L’insuffisance rénale aiguë après chirurgie cardiaque : évaluation des critères RIFLE

IntroductionAcute renal failure is a common complication is a common complication in cardiac surgery under cardiopulmonary bypass. It is associated with increased morbidity and mortality. Acute kidney injury (AKI) is a clinical entity encompassing the entire spectrum of acute renal failure, since minor alterations to the need for renal replacement therapy. The RIFLE criteria have been proposed for defining and classifying AKI. The aim of our study was to apply the RIFLE to a population of patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to assess its relevance in terms of risk factor for hospital mortality compared to other risk factors.MethodsIn this prospective observational study, we included patients who were operated for programmed cardiac surgery. The assay of blood creatinine was performed at admission, after surgery and daily for 5 days post-surgery. The AKI was evaluated according to the criteria of classification RIFLE. The patients were divided into three levels of severity based on plasmatic creatinine (R: Risk = creatinine × 1.5; I: Injury = creatinine × 2; F: Failure = creatinine × 3). We have analyzed the different perioperative parameters and we sought associations with the occurrence of AKI. We also studied the impact of AKI on length of stay in ICU and mortality early and late.ResultsOne hundred and thirty-six patients were included. AKI was diagnosed in 17.6% of patients (RIFLE-R: 8.8%, RIFLE-I: 5.9% and RIFLE-F: 2.9%). AKI significantly prolongs the duration of ICU stay (7 ± 3.8 versus 5 ± 2.3 days; P = 0.02). RIFLE-R patients had a mortality of 8.3%, compared to 12.5% for I and 50% for F. Patients without PORD had a mortality of 1.8%. In univariate analysis, age, the EURO score, preoperative renal dysfunction, duration of aortic clamping, duration of CPB and C-reactive protein (CRP) were significantly associated with the occurrence of AKI. In multivariate analysis only preoperative renal dysfunction (clearance less than 63 mL/min) and CRP greater than 158 mg/L were found as independent factors of occurrence of AKI.ConclusionRIFLE classification seems to be a reliable way to detect acute renal failure and to classify its severity. The AKI is a common complication and is associated with increased morbidity and mortality. Identifying the risk factors allows a better prevention strategy.     

Clinical characteristics and risk factors for severe burns complicated by early acute kidney injury

BackgroundEarly acute kidney injury (AKI) is a frequent fatal complication of severely burned patients. Although significant progress has been made in fluid resuscitation, intensive care, and renal replacement therapy (RRT) technology in recent years, the incidence and mortality rate in severely burned patients with AKI remains considerable. This study aims to provide theoretical evidence for prevention and treatment by investigating the clinical characteristics and risk factors influencing the incidence and severity of early AKI in severely burned patients.MethodsThis 3-year retrospective, single-center study was conducted in critically ill burned patients admitted to the Burn ICU at Guangzhou Red Cross Hospital of Jinan University. Patients whose age is older than 18 years with ≥30% burned total body surface area (TBSA) were enrolled in this study. Those patients who arrived at our burn ICU > 72 h after injury or died within 48 h from arrival were excluded. Data of 128 patients were studied in the final. Demographic and injury details were recorded. KDIGO criteria were used to assess the incidence and severity of early AKI. Factors influencing early AKI were determined using univariate and multiple logistic regression analysis.ResultsBetween January 2016 and December 2018, Data from 128 critically ill burned patients were available for analysis. The median age was 44.9 ± 16.8 years; 68.8% of the patients were male. The median TBSA% was 60 (IQR, 41.3–80%). According to the KDIGO criteria, 36 patients (28.3%) developed early AKI, as follows: stage 1 AKI, 69.4% (25/36); stage 2 AKI, 13.9% (5/36); and stage 3 AKI, 16.7% (6/36). The incidence of early AKI was associated with TBSA%, full-thickness TBSA%, abbreviated burn severity index on admission (ABSI), inhalation injury, mechanical ventilation, cardiovascular complications, and rhabdomyolysis. Multiple logistic regression analysis indicate that TBSA% (OR = 0.224, p = 0.007), full-thickness TBSA% (OR = 0.254, p = 0.014), ABSI (OR = 18.326, p = 0.009), and rhabdomyolysis (OR = 24.036, p = 0.000) were independent risk factors for the occurrence of early AKI. Significant factors influencing the severity of early AKI included full-thickness body surface area burns, electrical burns, and rhabdomyolysis. Full-thickness TBSA% (OR = 1.437, p = 0.041) and rhabdomyolysis (OR = 5.401, p = 0.035) are associated with mortality. The risk of death due to the occurrence of AKI was 5.407 in the Cox model adjusted for TBSA%, full-thickness body surface area burns, ABSI and rhabdomyolysis. Three patients died, all of whom had stage 3 AKI, accounting for 8.3% (3/36) of AKI patients. The death rate of stage 3 AKI who did and did not receive early RRT was 33.3% and 66.7%, respectively.ConclusionRhabdomyolysis is an independent risk factor for early AKI and closely related to the severity of early AKI in critically ill burned patients. Although with a high incidence of early AKI in severely burned patients, most of them are mild. Early adequate fluid resuscitation, timely and effective escharotomy, reducing the incidence and severity of rhabdomyolysis, most of them can achieve a relatively good prognosis.     

