Ramesh Venkataraman

Apollo Hospitals, Chennai, Tamil Nadu, India

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Publications (57)266.58 Total impact

  • Bhuvaneshwari Shankar · D K Daphnee · Nagarajan Ramakrishnan · Ramesh Venkataraman ·
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    ABSTRACT: In critically ill patients, early enteral nutrition (EN) within 24 to 72 hours is recommended. Although vasopressor-dependent shock after resuscitation is not a contraindication for EN initiation, feasibility and safety of very early (within 6 hours) EN initiation soon after resuscitation are unknown. To evaluate the feasibility, safety, tolerance, and adequacy of very EN delivery in critically ill patients within 6 hours of intensive care unit (ICU) admission. Prospectively collected data from a total of 308 medical and surgical patients admitted to the ICU for at least 3 days were analyzed. The patients in whom EN was initiated within 6 hours of ICU admission (n = 166) were compared with those in whom EN was initiated after 6 hours (n = 142). Comparisons were made between groups in the percentage of target calories and proteins delivered on day 3, percentages of patients achieving target calories and proteins on day 3, incidence of feed intolerance, ICU length of stay (LOS), hospital LOS, ICU/hospital discharge, and mortality. No significant differences were seen in percentage of calories (71.62% vs 71.83%; P = .09) and proteins (71.85% vs 68.89%; P = .2) delivered on day 3 between patients receiving EN within 6 hours and after 6 hours of admission. Similar number of patients achieved target calories (66.3% vs 67.6%; P = .8) and target proteins (66.9% vs 62.7%; P = .5) on day 3 in both groups. There were no significant differences between the groups for ICU LOS (11.41 days vs 11.72 days; P = .7) and hospital LOS (20.7 days vs 17.96 days; P = .1). A total of 77.1% patients were discharged in the group in whom EN was initiated within 6 hours and 67.6% patients were discharged in the group where EN was initiated after 6 hours (P = .07). The mortality rate was 22.9% and 32.4%, respectively (P = .07), in these groups. Overall incidence of EN interruption was 20.13% without significant difference between the 2 groups (<6 hours, 16.2%; >6 hours, 24.7%; P = .087). Initiation of EN within 6 hours of ICU admission is feasible and safe and can be implemented routinely in all ICU patients. Copyright © 2015. Published by Elsevier Inc.
    Journal of critical care 02/2015; 30(3). DOI:10.1016/j.jcrc.2015.02.009 · 2.00 Impact Factor
  • Ramesh Venkataraman · Nagarajan Ramakrishnan ·
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    ABSTRACT: Telemedicine has been increasingly used in the intensive care unit setting (Tele-ICU) for providing care. Given the shortage of qualified intensivists and critical care nurses in the United States and the ever-increasing demand for intensive care services, Tele-ICU has been proposed as a strategy to bridge this supply/demand gap. The Tele-ICU staffing model provides for many important outcome benefits that have been evaluated over the years by several studies. In this review, the authors summarize the existing evidence and identify areas where further evaluation is warranted. Copyright © 2015 Elsevier Inc. All rights reserved.
    Critical Care Clinics 02/2015; 31(2). DOI:10.1016/j.ccc.2014.12.003 · 2.16 Impact Factor

  • Indian Journal of Critical Care Medicine 01/2015; 19(11):665. DOI:10.4103/0972-5229.169342
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    ABSTRACT: Medical accreditation bodies and licensing authorities are increasingly mandating continuing medical education (CME) credits for maintenance of licensure of healthcare providers. However, the costs involved in participating in these CME activities are often substantial and may be a major deterrent in obtaining these mandatory credits. It is assumed that healthcare providers often obtain sponsorship from their institutions or third party payers (i.e. pharmaceutical-industry) to attend these educational activities. Data currently does not exist exploring the funding sources for CME activities in India. In this study, we examine the relative proportion of CME activities sponsored by self, institution and the pharmaceutical-industry. We also wanted to explore the characteristics of courses that have a high proportion of self-sponsorship.
