Elevated preoperative serum asymmetrical dimethylarginine (ADMA) is associated with poor outcomes after pediatric cardiac surgery

Purpose

Asymmetrical dimethylarginine (ADMA), an endogenous competitive inhibitor of nitric oxide synthase, is elevated in vascular pathologies such as hypertension and chronic kidney disease. Children undergoing cardiac surgery are at high risk of poor hemodynamic and renal outcomes secondary to cardiopulmonary bypass (CPB). This study tested the hypothesis that elevated preoperative ADMA levels are associated with overall worse clinical outcomes after pediatric CPB.

Methods

This was a prospective, observational study of 100 patients aged from 2?weeks to 18?years who underwent cardiac surgery involving CPB. Serum ADMA levels were obtained preoperatively and on postoperative days zero through four. Clinical outcomes measured included acute kidney injury (AKI) by pRIFLE criteria, low cardiac output syndrome (LCOS), length of mechanical ventilation, hospital and ICU length of stay, unplanned reoperation, and mortality.

Results

The 29 patients with an elevated preoperative ADMA were more likely to have prolonged mechanical ventilation, increased ICU and hospital length of stay, unplanned reoperation, and LCOS than those with a normal preoperative level. ADMA levels inversely correlated with estimated glomerular filtration rate (eGFR), but did not differ between patients with and without AKI after CPB. Preoperative ADMA levels correlated with hospital length of stay (r _s?=?0.289), ICU length of stay (r _s?=?0.308), and length of mechanical ventilation (r _s?=?0.402); [all p?p?Conclusions Patients with elevated ADMA before surgery were more likely to have prolonged mechanical ventilation, develop LCOS, require an extended length of stay, and require reoperation. ADMA levels inversely correlated with eGFR, but did not predict AKI. Preoperative serum ADMA appears to identify pediatric cardiac surgery patients at risk of poor postoperative outcomes following CPB.     

Statistics review 14: Logistic regression

Introduction

Tracheostomy is frequently performed in critically ill patients for prolonged intubation. However, the optimal timing of tracheostomy, and its impact on weaning from mechanical ventilation and outcomes in critically ill patients who require mechanical ventilation remain controversial.

Methods

The medical records of patients who underwent tracheostomy in the medical intensive care unit (ICU) of a tertiary medical centre from July 1998 to June 2001 were reviewed. Clinical characteristics, length of stay in the ICU, rates of post-tracheostomy pneumonia, weaning from mechanical ventilation and mortality rates were analyzed.

Results

A total of 163 patients (93 men and 70 women) were included; their mean age was 70 years. Patients were classified into two groups: successful weaning (n = 78) and failure to wean (n = 85). Shorter intubation periods (P = 0.02), length of ICU stay (P = 0.001) and post-tracheostomy ICU stay (P = 0.005) were noted in patients in the successful weaning group. Patients who underwent tracheostomy more than 3 weeks after intubation had higher ICU mortality rates and rates of weaning failure. The length of intubation correlated with the length of ICU stay in the successful weaning group (r = 0.70; P < 0.001). Multivariate analysis revealed that tracheostomy after 3 weeks of intubation, poor oxygenation before tracheostomy (arterial oxygen tension/fractional inspired oxygen ratio <250) and occurrence of nosocomial pneumonia after tracheostomy were independent predictors of weaning failure.

Conclusion

The study suggests that tracheostomy after 21 days of intubation is associated with a higher rate of failure to wean from mechanical ventilation, longer ICU stay and higher ICU mortality.     

Noninvasive ventilation after early extubation in patients recovering from hypoxemic acute respiratory failure: a single-centre feasibility study

Purpose

The use of noninvasive ventilation (NIV) to facilitate discontinuation of mechanical ventilation in patients with acute hypoxemic respiratory failure (hypoxemic ARF) has never been explored. This pilot study aims to assess the feasibility of early extubation followed by immediate NIV, compared conventional weaning, in patients with resolving hypoxemic ARF.

Methods

Twenty consecutive hypoxemic patients were randomly assigned to receive either conventional weaning or NIV. The changes in arterial blood gases and respiratory rate were compared between the two groups at 1, 12, 24 and 48?h. Differences in the rate of extubation failure, ICU and hospital mortality, number of invasive-ventilation-free-days at day 28, septic complications, number of tracheotomies, days and rates of continuous intravenous sedation, and ICU length of stay were also determined.

