to high-certainty evidence. 1. Non-bleeding cancer patients or stem cell recipients Threshold: < 10,000/μL. Rationale: Evidence shows no benefit from transfusing at higher counts. 2. […]
July 14, 2025
As surgical volumes increase globally, the importance of managing patients’ psychological well-being is coming into sharper focus. Mental health disorders, particularly depression and anxiety, are increasingly prevalent and carry significant implications for perioperative outcomes. According to a 2024 review by Rolfzen et al., integrating mental health care into surgical workflows can lead to better pain management, faster recovery, and reduced mortality. The silent burden of mental illness in surgery Mental illness is a major contributor to global disability. In the U.S., the prevalence of major depressive disorder and generalized anxiety disorder in adults aged 18–65 stands at 15.5% and 10%, respectively. Yet, the burden is even higher among surgical patients due to stressors related to surgery, including pain, hospitalization, and uncertainty. Key implications of untreated perioperative mental illness: Increased postoperative pain Higher hospital readmission rates Elevated risk of postoperative delirium Reduced quality of life and prolonged recovery Increased 30-day postoperative mortality Despite these risks, only 47.2% of patients with a diagnosed mental illness receive any treatment. Preoperative considerations: screening and risk assessment Mental health screening tools for surgical patients: PHQ-9 / PHQ-2: Quick assessments for depression severity GAD-7 / GAD-2: Widely used for anxiety detection Amsterdam Preoperative Anxiety and Information Scale: Tailored for surgical patients Computerized Adaptive Tests: AI-driven tools for personalized assessment Digital innovation: Adaptive computerized tools enable rapid screening (3–5 minutes) and can be embedded in electronic health records to prompt early intervention. Nonpharmacologic interventions Behavioral therapies are essential in managing preoperative and postoperative psychological distress. These include: Cognitive Behavioral Therapy (CBT): Four short sessions can significantly reduce depressive and anxiety symptoms in cardiac surgery patients. Group psychotherapy: Eight weekly sessions cut depression and anxiety by over 60% in lung cancer patients. Music medicine: Passive music listening reduces anxiety and improves satisfaction in diverse surgical populations. Mindfulness and […]
July 11, 2025