Incidence and risk factors of acute kidney injury in the Japanese trauma population: A prospective cohort study

IntroductionPrevious studies have reported the prevalence and risk factors of acute kidney injury (AKI) in relatively young trauma patients. The aims of this study were to identify the prevalence and risk factors of AKI among older Japanese trauma patients.MethodsWe conducted a prospective observational study in the 8-bed intensive care unit (ICU) of a Japanese tertiary-care hospital. Participants comprised trauma patients aged 18 years or older admitted to the ICU. Our primary outcome was the incidence of AKI within 10 days of admission, according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.ResultsAmong 333 patients, 66 (19.8%) developed AKI (Stage 1, n = 54; Stages 2, n = 5; and Stage 3, n = 7). Multivariate logistic regression analysis revealed that the incidence of AKI was associated with increased age (odds ratio (OR), 1.38; 95% confidence interval (CI), 1.15–1.65), male sex (OR, 2.06; 95%CI, 1.04–4.07), greater amount of red blood cell transfusions (OR, 1.61; 95%CI, 1.04–1.17), and presence of underlying chronic kidney disease (CKD) (OR, 3.97; 95%CI, 1.78-8.83). Length of stay in the ICU was significantly longer in patients with AKI (6 days) than in those without (3 days; p < 0.001). Patients ≥65 years old were more likely to develop AKI (26.2% vs 11.6%; p < 0.001). No significant differences in ICU stay (median, 4 vs 4 days; p = 0.70), hospital stay (median, 24 vs 21 days; p = 0.45), or 28-day mortality (2.1% vs 1.4%; p = 0.19) were evident between age groups.ConclusionsApproximately 20% of trauma patients developed AKI, and the elderly were more likely to develop AKI. Older age, male, greater units of red blood cell transfusions, and underlying CKD were associated with incidence of AKI.     