Results

No patient interrupted the study protocol. Arterial blood gases were similar during invasive mechanical ventilation, 1?h after NIV application following extubation, and after 12, 24 and 48?h. Respiratory rate was higher after 1?h in the NIV group, but no different after 12, 24 and 48?h. The number of invasive-ventilation-free-days at day 28 was 20?±?8 (min?=?0, max?=?25) days in the treatment group and 10?±?9 (min?=?0, max?=?25) days in the control group (p?=?0.014). The rate of extubation failure, ICU and hospital mortality, tracheotomies, septic complications, days and rates of continuous sedation, and ICU length of stay were not significantly different between the two groups.

Conclusions

In a highly experienced centre NIV may be used to facilitate discontinuation of mechanical ventilation in selected patients with resolving hypoxemic ARF.     

Clinical impact and risk factors for colonization with extended-spectrum β-lactamase-producing bacteria in the intensive care unit

Purpose

The changed epidemiology of extended spectrum beta-lactamases (ESBL), the spread to the community and the need for prudent use of carbapenems require updated knowledge of risk factors for colonization with ESBL-producing enterobacteriaceae (ESBL-PE).

Methods

An 8-month prospective study in the medical ICU of an 850-bed general and university-affiliated hospital.

Results

Of 610 patients admitted, 531 (87?%) had a rectal swab obtained at admission, showing a 15?% (82 patients) ESBL-PE carriage rate, mostly of E. coli (n?=?51, 62?%); ESBL-PE caused 9 (3?%) infections on admission. By multivariable analysis, transfer from another ICU (OR?=?2.56 [1, 22]), hospital admission in another country [OR?=?5.28 (1.56–17.8)], surgery within the past year [OR?=?2.28 (1.34–3.86)], prior neurologic disease [OR?=?2.09 (1.1–4.0)], and prior administration of third generation cephalosporin (within 3–12?months before ICU admission) [OR?=?3.05 (1.21–7.68)] were independent predictive factors of colonization by ESBL-PE upon ICU admission. Twenty-eight patients (13?% of those staying for more than 5?days) acquired ESBL carriage in ICU, mostly with E. cloacae (n?=?13, 46?%) and K. pneumoniae (n?=?10, 36?%). In carriers, ESBL-PE caused 10 and 27?% of first and second episodes of ICU-acquired infections, respectively.

Conclusion

We found a high prevalence of ESBLE-PE colonization on admission to our ICU, even in the subgroup admitted from the community, but few first infections. Identifying risk factors for ESBL-PE colonization may help identifying which patients may warrant empiric ESBL-targeted antimicrobial drug therapy as a means to limit carbapenem use.     

Preoperative hypoalbuminemia is a major risk factor for acute kidney injury following off-pump coronary artery bypass surgery

Purpose

To investigate the association between preoperative low serum albumin level and acute kidney injury (AKI) after off-pump coronary artery bypass surgery (OPCAB)

Method

We assessed preoperative and perioperative risk factors, and preoperative serum albumin concentration in 1,182 consecutive adult patients with preoperative normal renal function who underwent OPCAB surgery. Each patient was categorized by maximal Acute Kidney Injury Network (AKIN) criteria based on creatinine changes within the first 48?h after OPCAB. Logistic regression and propensity analyses were performed to evaluate the association between preoperative low serum albumin level and postoperative AKI.

Results

Of the 1,182 patients, 334 (28.3%) developed AKI. Risk factors for AKI were old age, diabetes mellitus, maximal cardiovascular component of the sequential organ failure assessment score, perioperative transfusion, and postoperative C-reactive protein concentration. The risk of AKI was negatively correlated with the volume of crystalloid infused during surgery. A preoperative serum albumin level of?<4.0?g/dl was independently associated Ith postoperative AKI [multivariable logistic analysis: odds ratio (OR) 1.83, 95?% confidence interval (CI) 1.27–2.64; P?=?0.001; propensity analysis: OR 1.62, 95?% CI 1.12–2.35; P?=?0.011). AKI was associated with prolonged stay in the intensive care unit and hospital and a high mortality rate.

Conclusions

Preoperative low serum albumin level is an independent risk factor for AKI, and postoperative AKI is associated with poor outcomes after OPCAB in patients with preoperative normal renal function.     

Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial

Objectives

To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients.

Methods

In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay.

