Invasive pulmonary aspergillosis is associated with cytomegalovirus viremia in critically ill patients - A retrospective cohort study

Background/PurposeCytomegalovirus (CMV) viremia is associated with a higher mortality rate and prolonged intensive care unit (ICU) stay for critically ill patients. CMV infection causes transient but substantial immunosuppression for transplant recipients, increasing risk of fungal infection. The association between CMV viremia and invasive pulmonary aspergillosis (IPA) for critically ill patients is still unknown.MethodsWe retrospectively analyzed patients received bronchoalveolar lavage (BAL), galactomannan test, influenza survey and blood CMV viral load test in ICUs of a university hospital between April 2017 and May 2020. Independent risks for IPA were analyzed by multivariable logistic regression.ResultsA total of 136 patients were included. Twenty-one patients had IPA, 48 patients had CMV viremia and 22 patients had influenza. In a multivariable logistic regression model, patients with CMV viremia or influenza had higher IPA risk (adjusted odds ratio, 3.98 and 8.72; 95% CI, 1.26–12.60 and 2.64–28.82; p value = 0.019 and <0.001, respectively.). Patients with detectable CMV in BAL fluid did not have higher IPA risk (crude odds ratio, 0.95; 95% CI, 0.33–2.79; p value = 0.933). After stratifying patients by CMV viral load, the IPA risk is higher for patients with higher viral loads. There is an additive synergistic effect on IPA risk between CMV viremia and influenza infection.ConclusionFor critically ill patients, CMV viremia is an independent risk factor of IPA. Patients with higher blood CMV viral loads have a higher risk of IPA. CMV viremia and influenza have an additive synergistic effect for IPA risk in critically ill patients.     

Safe transport of critically ill adult patients on extracorporeal membrane oxygenation support to a regional extracorporeal membrane oxygenation center

Patients with severe cardiac or pulmonary failure who require transport to specialized hospitals currently pose a challenge. Mechanical support in the form of extracorporeal membrane oxygenation (ECMO) may increase the safety of transporting such patients to an institution where they will have access to advanced medical therapy. Over 2.5 years, 17 patients were successfully cannulated and placed on a simplified ECMO circuit at other institutions and transported via ambulance to our hospital. Fourteen patients with acute respiratory distress syndrome (ARDS) were placed on venovenous (VV) ECMO. Two patients with isolated cardiogenic shock and one patient with ARDS were placed on venoarterial (VA) ECMO. The two cardiogenic shock patients were converted to a biventricular assist device shortly after arrival. The median unit-to-unit transport time was 60 minutes (interquartile range 50-92 minutes), and the median distance traveled was 23 miles (interquartile range 17-55 miles). There was no transport-related morbidity or mortality. The median duration of ECMO support was 8 days (interquartile range 4-11 days). Thirteen patients (76%) were successfully decannulated. Ten patients (59%) were weaned from the ventilator, and nine patients (53%) survived up to 3 months and were discharged from the hospital. Critically ill patients with severe ARDS or cardiogenic shock can be safely transported on VV or VA ECMO support to regional ECMO centers. As the indications and demands for ECMO support expand, so will the role for transporting patients on ECMO.     

体外膜肺技术在9例危重症患儿中的应用

目的探讨心肺功能衰竭患儿体外膜肺（ECMO）支持治疗的临床经验。方法回顾性分析2008年12月至2012年5月收住复旦大学附属儿科医院重症监护病房及心脏监护病房的9例危重症患儿接受ECMO治疗的情况及转归。结果 9例患儿均采用颈内动、静脉置管,V-AECMO模式,体外肝素抗凝,活化凝血时间（ACT）维持在180～220s;体外辅助血流量为50～100mL·kg-1·min-1。治疗期间进行心肺功能、血液指标和影像学等监测。9例患儿ECMO使用时间为5～280h,中位数112h。经治疗后8例病情好转,撤离ECMO治疗,其中7例痊愈出院,1例撤离ECMO治疗后3d自动出院。1例因室间隔缺损修补术后合并严重脓毒症、脓毒症休克和心肺功能衰竭,ECMO治疗1周,撤机后死亡。发生各类并发症共14例次,其中机械系统并发症6例次,包括氧合器漏液3例次,管路血栓2例次,水箱加温器故障1例次;机体并发症7例次,其中6例发生贫血,1例右上肢功能障碍;意外事件1例,患儿在ECMO运行过程中因右腋下动脉置管意外滑脱而形成血肿。未发生颅内并发症、出血和感染等。结论 ECMO能有效对危重症患儿行心肺功能支持,使用安全。建立一支专业的技术团队能促进ECMO的更好开展。     

Invasive pulmonary aspergillosis infection in severely ill COPD patients in pulmonary ward and ICU