Acute Kidney Injury: It's not just the ‘big’ burns

BackgroundAcute Kidney Injury (AKI) complicates the management of at least 25% of patients with severe burns and is associated with long term complications. Most research focuses on the patients with more severe burns, and whether the same factors are associated with the development of AKI in patients with burns between 10 and 19% total body surface area (TBSA) is unknown. The aims of this study were to examine the incidence of, and factors associated with, the development of AKI in patients with %TBSA ≥ 10, as well as the relationship with hospital metrics such as length of stay (LOS).MethodsRetrospective medical record review of consecutive burns patients admitted to The Alfred Hospital, the major adult burns centre in Victoria, Australia. Demographic and injury details were recorded. Factors associated with AKI were determined using multiple logistic regression.ResultsBetween 2010 and June 2014, 300 patients were admitted with burn injury and data on 267 patients was available for analysis. Median age was 54.5 years with 78% being male. Median %TBSA was 15 (IQR 12, 20). The AKI incidence, as measured by the RIFLE criteria, was 22.5%, including 15% (27/184) in patients with %TBSA 10–19. Factors associated with AKI included increasing age and %TBSA (OR 1.05 p < 0.001) as well as increased surgeries (p < 0.041) and a cardiac comorbidity (p < 0.01). All patients with renal comorbidity developed AKI. In the %TBSA 10–19 cohort, only increasing age (OR 1.05 p < 0.001) was associated with AKI. After accounting for confounding factors, the probability of discharge from hospital in Non-AKI group was greater than for the AKI patients at all time points (P < 0.001).ConclusionThis is the first study to show an association between patients with %TBSA 10–19 and AKI. Given the association between AKI and complications, prospective research is needed to further understand AKI in burns with the aim of risk reduction.     

The application of a new regimen for short term sedation in the ICU (ketofol) – Case series

ObjectiveSedation is an effective component of care in ICU patients. The aim of this study was to evaluate the safety and efficacy of ketamine/propofol combination in short term sedation for the critically ill patients in ICU.DesignProspective case series study.SettingIntensive care unit (ICU) in a tertiary hospital (Kasr Al Aini).MethodsFourteen critically ill patients who were mechanically ventilated and were in need for sedation were included in this case series. An initial bolus dose (500 μg/kg) of ketamine/propofol 1:1 (ketamine 8 mg/ml and propofol 8 mg/ml) was given to all patients followed by a maintenance dose of 10 μg/kg/min and the infusion dose adjusted (in 5 μg/kg/min increments) to achieve Ramsay Sedation Scale of 4. Recorded parameters included heart rate, systolic blood pressure, Ramsay score, the need for use of noradrenalin and the recovery time from discontinuation of sedation.ResultsThe mean and standard deviation of the age of the patients was 60 ± 14.5 y and their APACHEII score ranged from 18 to 35. The median initial bolus dose of ketofol administered was 5 ml of aliquot with median infusion rate 6 ml/h (range: 4.8–7.5 ml/h) only three patients (21.4%) needed the infusion rate to be increased to achieve Ramsay score 4. Only one patient experienced hypotension due to hypovolemia secondary to internal hemorrhage.ConclusionContinuous intravenous infusion of ketofol may provide adequate and safe short term sedation (less than 24 h) for critically ill patients in the intensive care units, with rapid recovery and no clinically significant complications. Further studies with larger number of patients are required to evaluate and validate these findings.     

Optimal blood pressure decreases acute kidney injury after gastrointestinal surgery in elderly hypertensive patients: A randomized study: Optimal blood pressure reduces acute kidney injury

Study objectiveTo determine the appropriate mean arterial pressure (MAP) control level for elderly patients with hypertension during the perioperative period.DesignA prospective, randomized study.SettingThree teaching hospitals in China.PatientsSix hundred seventy-eight elderly patients with chronic hypertension undergoing major gastrointestinal surgery.InterventionsPatients were randomly allocated to three groups and the target MAP level was strictly controlled to one of three levels: level I (65–79 mm Hg), level II (80–95 mm Hg), or level III (96–110 mm Hg).MeasurementsThe primary outcome was acute kidney injury (AKI) (50% or 0.3 mg·dL^− 1increase in creatinine level) during the first 7 postoperative days. The secondary outcomes were perioperative adverse complications. Moreover, vasoactive agents were observed during surgery.Main resultsThe overall incidence of postoperative AKI was 10.9% (71/648). AKI occurred significantly less often in patients with level II MAP control (6.3%;13/206) than in patients with level I (13.5%; 31/230) and level III (12.9%; 27/210) (P < 0.001) MAP control. Level II was associated with lower incidences of hospital-acquired pneumonia (6.7%; 14/206; P = 0.014) and admission to the intensive care unit (ICU) (4.4%; 9/206; P = 0.015) and with shorter length of stay in the ICU (P = 0.025) when compared with level I and level III. Use of norepinephrine, phenylephrine, and nitroglycerin was significantly higher for patients with level III MAP control than for patients with level I and level II MAP control (P = 0.001).ConclusionsFor elderly hypertensive patients, controlling intraoperative MAP levels to 80 to 95 mm Hg can reduce postoperative AKI after major abdominal surgery.     