Measurements and main results

ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7 %, p = 0.93). ARF rate was 18.8 % in the prophylactic NIV group and 24.5 % in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5 %) and 13/179 (7.2 %), respectively, p = 0.53]. Mortality rates were 5 and 2.2 % in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups.

Conclusions

Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.     

Elevation of creatine kinase is associated with worse outcomes in 2009 pH1N1 influenza?A infection

Background

Current medical knowledge lacks specific information regarding creatine kinase (CK) elevation in influenza?A pH1N1 (2009) infection.

Objectives

Primary endpoints were correlation between CK at intensive care unit (ICU) admission and ICU mortality. Secondary endpoints were ICU length of stay (LOS), mechanical ventilation (MV), and requirement of renal replacement techniques (RRT).

Materials and methods

A prospective multicenter register included all adults admitted for severe acute respiratory insufficiency (SARI) with confirmed pH1N1 in 148 ICUs. Clinical data including demographics, comorbidities, laboratory information, organ involvement, and prognostic data were registered. Post?hoc classification of subjects was determined according to CK level. Data are expressed as median (interquartile range).

Results

Five hundred and five (505) patients were evaluable. Global ICU mortality was 17.8?% without documented differences between breakpoints. CK ≥500?UI/L was documented in 23.8?% of ICU admissions, being associated with greater renal dysfunction: acute kidney injury (AKI) was more frequent (26.1 versus 17.1?%, p?p?p?p?=?0.07) and duration of mechanical ventilation (median 15?days versus 11?days, p?Conclusions CK is a biomarker of severity in pH1N1 infection. Elevation of CK was associated with more complications and increased ICU LOS and healthcare resources.     

Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis

Purpose

Single studies of video laryngoscopy (VL) use for airway management in intensive care unit (ICU) patients have produced controversial findings. The aim of this study was to critically review the literature to investigate whether VL reduces difficult orotracheal intubation (OTI) rate, first-attempt success, and complications related to intubation in ICU patients, compared to standard therapy, defined as direct laryngoscopy (DL).

Methods

We performed a systematic review and meta-analysis of randomized controlled trials, as well as prospective and retrospective observational studies, by searching PubMed, EMBASE, and bibliographies of articles retrieved. We screened for relevant studies that enrolled adults in whom the trachea was intubated in the ICU and compared VL to DL. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis. We generated pooled odd ratios (OR) across studies. The primary outcome measure was difficult OTI. The secondary outcomes were first-attempt success, Cormack 3/4 grades, and complications related to intubation (severe hypoxemia, severe cardiovascular collapse, airway injury, esophageal intubation).

Results

Nine trials with a total of 2,133 participants (1,067 in DL and 1,066 in VL) were included in the current analysis. Compared to DL, VL reduced the risk of difficult OTI [OR 0.29 (95 % confidence interval (CI) 0.20–0.44, p < 0.001)], Cormack 3/4 grades [OR 0.26 (95 % CI 0.17–0.41, p < 0.001)], and esophageal intubation [0.14 (95 % CI 0.02–0.81, p = 0.03)] and increased the first-attempt success [OR 2.07 (95 % CI 1.35–3.16, p < 0.001)]. No statistically significant difference was found for severe hypoxemia, severe cardiovascular collapse or airway injury.

Conclusions

These results suggest that VL could be useful in airway management of ICU patients.     

Outcomes in critically ill chronic lymphocytic leukemia patients

Background

Although recent studies have demonstrated an improvement in the prognosis of critically ill cancer patients, little is known regarding the prognosis of patients with non-aggressive underlying malignancies. The aims of this study were to assess the prognosis of critically ill patients with chronic lymphocytic leukemia (CLL) and to evaluate risk factors for hospital mortality.

Methods

In retrospective mono-center cohort study, consecutive adult patients with CLL requiring ICU admission from 1997 to 2008 were included.

Results

Sixty-two patients of 67 years (62–75) were included. Median time interval between CLL diagnosis and ICU admission was 6.7 years (2.6–10.8). Nine patients (15 %) had stage C disease at the time of ICU admission, and seven patients (11 %) had Richter syndrome. Most ICU admissions were related to bacterial or fungal pulmonary infections (n?=?47; 76 %). ICU, in-hospital, and 90-day mortality were 35 % (n?=?22), 42 % (n?=?26), and 58 % (n?=?36), respectively. Only three factors were independently associated with in-hospital mortality: oxygen saturation lower than 95 % when breathing room air (odds ratio (OR) 5.80; 95 % confidence interval (CI) 1.23–27.33), need for vasopressors (OR 27.94; 95 % CI 5.37–145.4), and past history of infection (OR 6.62; 95 % CI 1.34–32.68). The final model did not change when disease-related variables (Binet classification, Richter syndrome, long-term steroids) or treatment-related variables (fludarabine, rituximab, or alemtuzumab) were included.

