Acute Renal Failure

ARF occurs in 19% of septic patients, 25% of severe septic patients, and 51% of septic 20

shock patients. Sepsis and ARF together have a 70% mortality, compared to 45% among patients with ARF alone.20 ARF leads to fluid in the extravascular space, including the lungs, followed by impairment in gas exchange and severe hypoxemia. The hypoxemia will exacerbate ischemia and organ damage. Renal replacement therapy with the use of continuous venovenous hemofiltration and intermittent hemodia-

lysis can be used to facilitate volume and electrolytes. Hemodynamic Compromise

Arterial vasodilatation is the hallmark of hemodynamic effects related to sepsis. High cardiac output and low systemic vascular resistance characterize arterial vasodilation. Inflammatory cytokines (i.e., tumor necrosis factor-a [TNF-a]) and endotoxin directly depress cardiovascular function. Persistent hypotension offsets the delivery of oxygen to tissues (DO2) and oxygen consumption by tissues (VO2).21 Certain tissues may receive adequate oxygen during sepsis; however, in other tissues oxygen demands may not be met because of decreased perfusion. This perfusion defect is accentuated by increased precapillary atrioventricular shunt. If perfusion decreases, oxygen extraction increases, and the atrioventricular oxygen gradient widens. Cellular DO2 is decreased, but VO2 remains unchanged. If perfusion decreases significantly, reserve DO2 will be exceeded, and tissue ischemia results. Tissue ischemia leads to organ failure. Therefore, increasing oxygen delivery or decreasing oxygen consumption in a hypermeta-bolic patient should optimize systemic DO2 relative to VO2.21

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