Characterization of critically ill adult burn patients admitted to a Brazilian intensive care unit

IntroductionTo characterize the evolution of clinical and physiological variables in severe adult burn patients admitted to a Brazilian burn ICU, we hypothesized that characteristics of survivors are different from non-survivors after ICU admission.MethodsA five-year observational study was carried out. The clinical characteristics, physiological variables, and outcomes were collected during this period.ResultsA total of 163 patients required ICU support and were analyzed. Median age was 34 [25,47] years. Total burn surface area (TBSA) was 29 [18,43]%, and hospital mortality rate was 42%. Lethal burn area at which fifty percent of patients died (LA50%) was 36.5%. Median SAPS3 was 41 [34,54]. Factors associated with hospital mortality were analyzed in three steps, the first incorporated ICU admission data, the second incorporated first day ICU data, and the third incorporated data from the first week of an ICU stay. We found a significant association between hospital mortality and SAPS3 [OR(95%CI) = 1.114(1.062–1.168)], TBSA [OR(95%CI) = 1.043(1.010–1.076)], suicide attempts [OR(95%CI) = 8.126(2.284–28.907)], and cumulative fluid balance per liter within the first week [OR(95%CI) = 1.090(1.030–1.154)]. Inhalation injury was present in 45% of patients, and it was not significantly associated with hospital mortality.ConclusionsIn this study of an ICU in a developing country, the mortality rate of critically ill burn patients was high and the TBSA was an independent risk factor for death. SAPS3 at admission and cumulative fluid balance in the first seven days, were also associated with unfavorable outcomes. The implementation of judicious fluid management after an acute resuscitation phase may help to improve outcomes in this scenario.     

Hepatic dysfunction: A common occurrence in severely injured patients

BackgroundHepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes.MethodsA retrospective observational study was performed on all patients admitted to the Level 1 Trauma Unit ICU at Inkosi Albert Luthuli Central Hospital in Durban, South Africa (IALCH) from 01/01/2012 until 31/12/2012. HD was defined as a total bilirubin greater than 34.2 μmol/l (2 mg/dL). Additional demographic, physiological, biochemical, and pharmaceutical risk factors for hepatic dysfunction were identified and recorded.ResultsTwo hundred and twenty five patients were included in the study of whom 48 (21.3%) developed HD. An increased duration of ventilation (median 15 days [inter-quartile range 6–19] vs 6 days [IQR 3–11] p < 0.001), prolonged length of stay (median 19 days [IQR 8.5–31] vs 7 days [IQR 3–13] p < 0.001), and higher mortality rate (31.3% vs. 14.7% p = 0.01) were all significantly associated with HD. Shock on admission was twice as common in patients developing HD (p < 0.001). The only drugs associated with HD were piperacillin-tazobactam (p < 0.001) and enalapril (p = 0.04). On multivariable analysis however, HD was not associated with mortality.ConclusionHD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.     