Conclusion

Acute pulmonary infections remain the leading cause of ICU admission in patients with CLL. The severity at ICU admission and past history of infection were the only factors associated with hospital mortality. Neither disease characteristics nor previous cancer treatments were associated with outcome.     

Clinical course and outcome for critically ill children with Down syndrome: a retrospective cohort study

Purpose

Children with Down syndrome (DS) have several genetic anomalies within chromosome?21 which may influence their response to critical illness. We compared the intensive care course and outcome of children with DS versus those without.

Methods

Retrospective cohort study in four English paediatric intensive care units (ICUs) (2003–2009, n?=?33,485). We examined, via a competing risks model, whether risk (subhazard) for ICU mortality differed for children with DS, after adjusting for important confounders.

Results

DS patients exhibited lower disease severity at ICU admission but subsequently required a higher proportion of cardiovascular support, and similar renal support to non-DS patients. Children with DS (n?=?1,278) had lower crude mortality than those without (4.2 versus 6.2?%, p?=?0.003). This was not significant when expressed as standardized mortality ratio: 0.83 [95?% confidence interval (CI) 0.63–1.09] versus 0.90 (95?% CI 0.86–0.94). However, the competing risks model showed that mortality risk was influenced by length of ICU stay. At admission, DS patients exhibited a subhazard for mortality of 0.63 (95?% CI 0.46–0.85), which increased to 1.00 by day?10 of admission, and continued rising above that of non-DS children thereafter.

Conclusions

Children with DS require a higher proportion of organ support than expected by disease severity at ICU admission. In addition, the mortality risk for children with DS is dependent upon length of ICU stay. These findings could reflect differences in case mix, but are also compatible with different response to critical illness in this group.     

Outcomes in children with refractory pneumonia supported with extracorporeal membrane oxygenation

Purpose

To review the use of extracorporeal membrane oxygenation (ECMO) in severe paediatric pneumonia and evaluate factors that may affect efficacy of this treatment.

Methods

Retrospective study of the ECMO database of a tertiary paediatric intensive care unit and chart review of all patients who were managed with ECMO during their treatment for severe pneumonia over a 23-year period. The main outcome measures were survival to hospital discharge, and ICU and hospital length of stay. We compared the groups of culture-positive versus culture-negative pneumonia, venoarterial (VA) versus venovenous (VV) ECMO, community- versus hospital-acquired cases, and cases before and after 2005.

Results

Fifty patients had 52 cases of pneumonia managed with ECMO. Community-acquired cases were sicker with higher oxygenation index (41.5?±?20.5 versus 26.8?±?17.8; p?=?0.031) and higher inotrope score [20 (5–37.5) versus 7.5 (0–18.8); p?=?0.07]. Use of VA compared with VV ECMO was associated with higher inotrope scores [20 (10–50) versus 5 (0–20); p?=?0.012]. There was a trend towards improved survival in the VV ECMO group (82.4 versus 62.9?%; p?=?0.15). Since 2005, patients have been older [4.7 (1–8) versus 1.25 (0.15–2.8)?years; p?=?0.008] and survival has improved (88.2 versus 60.0?%; p?=?0.039).

Conclusions

Survival in children with pneumonia requiring ECMO has improved over time and is now 90?% in the modern era. Risk factors for death include performing a circuit change [odds ratio (OR) 5.0; 95?% confidence interval (CI) 1.02–24.41; p?=?0.047] and use of continuous renal replacement therapy (OR 4.2; 95?% CI 1.13–15.59; p?=?0.032).     

Levosimendan infusion in newborns after corrective surgery for congenital heart disease: randomized controlled trial

Purpose

To evaluate the safety and efficacy of levosimendan in neonates with congenital heart disease undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Methods

Neonates undergoing risk-adjusted classification for congenital heart surgery (RACHS) 3 and 4 procedures were randomized to receive either a 72?h continuous infusion of 0.1?μg/kg/min levosimendan or standard post-CPB inotrope infusion.

