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Antibiotics should only be administered after microbiological specimens are taken, except in emergencies. Most antibiotics are removed from the body via the kidneys. Renal failure may cause the accumulation of a drug, or its metabolites. This is a particular problem with glycopeptides and aminoglycosides where toxic levels are associated with severe and permanent side effects such as ototoxicity and renal impairment. Organisms resistant to multiple antibiotics such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) have emerged in healthcare environments and have proved difficult to control in many countries. Prophylaxis is recommended where a bacteraemia is expected, and the resultant infection may result in significant morbidity or mortality. The commonly used antibiotics on intensive care unit are: beta-lactams, carbapenems, aminoglycosides, glycopeptides, quinolones, macrolides, rifampicin, oxazolidinone and nitroimidazoles. The three major classes of anti-fungal drug are: azoles, polyenes, and echinocandins.
Disorders of acid-base equilibrium are common in critically ill and injured patients. The presence of these disorders often signals severe underlying pathophysiology and, particularly in the case of metabolic acidosis, is a significant marker of adverse outcome. The traditional theory makes us believe that the hydrogen ion concentration (pH) in blood is mainly influenced by balance between the carbon dioxide and the bicarbonate ions in the blood. An acid load sufficient to reduce an unbuffered solution to a pH less than 2 only reduces the blood pH of an animal by 0.3 pH units. Disturbances of the acid-base equilibrium have their own morbidity and mortality. A blood pH less than normal (normal range 7.35-7.45) is called acidaemia; the underlying process causing acidaemia is called acidosis. Similarly, alkalaemia and alkalosis refer to a raised pH and the underlying process, respectively.
Fluid and electrolyte balance is an important everyday practice on the intensive care unit. The different types of fluids are crystalloids that include Hartmann's solution, normal (isotonic) saline, dextrose, and colloids that include albumin, starch and gelatins. The disorders of sodium concentration are nearly always caused by excess free water (hyponatraemia) or free water loss (hypernatraemia). The potassium balance is affected by hypokalaemia and hyperkalaemia. The abnormalities in magnesium are caused by hypomagnesaemia and hypermagnesaemia. The abnormalities in phosphorous are caused by hypophosphataemia and hyperphosphataemia. The abnormalities in calcium are caused by hypocalcaemia and hypercalcaemia. Hypercalcaemia is not a common problem in intensive care. In 90% of cases, the underlying cause is hyper-parathyroidism or malignancy. Treatment is indicated when the hypercalcaemia is associated with adverse effects, or when the serum calcium is greater than 14 mg/dl (ionized calcium above 3.5 mmol/l).
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