Investigating the interrater reliability of a novel functional outcome measure for use in the burns intensive care unit: The Functional Assessment for Burns — Critical Care (FAB-CC)

IntroductionIntensive Care Unit Acquired Weakness challenges the clinical care of critically ill patients. Despite a surge in validated ICU functional outcome measures following the publication of Clinical Guideline 83 ‘Rehabilitation After Critical Illness’ by the National Institute for Health and Care Excellence (2009), there are none composed specifically for use in the Burns ICU. We therefore developed and tested the inter-rater reliability of a burn specific novel functional outcome measure; The Functional Assessment for Burns-Critical Care (FAB-CC).ObjectivesThis research aimed to investigate the interrater reliability of the FAB-CC.MethodsA quantitative reliability study assessed the ability of the FAB-CC to obtain accurate data when utilised by three separate raters (m = 3) scoring the same clinical episodes (n = 24).ResultsThe Intraclass Correlation Coefficient (ICC) for the FAB-CC as a complete tool revealed excellent agreement (ICC 0.998; P < 0.001, 95% confidence interval 0.996-0.999), with Cronbach’s Alpha (α 0.999). Individual components of the FAB-CC displayed excellent agreement (ICC > 0.983; P < 0.001) with narrow 95% confidence intervals.ConclusionsThe FAB-CC is a novel functional outcome measure that is reliable for use with critically ill burn patients. It has demonstrated real clinical utility in the identification and management of ICU-AW in this unique patient group.     

Influence of late fluid management on the outcomes of severe trauma patients: A retrospective analysis of 294 severely-injured patients

BackgroundLiberal late fluid management (LFM) is associated with higher morbi-mortality in critically ill populations. The aim of the study was to assess the association between LFM and duration of mechanical ventilation in a severe trauma population.MethodsA retrospective analysis of consecutive patients with an ISS ≥ 16 and a length of stay in the intensive care unit (ICU) ≥ 7 days was performed. The conservative LFM group included patients with at least 2 consecutive days with a negative fluid balance between day 3 and day 7; other patients were allocated to the liberal LFM group.Results294 severely injured patients were included, 157 (53%) as conservative LFM and 137 (47%) as liberal LFM. The groups did not differ significantly in terms of baseline characteristics, severe injuries, severity criteria or transfusion needs. Liberal LFM was significantly associated with more ventilation days (11 vs 8.5 days; P = 0.02), less ventilator-free days at day 30 (19 vs 21 days; P = 0.03), longer ICU stay (19 vs 16 days; P = 0.03) and longer hospital stay (30 vs 25 days; P = 0.04). Mortality rates were comparable between groups (6%). Liberal LFM was significantly associated in multivariable analysis with a reduced number of ventilator-free days at day 30 (β = − 2.14 [95% CI, −4.2 to −0.08], P = 0.042).ConclusionsLiberal LFM was associated with higher morbidity in severe trauma patients, longer duration of ventilation, and longer ICU and hospital stays. These results were observed despite similar severity on admission and early fluid management.     

Incidence of complications in the post-anesthesia care unit and associated healthcare utilization in patients undergoing non-cardiac surgery requiring neuromuscular blockade 2005–2013: A single center study

Study objectiveThe use of neuromuscular blockade agents (NMBA), had been associated with significant residual post-operative paralysis and morbidity. There is a lack of clinical evidence on incidence of postoperative complications within the post-anesthesia care unit (PACU) in patients exposed to intraoperative NMBA's. This study aims to estimate the incidence of post-operative complications associated with use of NMBAs and assessing its association with healthcare resource utilization.DesignRetrospective cohort.SettingPost-anesthesia care unit in tertiary care center.PatientsAdults having non-cardiac surgery and receiving NMBAs between April-2005 and December-2013MeasurementsWe assessed: 1) incidences of major and minor PACU complications, 2) incidence of any postoperative complication in patients receiving a NMBA reversal (neostigmine) vs. without. 3) We secondarily assessed the relationship between PACU complications and use of healthcare resources.Main resultsThe incidence of any major complications was 2.1% and that of any minor complication was 35.2%. ICU admission rate was 1.3% in patients without any complications, versus 5.2% in patients with any minor and 30.6% in patients with any major complication. ICU length of stay was prolonged in patients with any major (52.1 ± 203 h), compared to patients with any minor (6.2 ± 64 h) and with no complications (1.7 ± 28 h). Patients who received a NMBA and neostigmine, compared to without neostigmine, had a lower incidence of any major complication (1.7% vs. 6.05%), rate of re-intubation (0.8% vs. 4.6%) and unplanned ICU admission (0.8% vs. 3.2%).ConclusionsThis study documents that incidence of major PACU complications after non-cardiac surgery was 2.1%, with the most frequent complications being re-intubation and ICU admission. Patients receiving NMBA reversal were at a lower risk of re-intubation and unplanned ICU admission, justifying routine use of reversals. Complete NMBA reversals are crucial in reducing preventable patient harm and healthcare utilization.     