Results

Sixty-three patients (32 cases and 31 controls) were recruited. There were no differences between groups regarding demographic and baseline clinical data. No side effects were observed. There were no significant differences in mortality (1 vs. 3 patients, p?=?0.35), length of mechanical ventilation (5.9?±?5 vs. 6.9?±?8?days, p?=?0.54), and pediatric cardiac intensive care unit (PCICU) stay (11?±?8 vs. 14?±?14?days, p?=?0.26). Low cardiac output syndrome occurred in 37?% of levosimendan patients and in 61?% of controls (p?=?0.059, OR 0.38, 95?% CI 0.14–1.0). Postoperative heart rate, with a significant difference at 6 (p?=?0.008), 12 (p?=?0.037), and 24?h (p?=?0.046), and lactate levels, with a significant difference at PCICU admission (p?=?0.015) and after 6?h (p?=?0.048), were lower in the levosimendan group. Inotropic score was significantly lower in the levosimendan group at PCICU admission, after 6?h and after 12?h, (p?Conclusions Levosimendan infused in neonates undergoing cardiac surgery was well tolerated with a potential benefit of levosimendan on postoperative hemodynamic and metabolic parameters of RACHS 3–4 neonates.     

Impact of hypoxic hepatitis on mortality in the intensive care unit

Purpose

Hypoxic hepatitis (HH) is a form of hepatic injury following arterial hypoxemia, ischemia, and passive congestion of the liver. We investigated the incidence and the prognostic implications of HH in the medical intensive care unit (ICU).

Methods

A total of 1,066 consecutive ICU admissions at three medical ICUs of a university hospital were included in this prospective cohort study. All patients were screened prospectively for the presence of HH according to established criteria. Independent risk factors of mortality in this cohort of critically ill patients were identified by a multivariate Poisson regression model.

Results

A total of 118 admissions (11%) had HH during their ICU stay. These patients had different baseline characteristics, longer median ICU stay (8 vs. 6?days, p?p?p?p?p?=?0.359).

Conclusions

Hypoxic hepatitis (HH) occurs frequently in the medical ICU. The presence of HH is a strong risk factor for mortality in the ICU in patients requiring vasopressor therapy.     

Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury

Introduction

The optimal dialysis dose for the treatment of acute kidney injury (AKI) is controversial. We sought to evaluate the relationship between renal replacement therapy (RRT) dose and outcome.

Methods

We performed a prospective multicentre observational study in 30 intensive care units (ICUs) in eight countries from June 2005 to December 2007. Delivered RRT dose was calculated in patients treated exclusively with either continuous RRT (CRRT) or intermittent RRT (IRRT) during their ICU stay. Dose was categorised into more-intensive (CRRT ≥ 35 ml/kg/hour, IRRT ≥ 6 sessions/week) or less-intensive (CRRT < 35 ml/kg/hour, IRRT < 6 sessions/week). The main outcome measures were ICU mortality, ICU length of stay and duration of mechanical ventilation.

Results

Of 15,200 critically ill patients admitted during the study period, 553 AKI patients were treated with RRT, including 338 who received CRRT only and 87 who received IRRT only. For CRRT, the median delivered dose was 27.1 ml/kg/hour (interquartile range (IQR) = 22.1 to 33.9). For IRRT, the median dose was 7 sessions/week (IQR = 5 to 7). Only 22% of CRRT patients and 64% of IRRT patients received a more-intensive dose. Crude ICU mortality among CRRT patients were 60.8% vs. 52.5% (more-intensive vs. less-intensive groups, respectively). In IRRT, this was 23.6 vs. 19.4%, respectively. On multivariable analysis, there was no significant association between RRT dose and ICU mortality (Odds ratio (OR) more-intensive vs. less-intensive: CRRT OR = 1.21, 95% confidence interval (CI) = 0.66 to 2.21; IRRT OR = 1.50, 95% CI = 0.48 to 4.67). Among survivors, shorter ICU stay and duration of mechanical ventilation were observed in the more-intensive RRT groups (more-intensive vs. less-intensive for all: CRRT (median): 15 (IQR = 8 to 26) vs. 19.5 (IQR = 12 to 33.5) ICU days, P = 0.063; 7 (IQR = 4 to 17) vs. 14 (IQR = 5 to 24) ventilation days, P = 0.031; IRRT: 8 (IQR = 5.5 to 14) vs. 18 (IQR = 13 to 35) ICU days, P = 0.008; 2.5 (IQR = 0 to 10) vs. 12 (IQR = 3 to 24) ventilation days, P = 0.026).

