What's New | Decker

2024 KDIGO Practice Guidelines
Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada
Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update.

Early recognition of shock is difficult but essential for preservation of cellular and organ function and survival. The earliest clinical signs are nonspecific, with the initial inflammatory response including tachycardia, fevers, or cool or clammy skin.
The approach to shock ultimately requires understanding and correcting its etiology (eg, antibiotics and source control for sepsis, thrombectomy after massive pulmonary embolus, hemorrhage control after trauma, and so forth). However, until these are diagnosed and addressed directly, clinicians ultimately have three approaches in their armamentarium: volume expansion, vasopressors, and cardioactive agents.
The PAC was introduced in 1970. Its use increased over the next 3 decades and eventually was considered the standard of care for most critically ill patients. However, the use of PACs declined rapidly after the results of the randomized, controlled trial published in the New England Journal of Medicine revealing no benefit in high-risk surgical patients.

Many iatrogenic withdrawal syndromes have been identified, the most common of which is opioid or benzodiazepine withdrawal. Generally speaking, the approach to treating opioid and/or benzodiazepine withdrawal is to provide enough medication to saturate target receptors, followed by a period of gradual dose reduction to allow the body to return to a state of homeostasis.
The Neonatal Abstinence Score (NAS) was designed to assess withdrawal symptoms in infants with multiple drug exposure during pregnancy. Because the NAS was validated in infants, it is not applicable in older children with iatrogenic withdrawal. In recent years, withdrawal assessment tools for pediatrics have been developed for iatrogenic withdrawal to provide an objective assessment of withdrawal.
There have been no randomized clinical trials that have compared the efficacy of various weaning strategies. However, a recent multicenter clinical trial, named the RESTORE trial, examined the effects of a standardized sedation protocol in pediatric intensive care units.

Sepsis syndromes have been redefined (Sepsis-3 definitions) by international experts, based on sepsis mortality data extracted large administrative databases.
National focus has turned to early identification of sepsis as a key determinant of outcomes. International critical care experts have recommended using the qSOFA criteria in the Emergency Department setting to identify sepsis risk in patients prior to obtaining diagnostics.
The Center for Medicare and Medicaid Services (CMS) has added a sepsis quality measure (SEP-1) as a reporting requirement for all US hospital tied to Medicare & Medicaid reimbursement. This measure has increased awareness of sepsis performance and focused quality efforts on improvement.
2018 update to bundles to simplify to 1-hour bundle.

Initial volume resuscitation should commence with 1 L isotonic crystalloid solution followed by blood products at 1:1:1 ratio (1 unit packed red blood cells to 1 unit fresh frozen plasma to 1 unit platelets) if the patient is not responsive to the initial fluid bolus.
In patients with massive hemorrhage or evidence of fibrinolysis, tranexamic acid has demonstrated improved survival if administered within 3 hours of injury.
Use of resuscitative endovascular balloon occlusion of the aorta may be an important adjunct in the control of life-threatening abdominal or pelvic hemorrhage.
In cases of external hemorrhage of an extremity, a tourniquet should be used to control bleeding.

Extracorporeal membrane oxygenation (ECMO) is a modified method of cardiopulmonary bypass that is used as a last resort modality for support of the pediatric patient in cardiac and/or respiratory failure.
VADs are a newer, alternative method of mechanical circulatory support for children in refractory heart failure or cardiogenic shock who are awaiting transplantation. VAD use in adults is well established, and its use in children has been steadily increasing over the last decade.
Lactate is a by-product of anaerobic metabolism and is often used to diagnose and monitor the progression of shock. Although lactate is less frequently elevated in pediatric patients, an initial elevated lactate level has been found to be associated with increased risk of organ dysfunction in pediatric sepsis and can be followed as a marker of resuscitation.

Use of HVPG to accurately diagnose portal hypertension
Child-Pugh score and MELD score in risk stratification and decision-making
Fibroelastography, multidetecter row CT scan, and capsule endoscopy as emerging modalities in detection of varices.

The use of microvascular free tissue transfer to reconstruct surgical defects in the head has allowed surgeons to resect large tumors with large margins while simultaneously achieving improved functional results.
Imaging studies (e.g., computed tomography [CT] and magnetic resonance imaging) may be helpful in locating the source of a cervical metastasis. Positron emission tomography (PET) detects lesions with increased metabolic activity but has the limitation of being unable to detect lesions smaller than 1 cm in diameter.

Nephrology