Étude comparative de l’insuffisance rénale aiguë communautaire chez le sujet VIH positif et le sujet VIH négatif : expérience d’un service de médecine interne à Abidjan (Côte d’Ivoire)

BackgroundAcute kidney injury (AKI) is commonly associated with HIV infection.ObjectivesTo describe the profile of AKI in HIV infected versus non-infected persons.Patients and methodsThis is a prospective study that was carried out during the study period from January 2010 to December 2015 in the department of nephrology-internal medicine D of Treichville University Hospital (Côte d’Ivoire).ResultsThe prevalence of HIV infection was 35.2% in the population of AKI. The average age of patients was 42 ± 18 years in the HIV positive group against 51 ± 18 years in the HIV negative group (P = 0.0001). Etiologies were infections in 65.1% in the HIV positive group against 38.8% in the HIV negative group (P = 0.0001) and water loss in 24.7% in the HIV positive group against 7.8% in the HIV negative group (P = 0.0001). Factors such as the AIDS stage (P = 0.002), severe sepsis (P = 0.002) and acute pyelonephritis (P = 0.001) were associated with mortality in HIV positive patients against severe anemia (P = 0.0001) and severe sepsis (P = 0.0001) in the HIV-negative group.ConclusionHIV positive patients are younger with a female predominance. The mortality rate is identical in both groups.     

Acute Kidney Injury After Pediatric Liver Transplantation

BackgroundThe aim of the present study is to assess acute kidney injury (AKI) incidence according to the pRIFLE and AKIN criteria and to evaluate the risk factors for early developing AKI in postoperative intensive care unit after pediatric liver transplantation (LT).MaterialsAfter exclusion of retransplantations, 7 cadaveric and 44 living donors, totaling 51 pediatric LT patients that were performed between 2005 and 2017, were reviewed retrospectively. AKI was defined according to both pediatric RIFLE (Risk for renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal disease) and Acute Kidney Injury Network (AKIN) criteria. Documented data were compared between AKI and non-AKI patients.ResultsAKI incidences were 17.6% by AKIN and 37.8% by pRIFLE criteria. AKIN-defined AKI group had statistically lower serum albumin level, higher serum sodium level, higher furosemide dose, and higher rate of red blood cell (RBC) transfusion than the non-AKI group (P = .02, P = .02, P = .01 and P = .04, respectively). AKI patients had significantly prolonged mechanical ventilation (P = .01) and hospital LOS (P = .02). The pRIFLE-defined AKI group had significantly lower serum albumin level, higher blood urea nitrogen (BUN) level, and higher ascites drained and also showed higher requirement for RBC and 20% human albumin transfusions than the non-AKI group (P = .02, P = .04, P: =.007, P = .02 and P = .05, respectively).ConclusionWe evaluated that hypoalbuminemia, high requirement for RBC and 20% human albumin transfusions, high serum sodium, high furosemide use, and high flow of ascites are risk factors for AKI and high BUN levels can be predictive for AKI in pediatric LT patients. The effect of AKI on outcome variables were prolonged mechanical ventilation and hospital LOS.     