    Indian Journal of Critical Care Medicine 08/2014; 18(8):513-7. DOI:10.4103/0972-5229.138152
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    ABSTRACT: Background:Use of noninvasive ventilation (NIV) outside guideline recommendations is common. We audited use of NIV in our tertiary care critical care unit (CCU) to evaluate appropriateness of use and patient outcomes when used outside level I recommendations.Materials and Methods:Prospective observational study of all patients requiring NIV. Clinical parameters and arterial blood gases were recorded at initiation of NIV and 2 h later (or earlier if clinically warranted). NIV titration and decision to intubate were left to the discretion of treating intensivist. Patients were categorized into two groups: Group 1: Those with level I indications for use of NIV and group 2: All other levels of indications. Patients were followed until hospital discharge.Results:From January 2010 to June 2010, 1120 patients were admitted to the CCU. Of these 106 patients required NIV support with 40.6% (n = 43/106) being in group 1 and 59.4% (n = 63/106) in group 2. Of these 35.8% patients (38/106) failed NIV and required endotracheal intubation. NIV failure rates (41.27% vs. 27.91%; P = 0.02) and mortality (30.6% vs. 18.6%; P = 0.03) were significantly higher in group 2 patients. In a logistic regression analysis Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.02), time on NIV before intubation (P = 0.001) and baseline PaCO2 levels (P = 0.01) were strongly associated with mortality.Conclusion:Noninvasive ventilation failure and mortality rates were significantly higher when used outside level I recommendations. APACHE II score, baseline PaCO2 and duration on NIV prior to intubation were predictors of increased mortality.
    Indian Journal of Critical Care Medicine 08/2014; 18(8):503-7. DOI:10.4103/0972-5229.138147
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    ABSTRACT: Abstract Although the epidemiology and the impact of Acute Kidney Injury on outcomes are well-known in the Western literature, good data is lacking from India. Most studies published from India have not evaluated epidemiology of Acute Kidney Injury in the Intensive Care Unit setting and/or have not used validated criteria. In our observational study of 250 patients, admitted to a tertiary level ICU, we have explored the epidemiology of Acute Kidney Injury using both RIFLE and AKIN criteria and have validated them. We have also demonstrated that the severity of AKI is an independent predictor of mortality in critically ill patients. Our results are very much comparable to other studies and we feel that this study will remain as an epidemiological reference point for Indian clinicians dealing with AKI.
    Renal Failure 04/2014; 36(6). DOI:10.3109/0886022X.2014.899432 · 0.94 Impact Factor
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    ABSTRACT: Cities are expanding rapidly in middle-income countries, but their supply of acute care services is unknown. We measured acute care services supply in seven cities of diverse economic background. In a cross-sectional study, we compared cities from two high-income (Boston, USA and Paris, France), three upper-middle-income (Bogota, Colombia; Recife, Brazil; and Liaocheng, China), and two lower-middle-income (Chennai, India and Kumasi, Ghana) countries. We collected standardized data on hospital beds, intensive care unit beds, and ambulances. Where possible, information was collected from local authorities. We expressed results per population (from United Nations) and per acute illness deaths (from Global Burden of Disease project). Supply of hospital beds where intravenous fluids could be delivered varied fourfold from 72.4/100,000 population in Kumasi to 241.5/100,000 in Boston. Intensive care unit (ICU) bed supply varied more than 45-fold from 0.4/100,000 population in Kumasi to 18.8/100,000 in Boston. Ambulance supply varied more than 70-fold. The variation widened when supply was estimated relative to disease burden (e.g., ICU beds varied more than 65-fold from 0.06/100 deaths due to acute illnesses in Kumasi to 4.11/100 in Bogota; ambulance services varied more than 100-fold). Hospital bed per disease burden was associated with gross domestic product (GDP) (R (2) = 0.88, p = 0.01), but ICU supply was not (R (2) = 0.33, p = 0.18). No city provided all requested data, and only two had ICU data. Urban acute care services vary substantially across economic regions, only partially due to differences in GDP. Cities were poor sources of information, which may hinder their future planning.