PurposeThis study was planned to determine the trends and susceptibility pattern of invasive pulmonary aspergillosis (IPA) in severely ill chronic obstructive pulmonary disease (COPD) patients admitted in pulmonary ward and ICU of our tertiary care centre.MethodsFifty COPD patients suspected of IPA from pulmonary ward and ICU from April 2017 to September 2018 were investigated. Samples were processed by standard methods, culture positive isolates were confirmed by MALDI-TOF MS and antifungal susceptibility testing was performed by microbroth dilution method.ResultsTwenty-two critically ill COPD patients were microbiologically positive for IA infection, of which 13 were classified as putative invasive aspergillosis. The most common comorbid illness associated was diabetes. A. flavus and A. fumigatus were the commonest species isolated. The minimum inhibitory concentration of the antifungals was low. Morbidity due to IPA in COPD patients was very high.ConclusionsPrevalence of IPA in the pulmonary ward and ICU was found to be 9.6%. MALDI-TOF seems to be a promising tool for aiding rapid identification especially for slow growing and non-sporulating fungi. Heightened awareness and suspicion for pulmonary mould infections along with early diagnosis can substantially alter the patient prognosis.     

Body mass index and echocardiography in refractory ARDS treated with veno-venous extracorporeal membrane oxygenation

The aims of the present investigation, performed in 118 consecutive patients with refractory ARDS treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO), were as follows: (a) to assess ICU mortality in overweight, obese and morbid obese patients in respect to normal weight; (b) to evaluate echocardiographic findings according to BMI subgroups. Echocardiography was performed before VV-ECMO implantation. Forty-five patients (38.1%) showed normal BMI, 37 patients (31.4%) were overweight and the remaining were obese (21.2%), or morbid obese (9.3%). Morbid obese showed the lowest ICU mortality rate (p = 0.003). No differences were detectable among BMI subgroups in echocardiographic findings apart from the fact that obese patients showed the lowest incidence of LV dysfunction (p = 0.015). At stepwise regression analysis the following variables were independent predictor of ICU mortality (when adjusted for age): RV dilatation (OR 4.361, 95 % CI 1.809–10.512, p < 0.001), BMI (OR 0.884, 95% CI 0.821–0.951, p < 0.001). In other terms, the presence of RV dilatation is an independent predictor of ICU mortality. In refractory ARDS treated with VV-ECMO, BMI > 30 kg/m² is common (accounting for one-third of the entire population) but it is not associated with a worse outcome, so that it cannot be considered per se a contraindication to ECMO implantation. The incidence of RV dilatation and failure, which are known to negatively affect prognosis in ARDS patients, were comparable among BMI subgroups.     

Furosemide is associated with acute kidney injury in critically ill patients

Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24 h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02, 95%CI = 1.00-1.04. Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%)     

Plasma concentrations of midazolam in neonates receiving extracorporeal membrane oxygenation

Drug disposition is affected during extracorporeal membrane oxygenation (ECMO). This study investigates the dose-concentration relationship of midazolam in neonates requiring ECMO during continuous infusion into the circuit (extracorporeally; n = 10) and intravenously (n = 10). Data on hourly doses and sedation scores were collected for 120 hours. Plasma concentrations were analyzed at times 0, 2, 4, 6, 12, 18, and 24, and every 12 hours thereafter. Both groups were clinically similar. Mean (standard deviation) dose for all patients was 250 (185) microg/kg/h, four times greater than previously reported. Doses administered in the first 24 hours were significantly greater extracorporeally [361 (300)] compared with intravenous [258 (190) microg/kg/h, p < 0.001]. Mean (standard deviation) plasma concentrations in all patients at 24, 48, and 72 hours were 1.4 (0.9), 1.8 (1.2), and 2.6 (1.8) microg/ml, respectively. Satisfactory sedation levels were achieved in all patients. Comparison of the actual observed with predicted (simulated) midazolam concentrations suggested significant attenuation of plasma levels during the first 24 hours of ECMO. However, at 48 hours, observed concentrations exceeded those predicted, suggesting accumulation. We conclude that in the first 24 hours of ECMO, because of an expanded circulating volume and sequestration by the circuit, significantly more midazolam is required to achieve adequate sedation. Subsequently, and because of circuit saturation, maintenance doses should be reduced.     

Invasive pulmonary aspergillosis in patients with HBV-related liver failure

Invasive pulmonary aspergillosis (IPA) has been increasingly frequent in severe liver disease. We aim to investigate the clinical presentation, predisposing factors, and treatment of IPA in patients with liver failure caused by hepatitis B virus (HBV) infection. Medical records from 798 patients with HBV-related liver failure were reviewed. A total of 43 patients with probable IPA were selected as the case group, another 43 patients with bacterial infection and 43 patients without any infections were selected, for whose age, sex, date of admission, and the disease onset were matched with the case group. We evaluated the risk factors, clinical manifestations, treatment, and subsequent outcome of IPA in patients with HBV-related liver failure. Multivariate logistic regression models were used to demonstrate risk factors associated with IPA. Compared with patients with bacterial infection and those without any infection, patients with probable IPA used more antibiotics and steroids, and had poorer conditions and the highest mortality (P < 0.0001). Multiple antibiotics use and frequent invasive procedures were independent factors associated with the occurrence of IPA in patients with HBV-related liver failure. Patients with HBV-related liver failure are predisposed to IPA and may have a more severe condition and poorer prognosis.     