Evaluation of renal effects of liposomal amphotericin B in children with malignancies with KDIGO and RIFLE criteria

BackgroundAmphotericin B is a broad-spectrum antifungal agent and is the backbone of the treatment for medically important opportunistic fungal pathogens in children. This study aimed to compare the nephrotoxicity associated with L-AmB in children with acute lymphoblastic leukemia and acute myeloid leukemia.Materials and methodsA total of 112 pediatric acute lymphoblastic leukemia or acute myeloid leukemia patients who received treatment with L-AmB (Ambisome®) at the University of Health Sciences Dr Behcet Uz Children's Hospital over 7 years were included. The incidence of hypokalemia, decreased estimated glomerular filtration rate and presence of acute kidney injury was recorded.ResultsThe average L-AmB treatment duration was 17.1 ± 15.0 days. Five patients (4.4%) of the patients had grade I acute renal injury according to KDIGO criteria and 16 patients (14.2%) had increased risk for kidney injury according to RIFLE criteria. There were no patients with eGFR decrease above 50% and no renal injury and failure were observed during L-AmB treatment. The rate of patients with hypokalemia in the pre-treatment was 17.9% and the post-L-AmB group was 50.0%. The rate of hypokalemia was higher in the post-treatment group (P = 0.0015). Among the 112 patients, only two patients (1.7%) required cessation of L-AmB treatment due to resistant hypokalemia despite supplementation.ConclusionsHypokalemia was more common compared to glomerulotoxicity and acute renal injury (according to KDIGO and RIFLE criteria) in pediatric leukemia patients treated with L-AmB. Hypokalemia developed in nearly half of the patients and the study shows the need for randomized controlled trials and strategies for hypokalemia associated with L-AmB treatment.     

Regional citrate anticoagulation for continuous renal replacement therapy in severe burns—A retrospective analysis of a protocol-guided approach

IntroductionFor critically ill patients, the use of regional citrate anticoagulation as part of continuous renal replacement therapy (CRRT) has become increasingly common in recent years. However, there are scarce data on the use of this technique in patients with burns. The aim of this study was to examine the effectiveness, feasibility and complications of regional citrate anticoagulation for CRRT in burn patients, as well as the effects on coagulation and the electrolyte and acid–base balance.MethodsThis retrospective study included all patients who received renal replacement therapy with citrate anticoagulation to treat acute kidney injury (AKI) between January 1, 2004 and December 31, 2009 at the burn unit of St. Georg Hospital GmbH in Leipzig.ResultsDuring the examination period, 18 patients were treated using CRRT with regional citrate anticoagulation (CVVHDF in the pre-dilution mode). The median patient age was 64 years (49.5; 71), with a median TBSA of 42.5% (33.25; 52.5) and a median ABSI score of 10 (9; 10). The CRRT was initiated on a median of 6 days (4; 8.75) after admission to the hospital and continued for a median duration of 7 days (5; 8). The median dialysis dose was 38.2 ml kg BW⁻¹ h⁻¹ (31.8; 42.1). The median effective filter operation time was 67 h (46; 72). No relevant disorders associated with acid–base balance, electrolytes or coagulation occurred, and there were no bleeding complications.ConclusionIn terms of bleeding risk and electrolyte and acid–base balance, regional citrate anticoagulation may be considered to be an effective, safe and user-friendly procedure for patients with severe burns and AKI.     

Prospective multicenter study on epidemiology of acute kidney injury in the ICU: a critical care nephrology Italian collaborative effort (NEFROINT)