    Intensive Care Medicine 12/2013; 40(3). DOI:10.1007/s00134-013-3174-7 · 7.21 Impact Factor
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    ABSTRACT: Introduction: Severity of illness scores are widely used by intensive care units (ICU) to audit, report and compare mortality rates. Despite availability of validated newer scores such as Acute Physiology and Chronic Health Evaluation IV (APACHE IV), APACHE II score is still commonly used for reporting ICU demographics and outcomes in research studies and ICU audits. It is unclear whether the outcomes reported using APACHE II and APACHE IV scores are comparable. Methods: Prospective study conducted from February to July 2013 in a tertiary multidisciplinary intensive care unit. All patients admitted to ICU during the study period were included in the study and APACHE II & APACHE IV scores calculated. Data from patients who were still in the hospital, discharged at request or transferred to another hospital were excluded from analysis. PMR and observed mortality rate (OMR) were used to calculate the SMR. The PMR of these two scoring systems was compared using Kruskal-Wallis test and their degree of agreement evaluated using Bland-Altman plot. Results: A total of 498 patients were included in this study. After excluding patients, data from 392 patients with a mean age of 55.61 +/- 16.78 was analysed. The OMR of the study population was 30.10%. The mean APACHE II score was 26.49 +/- 10.12 while the mean APACHE IV score was 81.32 +/- 36.33. The PMR obtained using APACHE II was significantly higher than that obtained using APACHE IV score (51% vs. 36.6%; p < 0.001). The SMR obtained using APACHE II and IV scores were 0.59 and 0.82 respectively. On Bland-Altman plot, the mean bias in the PMR between the two APACHE scoring systems was -18.6 with 95% limits of agreement between 9 and -46.1. Conclusions: Outcome prediction using APACHE IV & APACHE II systems provide different PMR and SMR. This variability can alter the reporting and the perception of the ICU quality and outcomes. Standardizing the scoring systems across ICUs globally will help to better compare quality of ICUs and interpret published data on outcomes.
    43rd Annual Critical Care Congress; 12/2013
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    S Murthy · S Austin · H Wunsch · NK Adhikari · V Karir · K Rowan · ST Jacob · J Salluh · F Bozza · B Du · Y An · B Lee · F Wu · C Oppong · R Venkataraman · V Velayutham · DC Angus ·

    Critical Care 03/2013; 17(2). DOI:10.1186/cc12427 · 4.48 Impact Factor
  • Ramesh Venkataraman · John A Kellum ·
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    ABSTRACT: Sepsis and septic shock are syndromes that overlap between several disciplines and subspecialties. Emerging evidence suggests that sepsis may be associated with short- and long-term adverse outcomes, even when the syndrome does not appear to be severe and is not managed in the intensive care unit. Hence, all practicing clinicians need to be familiar with the fundamental principles of diagnosis and management of sepsis. In this review, we have summarized the key components in the management of sepsis/septic shock, including early recognition, early resuscitation, principles of antibiotic therapy, organ support, and role of adjunctive therapies.
    Advances in chronic kidney disease 01/2013; 20(1):6-13. DOI:10.1053/j.ackd.2012.10.013 · 2.05 Impact Factor
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    ABSTRACT: BACKGROUND:: Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a "shift" model, both with increased handoffs. OBJECTIVE:: To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments. DESIGN:: Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1-2 month periods. SETTING:: A mixed medical-surgical intensive care unit at a tertiary care academic center. SUBJECTS:: Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients. INTERVENTIONS:: Implementation of shift-work schedule, combined with structured sign-out curriculum. MEASUREMENTS:: Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance. MAIN RESULTS:: There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15). CONCLUSIONS:: A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.
    Critical care medicine 10/2012; 40(12). DOI:10.1097/CCM.0b013e3182657b5d · 6.31 Impact Factor
  • B. Shankar · D. Daphnee · L. Ranganathan · R. Venkataraman · N. Ramakrishnan ·

    Clinical Nutrition Supplements 09/2012; 7(1):118. DOI:10.1016/S1744-1161(12)70288-0
  • A. Al-Khafaji · R. Murugan · R. Venkataraman · M. Elder · J. Kellum ·

    Transplantation 07/2010; 90. DOI:10.1097/00007890-201007272-01027 · 3.83 Impact Factor
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    ABSTRACT: On-pump coronary artery bypass graft (CABG) surgery has been traditionally associated with a higher magnitude of inflammatory response than off-pump CABG. However with the development of polymer-coated biocompatible extracorporeal circuits, we wanted to see if cardiopulmonary bypass still played an important role in triggering this inflammatory response. In this prospective observational study, 33 patients undergoing CABG surgeries (25 on-pump and 8 off-pump patients) were studied. Serial plasma cytokine (TNF IL-6, IL-10) and procalcitonin concentrations were measured at different time-points during and after the surgery. Demographic and baseline clinical data, intra-operative management details and post-operative complications were also collected from the patients' charts. Plasma levels of all 4 mediators increased during surgery and returned towards normal postoperatively. There were no differences between groups for any mediator at any time-point. We conclude that with the use of recent polymer-coated biocompatible extracorporeal circuits, the inflammatory response triggered by on-pump CABG becomes very similar in magnitude and pattern to that triggered by off-pump CABG. Thus, the surgical procedure contributes to most of the inflammatory response, with the extra-corporeal circuit having minimal to no effect on this response.