Pathogens and outcomes in pediatric septic shock patients supported by extracorporeal membrane oxygenation

Background

Refractory septic shock is the leading cause of mortality in children. There is limited evidence to support extracorporeal membrane oxygenation (ECMO) use in pediatric septic shock. We described the etiology and outcomes of septic patients in our institution and attempted to find predictive factors.

Acute pulmonary injury with refractory hypoxaemia after implantation of Levitronix CentriMag ventricular assist device: successful treatment with veno-venous extracorporeal membrane oxygenation

Although acute pulmonary injury after cardiopulmonary bypass has been detailed in the literature, it was seldom mentioned in the context of following implantation of a ventricular assist device. We report on a 65-year-old male with end-stage ischemic cardiomyopathy who underwent implantation of Levitronix CentriMag (Levitronix, Waltham, MA) for cardiac support and was listed for heart transplantation. Acute pulmonary injury with profound hypoxaemia was noted 6 h after the implantation. Despite optimal medical treatment and maximal ventilator support, refractory hypoxaemia persisted, and veno-venous extracorporeal membrane oxygenation (oxygenator: Affinity-NT; centrifugal pump: BPX-80 Bio-Pump, Medtronic, Minneapolis, MN, USA) was applied for ventilation support. The patient was weaned from the extracorporeal membrane oxygenation 4 days later and from the ventilator on the next 2 days. He underwent a successful orthotopic heart transplant after a total of 77 days on Levitronix left ventricular device cardiac support.     

Vitamin D deficiency is independently associated with mortality among critically ill patients

OBJECTIVE:

Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients.

METHOD:

In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity.

RESULTS:

Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity.

CONCLUSIONS:

This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients.     

Clinical outcomes and experience of 20 pediatric patients treated with extracorporeal membrane oxygenation in Fuwai Hospital

The purpose of this study was to report retrospectively the summarized clinical findings from 20 consecutive pediatric extracorporeal membrane oxygenation (ECMO) patients and to investigate the factors associated with mortality. The ECMO circuit system was completely covered using heparin-coating technique, and venoarterial ECMO was used in all patients. Heparin dosage was 4-20 U/kg/h and active clotting time was maintained between 146 and 360 seconds. ECMO was weaned off successfully in 15 patients (75%); 11 of 15 patients (73%) survived and were discharged from the hospital; 4 of 15 patients died of postoperative complications; 5 patients failed to be weaned off ECMO. The percentage of discharged patients was 55% (11 of 20) in this cohort study. Lactic acid concentration of artery blood before ECMO in survivor patients was significantly lower than in nonsurvivor patients (p = 0.009); patient weight between two groups also had statistical difference (p = 0.046). ECMO effectively treats cardiac and pulmonary failure secondary to cardiac surgeries for complicated congenital heart diseases. Early application of ECMO in patients with cardiac and respiratory failure is still the key point of success in preventing vital organs from irreversible damage.     

Recirculation in double lumen catheter veno-venous extracorporeal membrane oxygenation measured by an ultrasound dilution technique

Recirculation is a limiting factor for oxygen delivery in double lumen catheter veno-venous extracorporeal membrane oxygenation (DLVV-ECMO). This study compares three different methods for the determination of the recirculation fraction during double lumen catheter veno-venous ECMO at ECMO flow rates of 150, 125, 100, 75, and 50 ml/kg.min in nine lambs: (1) an ultrasound dilution method, in which the change in ultrasound velocity in blood after injection of a saline bolus as a marker is used for determination of recirculation; (2) an SvO2 method using real mixed venous blood oxygen saturation, the gold standard, for determination of recirculation fraction; and (3) the CVL method, in which oxygen saturation of a blood sample of the inferior vena cava is considered to represent mixed venous oxygen saturation. In all methods, the recirculation fraction increased with increasing ECMO flow rate. The correlation coefficient between the ultrasound dilution method and the SvO2 method was 0.68 (p < 0.01); mean difference was -2.4% (p = 0.6). Correlation coefficient between the ultrasound dilution method and the CVL method was 0.48 (p < 0.01); mean difference was -18.1% (p < 0.01). The correlation coefficient between the SvO2 method and the CVL method was 0.51 (p < 0.01); mean difference was -15.7% (p < 0.01). The ultrasound dilution method is a useful method for measurement of the recirculation fraction in DLVV-ECMO and is easier to use than the other methods.