Use of prolonged bivalirudin infusions following percutaneous coronary intervention.

INTRODUCTION: Antithrombotic therapy plays an integral role in percutaneous coronary intervention (PCI). Bivalirudin has been evaluated in elective procedures and across the spectrum of acute coronary syndromes and is associated with decreased bleeding events compared to unfractionated heparin (UFH) in combination with glycoprotein IIb/IIIa inhibitors (GPI) when used for the duration of PCI. The use of bivalirudin beyond the end of PCI is not as well established but is being explored as an option for specific patients. DISCUSSION: A small increase in stent thrombosis and ischemic events has been identified in large clinical trials using bivalirudin for acute coronary syndromes (ACS). The reasons for this finding are unclear, but may be related to the short duration of bivalirudin or the timing and dose of antiplatelet therapies in the trials. Two small, single center trials have evaluated bivalirudin continued for 4 h beyond the end of PCI. These trials suggest that prolonged bivalirudin infusions result in less periprocedural myocardial infarction with no increase in bleeding compared to intraprocedural only bivalirudin. However, these studies were not powered to identify a difference in bleeding. Efforts to decrease periprocedural myocardial infarction should include the appropriate use of oral antiplatelet agents. An adequate and appropriately timed loading dose of thienopyridines plays a key role in decreasing complications of PCI. CONCLUSION: The strategy of prolonging the bivalirudin infusion at a reduced infusion rate for 4 h after completion of the PCI procedure was explored and offers promising results.

Metabolic and nutritional aspects of acute renal failure in critically ill patients requiring continuous renal replacement therapy.

Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple-organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid-base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.