    The International journal of artificial organs 04/2010; 33(3):131-8. · 0.96 Impact Factor
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    N Ramakrishnan · S Bhuvaneshwari · R Venkataraman · B Abraham ·

    Critical Care 03/2010; 14(Suppl 1). DOI:10.1186/cc8786 · 4.48 Impact Factor
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    ABSTRACT: Brain death induces dramatic changes in hemodynamics. Ischemic injury and inflammation resulting from inadequate resuscitation might influence organ yield for transplantation. Using functional hemodynamic monitoring in brain-dead organ donors, we test the hypothesis that donor preload (fluid) responsiveness is associated with increased inflammatory response and lower organ yield for transplantation. Prospective, observational, pilot study. A large intensive care unit of a university hospital in the United States. Twenty-one brain-dead organ donors between July 2006 and April 2007. None. Following declaration of brain death, we collected data on donor demographics, mechanism of brain death, and number of organs procured and transplanted. Functional hemodynamics were monitored using pulse contour analysis technique. Plasma tumor necrosis factor, interleukin-6, and interleukin-10 concentrations were measured at study enrollment, after 4 hrs, and immediately before organ procurement for transplantation. Preload responsiveness (pulse pressure variation >13%) was observed in 48% of donors (mean +/- sd pulse pressure variation, 19.2% +/- 4.8%). Plasma interleukin-6 and tumor necrosis factor concentrations at study enrollment were greater in preload responsive donors: mean concentrations of interleukin-6 in preload responsive vs. unresponsive donors were 5420 +/- 9102 vs. 378 +/- 631 pg/mL (p = .009), and mean concentrations of tumor necrosis factor were 60.5 +/- 103.6 vs. 15.7 +/- 10.1 pg/mL (p = .048). Preload responsive compared with unresponsive donors had significantly increased interleukin-6 (p = .013) and tumor necrosis factor (p = .044) concentrations over time. Fewer organs were transplanted from preload responsive donors: mean organs transplanted from preload responsive vs. unresponsive donors were 1.8 +/- 0.9 vs. 3.7 +/- 2.5 (p = .034). In multivariable regression, older donor age (p = .028) and increased plasma interleukin-6 concentration (p = .035) were significantly associated with lower number of organs transplanted. Preload responsiveness is common in brain-dead organ donors and is associated with higher inflammatory response and lower organ yield. A controlled trial of preload optimization is warranted in brain-dead donors.
    Critical care medicine 07/2009; 37(8):2387-93. DOI:10.1097/CCM.0b013e3181a960d6 · 6.31 Impact Factor
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    ABSTRACT: Brain death induces a massive inflammatory response. However, the influence of this inflammatory response on organ procurement, transplantation, and recipient outcome is unknown. We describe the inflammatory response characteristics in brain-dead organ donors and examine associations with organ transplantation and recipient survival. We test the hypothesis that increased inflammatory response is associated with fewer organs transplanted and decreased recipient survival. Prospective, observational, cohort study. Two large intensive care units of tertiary care university hospitals in the United States. We recruited 30 consecutive brain-dead organ donors and 78 recipients between April 11, 2004, and November 23, 2004; recipients were followed through May 2005. Following declaration of brain death, we collected data on donor demographics, mechanism of brain death, number of organs procured and transplanted, and recipient characteristics. Plasma cytokines (tumor necrosis factor, interleukin-6, interleukin-10) were measured in donors at baseline following study enrollment, every hour for the first 4 hrs, and immediately before organ procurement for transplantation. None. We examined the relationships among clinical characteristics, demographics, and cytokine response in donors and their influence on organ procurement and transplantation using multivariable regression and recipient's 6-month hospital-free survival using a Cox proportional hazards regression. One hundred-eighteen organs were procured from 30 donors, and 91 (77%) were transplanted (mean of three organs transplanted per donor). All cytokines were increased following brain death. Older age in donors was significantly associated with lower number of organs transplanted (p < .001). Higher plasma interleukin-6 concentrations in donors before organ procurement was significantly associated with lower 6-month hospital-free survival in recipients (hazard ratio 1.77; 95% confidence interval, 1.17-2.69, p < .007). Among brain-dead organ donors, older age donors contribute fewer organs for transplantation, and increased donor interleukin-6 level before organ procurement is associated with lower recipient six-month hospital-free survival.