Conclusions

After adjustment for multiple variables, these data provide no evidence for a survival benefit afforded by higher dose RRT. However, more-intensive RRT was associated with a favourable effect on ICU stay and duration of mechanical ventilation among survivors. This result warrants further exploration.

Trial Registration

Cochrane Renal Group (CRG110600093).     

Impact of ureido/carboxypenicillin resistance on the prognosis of ventilator-associated pneumonia due to Pseudomonas aeruginosa

Introduction

Although Pseudomonas aeruginosa is a leading pathogen responsible for ventilator-associated pneumonia (VAP), the excess in mortality associated with multi-resistance in patients with P. aeruginosa VAP (PA-VAP), taking into account confounders such as treatment adequacy and prior length of stay in the ICU, has not yet been adequately estimated.

Methods

A total of 223 episodes of PA-VAP recorded into the Outcomerea database were evaluated. Patients with ureido/carboxy-resistant P. aeruginosa (PRPA) were compared with those with ureido/carboxy-sensitive P. aeruginosa (PSPA) after matching on duration of ICU stay at VAP onset and adjustment for confounders.

Results

Factors associated with onset of PRPA-VAP were as follows: admission to the ICU with septic shock, broad-spectrum antimicrobials at admission, prior use of ureido/carboxypenicillin, and colonization with PRPA before infection. Adequate antimicrobial therapy was more often delayed in the PRPA group. The crude ICU mortality rate and the hospital mortality rate were not different between the PRPA and the PSPA groups. In multivariate analysis, after controlling for time in the ICU before VAP diagnosis, neither ICU death (odds ratio (OR) = 0.73; 95% confidence interval (CI): 0.32 to 1.69; P = 0.46) nor hospital death (OR = 0.87; 95% CI: 0.38 to 1.99; P = 0.74) were increased in the presence of PRPA infection. This result remained unchanged in the subgroup of 87 patients who received adequate antimicrobial treatment on the day of VAP diagnosis.

Conclusions

After adjustment, and despite the more frequent delay in the initiation of an adequate antimicrobial therapy in these patients, resistance to ureido/carboxypenicillin was not associated with ICU or hospital death in patients with PA-VAP.     

The impact of using estimated GFR versus creatinine clearance on the evaluation of recovery from acute kidney injury in the ICU

Purpose

To quantify the error in evaluating recovery from acute kidney injury (AKI) with estimated GFR (eGFR) in relation to ICU stay.

Methods

Secondary analysis performed on the database of the EPaNIC trial. In a cohort of patients who developed AKI during ICU stay we compared eGFR with measured creatinine clearance (Clcr) at ICU discharge. Recovery of kidney function was assessed by comparison with baseline eGFR and the accuracy of eGFR to detect “potential CKD status” defined by Clcr was quantified. The same analysis was performed in subgroups with different ICU stay. Multivariate regression was performed to determine independent predictors of the eGFR–Clcr difference.

Results

A total of 757 patients were included. The bias (limits of agreement (LOA)) between eGFR and Clcr at ICU discharge related to ICU stay, increasing from +1.3 (?37.4/+40) ml/min/1.73 m² in patients with short stay to +34.7 (?54.4/+123.8) ml/min/1.73 m² in patients with ICU stay of more than 14 days. This resulted in a significantly different incidence of complete recovery with the two evaluation methods and reduced sensitivity to detect “potential CKD status” with eGFR in patients with prolonged ICU stay. Independent predictors of the bias included creatinine excretion on the last day in ICU, baseline eGFR, ICU stay, gender, and age.

Conclusion

Compared to Clcr, discharge eGFR results in overestimation of renal recovery in patients with prolonged ICU stay and in reduced accuracy of “CKD staging”. Since age, gender and race do not change during ICU stay the same conclusion can be drawn with regard to plasma creatinine.     

Association between length of storage of red blood cell units and outcome of critically ill children: a prospective observational study

Introduction

Acute kidney injury (AKI) in the ICU is associated with poorer prognosis. Hydroxyethylstarch (HES) solutions are fluid resuscitation colloids frequently used in the ICU with controversial nephrotoxic adverse effects. Our study objective was to evaluate HES impact on renal function and organ failures.

