The incidence of acute kidney injury (AKI) in the intensive care unit (ICU) has increased during the past decade due to increased acuity as well as increased recognition. Early epidemiology studies were confounded by erratic definitions of AKI until recent consensus guidelines (RIFLE and AKIN) standardized its definition. This paper discusses the incidence of AKI in the ICU with focuses on specific patient populations. The overall incidence of AKI in ICU patients ranges from 20% to 50% with lower incidence seen in elective surgical patients and higher incidence in sepsis patients. The incidence of contrast-induced AKI is less (11.5%–19% of all admissions) than seen in the ICU population at large. AKI represents a significant risk factor for mortality and can be associated with mortality greater than 50%.

Introduction Block scheduling during residency is an innovative model separating inpatient and ambulatory rotations. We hypothesized this format may have a positive impact on resident sleep and wellness as compared to a traditional format. Methods We performed a single-center, cross-sectional, observational study of residents rotating in the medical intensive care unit (MICU). Residents were observed for 4 weeks at a time: Internal Medicine (IM) residents for 3 MICU weeks followed by one ambulatory week, and non-IM residents for 4 weeks in the MICU. We monitored daily total sleep time (TST) utilizing actigraphy, and wellness measures with weekly Epworth Sleepiness Scale (ESS) and Perceived Stress Scale (PSS) questionnaires. Results 64 of 110 (58%) eligible residents participated, 49 (45%) were included in the final analysis. Mean daily TST for the entire cohort was 6.53h (± 0.78h). Residents slept significantly longer during the ambulatory block compared to the MICU block (mean TST 6.97h ±1.00h vs 6.43h ± .78h; p < .0005). Sleep duration during night call was significantly shorter than day shift (mean TST 6.07h ±1.16h vs 6.50h ± .73h; p = <.0005). 390 of 490 (80%) of ESS and PSS questionnaires were completed, scores significantly declined while in the MICU. IM residents had significant improvement in TST, ESS and PSS scores (p < .05) at the end of the ambulatory week. Non-IM residents, who remained in the MICU for a fourth week, continued a trend of decline in perceived wellness. Conclusion Despite duty hour restrictions, residents are getting inadequate sleep. As MICU days accumulate, measures of resident wellness decline. Residents in a block schedule experienced improvement in all measured parameters during the ambulatory week, while residents in a traditional schedule continued a downward trend. Block scheduling may have the previously unrecognized benefit of repaying sleep debt, correcting circadian misalignment and improving wellness.

Acute kidney injury (AKI) frequently occurs in the setting of critical illness and its management poses a challenge for the intensivist. Optimal management of volume status is critical in the setting of AKI in the ICU patient. The use of urine sodium, the fractional excretion of sodium (FeNa), and the fractional excretion of urea (FeUrea) are common clinical tools used to help guide fluid management especially further volume expansion but should be used in the context of the patient's overall clinical scenario as they are not completely sensitive or specific for the finding of volume depletion and can be misleading. In the case of oliguric or anuric AKI, diuretics are often utilized to increase the urine output although current evidence suggests that they are best reserved for the treatment of volume overload and hyperkalemia in patients who are likely to respond to them. Management of volume overload in ICU patients with AKI is especially important as volume overload has several negative effects on organ function and overall morbidity and mortality.

Obstructive sleep apnea (OSA) is highly prevalent in the general population. In addition, patients with comorbid OSA are frequently hospitalized for unrelated conditions. This review focuses on managing patients with comorbid OSA in inpatient and acute care settings for inpatient providers. OSA can impact the length of stay, the risk of intubation, the transfer to the intensive care unit, and mortality. Screening questionnaires such as STOP-BANG can help with screening hospitalized patients at admission. High-risk patients can also undergo additional screening with overnight pulse oximetry, which can be used to guide management. Options for empiric treatment include supplemental oxygen, continuous positive airway pressure therapy (CPAP), auto adjusting-PAP, bilevel positive airway pressure therapy (BPAP), or high-flow nasal cannula. In addition, discharge referral to a board-certified sleep physician may help improve these patients’ long-term outcomes and decrease readmission risks.