    Critical care medicine 06/2008; 36(6):1810-6. DOI:10.1097/CCM.0b013e318174d89f · 6.31 Impact Factor
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    Ramesh Venkataraman ·
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    ABSTRACT: To review the literature on prevention of acute kidney injury (AKI). MEDLINE- and PubMed-based review of literature published from 1965 to 2007. AKI is very common among critically ill patients. Even mild forms of AKI have significant attributable mortality. Hence, it is imperative that every effort to prevent AKI be made in clinical practice. However, there are very few interventions that have been shown to consistently prevent AKI. Measures such as adequate hydration, maintenance of adequate circulating blood volume and mean arterial pressure, and avoidance of nephrotoxins are still the mainstay of prevention. Loop diuretics and "renal-dose" dopamine have been clearly shown not to prevent AKI and may, in fact, do harm. Among the remaining pharmacologic options, N-acetylcysteine has the strongest evidence in prevention of AKI. Fenoldopam and theophylline need further investigation before being used to prevent septic AKI and contrast nephropathy, respectively. The role of prophylactic dialysis in preventing contrast nephropathy needs to be investigated further.
    Critical care medicine 05/2008; 36(4 Suppl):S166-71. DOI:10.1097/CCM.0b013e318168c74a · 6.31 Impact Factor
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    ABSTRACT: Inflammatory cytokines occur in the circulation and in the tissues after brain death and have been associated with dysfunction of donor organs before and after transplantation. To determine the feasibility of removing cytokines using a hemoadsorption device. Two-center, randomized, open-label, feasibility study in which brain-dead subjects were randomized to two treatment groups. Two U.S. academic hospitals. Eight brain-dead subjects deemed unsuitable for organ donation by respective organ procurement organizations. After obtaining consent from families, subjects were treated with hemoadsorption for 4 hrs using CytoSorb. Effects on cytokines (tumor necrosis factor, interleukin [IL]-6, and IL-10) were assessed both across the device and in the plasma over time. Feasibility for cytokine removal was assessed using objective criteria. Cytokine removal across the CytoSorb device ranged from 4% to 30% and was not significantly different from 1 hr to 4 hrs. Overall removal was greatest for IL-6, 28% (p = .006), and least for tumor necrosis factor, 8.5% (p = .13). Plasma concentrations of both IL-6 and tumor necrosis factor, but not IL-10, were significantly reduced after the first hour of therapy; mean differences were -13% +/- 7% for IL-6 (p = .039), -23% +/- 9% for tumor necrosis factor (p = .02), and -2% +/- 7% of IL-10 (p = 23). However, plasma concentrations for all three cytokines increased over time and were above baseline by the end of the intervention. No adverse effects of therapy were observed. However, removal of cortisol and triiodothyronine was similar to removal of cytokines. Hemoadsorption for removal of cytokines in brain-dead subjects is feasible. Evaluation of possible clinical benefit will require controlled trials in actual donors. However, the significant capacity for cytokine removal and absence of adverse events suggest that such trials are warranted.
    Critical care medicine 02/2008; 36(1):268-72. DOI:10.1097/01.CCM.0000291646.34815.BB · 6.31 Impact Factor
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    John A Kellum · Martine Leblanc · Ramesh Venkataraman ·
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    ABSTRACT: Acute renal failure is characterised by abrupt and sustained decline in glomerular filtration rate, which leads to accumulation of urea and other chemicals in the blood. The term acute kidney injury has been recently introduced to encompass a wide spectrum of acute alterations in kidney function from very mild to severe. Acute renal failure/acute kidney injury is classified according to the RIFLE criteria where a change from baseline serum creatinine or urine output determines the level of renal dysfunction. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent acute renal failure in people at high risk? What are the effects of treatments for critically ill people with acute renal failure? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We found 77 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. In this systematic review we present information relating to the effectiveness and safety of the following interventions: albumin supplementation plus loop diuretics (intravenous), aminoglycosides, aminophylline, amphotericin B, calcium channel blockers, contrast media, dialysis membranes, dopamine, fenoldopam, loop diuretics, mannitol, N-acetylcysteine, natriuretic peptides, renal replacement therapy, sodium bicarbonate-based fluids, sodium chloride-based fluids, and theophylline.
    Clinical evidence 02/2008; 2008.