Methods

This observational retrospective study included 363 patients hospitalized for more than 72 hours in our ICU. A hundred and sixty eight patients received HES during their stay and 195 did not. We recorded patients' baseline characteristics on admission and type and volume of fluid resuscitation during the first 3 weeks of ICU stay. We also noted the evolution of urine output, the risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function and end-stage kidney disease (RIFLE) classification and sepsis related organ failure assessment (SOFA) score over 3 weeks.

Results

Patients in the HES group were more severely ill on admission but AKI incidence was similar, as well as ICU mortality. The evolution of urine output (P = 0.74), RIFLE classification (P = 0.44) and SOFA score (P = 0.23) was not different. However, HES volumes administered were low (763+/-593 ml during the first 48 hours).

Conclusions

Volume expansion with low volume HES 130 kDa/0.4 was not associated with AKI.     

CPAP for acute cardiogenic pulmonary oedema from out-of-hospital to cardiac intensive care unit: a randomised multicentre study

Purpose

Continuous positive airway pressure (CPAP) is a useful treatment for patients with acute cardiogenic pulmonary oedema (CPE). However, its usefulness in the out-of-hospital setting has been poorly investigated and only by small and single-centre studies. We designed a multicentre randomised study to assess the benefit of CPAP initiated out of hospital.

Methods

A total of 207 patients with CPE were randomly allocated by emergency mobile medical units to receive either standard treatment alone or standard treatment plus CPAP. CPAP was maintained after admission to the intensive care unit (ICU). Inclusion criteria were orthopnoea, respiratory rate greater than 25?breaths/min, pulse oximetry less than 90% in room air and diffuse crackles. The primary end point was assessed during the first 48?h and combined: death, presence of intubation criteria, persistence of either all inclusion criteria or circulatory failure at the second hour or their reappearance before 48?h. Absence of all criteria defined successful treatment.

Results

CPAP was used for 60?min [40, 65] (median [Q1, Q3]) in the pre-hospital setting and 120?min [60, 242] in ICU and was well tolerated in all patients. Treatment was successful in 79% of patients in the CPAP group and 63% in the control group (p?=?0.01), especially for persistence of inclusion criteria after 2?h (12 vs. 26%) and for intubation criteria (4 vs. 14%). CPAP was beneficial irrespective of the initial PaCO₂ or left ventricular ejection fraction.

Conclusion

Immediate use of CPAP in out-of-hospital treatment of CPE and until CPE resolves after admission significantly improves early outcome compared with medical treatment alone.     

Outcome and predictors of mortality in patients requiring invasive mechanical ventilation due to acute respiratory failure while undergoing ambulatory chemotherapy for solid cancers

Purpose

Acute respiratory failure that requires invasive mechanical ventilation is a leading cause of death in critically ill cancer patients. The aim of this study was to evaluate the outcome and prognostic factors of patients requiring invasive mechanical ventilator for acute respiratory failure, within 1 month of ambulatory chemotherapy for solid cancer.

Methods

A retrospective observational study of patients who underwent ambulatory chemotherapy at Samsung Medical Center, between January of 2007 and April of 2009, was employed for this study.

Results

A total of 51 patients met the inclusion criteria and were included in the study. The median age was 65 years (25–87) and the majority of the patients were male (n?=?38, 74.5 %). There were 42 patients (82.3 %) with lung cancer. The most common cause of acute respiratory failure was pneumonia (n?=?24, 47.1 %), followed by acute respiratory failure due to extra-pulmonary infection, drug-induced pneumonitis, alveolar hemorrhage, and cancer progression. The intensive care unit (ICU) mortality was 68.6 % and the most common cause of death in the ICU was uncorrected cause of acute respiratory failure. Before adjustment for others factors, prechemotherapy Eastern Cooperative Oncology Group (ECOG) Performance Scale (PS) (P?=?0.03), Sequential Organ Failure Assessment score (P?=?0.01), and anemia (P?=?0.04) were significantly associated with ICU mortality. However, when adjusted for age, sex, and Acute Physiologic and Chronic Health Evaluation II score, only poor ECOG PS (≥2) was significantly associated with ICU mortality [OR 6.36 (95 % CI (1.02–39.5))].

Conclusions

The outcome of patients with acute respiratory failure needing invasive mechanical ventilation during ambulatory chemotherapy for solid cancer is poor. Prechemotherapy performance status is an independent predictor of mortality.     

The importance of differentiating between elective and emergency postoperative critical care patients

Purpose

The purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units.

Materials and Methods

A prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours).

Results

In groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality.

Conclusions

Substantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.