Acute kidney injury (AKI) is an independent risk factor for mortality in critically ill patients whose epidemiology has been made unclear in the past by the use of different definitions across various studies. The RIFLE consensus definition has provided a unifying definition for AKI leading to large retrospective studies in different countries. The present study is a prospective observational multicenter study designed to prospectively evaluate all incident admissions in 10 Intensive Care Units (ICUs) in Italy and the relevant epidemiology of AKI. A simple user-friendly web-based data collection tool was created with the scope to serve for this study and to facilitate future multicenter collaborative efforts. We enrolled 601 consecutive patients into the study; 25 patients with End-Stage Renal Disease were excluded leaving 576 patients for analysis. The median age was 66 (IQR 53-76) years, 59.4% were male, while median SAPS II and APACHE II scores were 43 (IQR 35-54) and 18 (IQR 13-24), respectively. The most common diagnostic categories for ICU admission were: respiratory (27.4%), followed by neurologic (17%), trauma (14.4%), and cardiovascular (12.1%). Crude ICU and hospital mortality were 21.7% and median ICU length of stay was 5 days (IQR 3, 14). Of 576 patients, 246 patients (42.7%) had AKI within 24 hours of ICU admission while 133 developed new AKI later during their ICU stay. RIFLE-initial class was Risk in 205 patients (54.1%), Injury in 99 (26.1%) and Failure in 75 (19.8%). Progression of AKI to a worse RIFLE class was seen in 114 patients (30.8% of AKI patients). AKI patients were older, with higher frequency of common risk factors. 116 AKI patients (30.6%) fulfilled criteria for sepsis during their ICU stay, compared to 33 (16.7%) of non-AKI patients (P<0.001). 48 patients (8.3%) were treated with renal replacement therapy (RRT) in the ICU. Patients were started on RRT a median of 2 (IQR 0-6) days after ICU admission. Among AKI patients, they were started on RRT a median of 1 (IQR 0-4) days after fulfilling criteria for AKI. Median duration of RRT was 5 (IQR 2-10) day. AKI patients had a higher crude ICU mortality (28.8% vs. non-AKI 8.1%, P<0.001) and longer ICU length of stay (median 7 days vs. 3 days [non-AKI], P<0.001). Crude ICU mortality and ICU length of stay increased with greater severity of AKI. Two hundred twenty five patients (59.4% of AKI patients) had complete recovery of renal function, with a SCr at time of ICU discharge which was ≤120% of baseline; an additional 51 AKI patients (13.5%) had partial renal recovery, while 103 (27.2%) had not recovered renal function at the time of death or ICU discharge. Septic patients had more severe AKI, and were more likely to receive RRT with less frequency of renal function recovery. Patients with sepsis had higher ICU mortality and longer ICU stay. The study confirms previous analyses describing RIFLE as an optimal classification system to stage AKI severity. AKI is indeed a deadly complication for ICU patients where the level of severity correlated with mortality and length of stay. The tool developed for data collection resulted user friendly and easy to implement. Some of its features including a RIFLE class alert system, may help the treating physician to collect systematically AKI data in the ICU and possibly may guide specific decision on the institution of renal replacement therapy.     

Intra-abdominal pressure and intra-abdominal hypertension in critically ill obstetric patients: a prospective cohort study

BackgroundCritically ill obstetric patients may have risk factors for intra-abdominal hypertension. This study evaluated the intra-abdominal pressure and its effect on organ function and the epidemiology of intra-abdominal hypertension.MethodsObstetric patients admitted to an Intensive Care Unit, with an anticipated stay greater than 24 hours, were included. Intra-abdominal pressure was measured daily via a Foley catheter, based on intravesical pressure.ResultsOne-hundred-and-one patients were enrolled. The intra-abdominal pressure was 5–7 mmHg in 34%; 7–12 mmHg in 60%; and ≥12 mmHg (intra-abdominal hypertension) in 6%. All six patients with intra-abdominal hypertension were pregnant at the time of admission. The intra-abdominal pressure in four patients normalized to <12 mmHg following delivery, but in the remaining two it persisted ≥12 mmHg and both these patients died. Correlation between intra-abdominal pressure and organ dysfunction was weak (r=0.211). Statistical comparison between patients with and without intra-abdominal hypertension for risk factors, daily intra-abdominal pressures, and Sequential Organ Failure Assessment score could not be done due to the disproportionately small number of patients with intra-abdominal hypertension as opposed to those without (6 versus 95). Intra-abdominal pressure did not significantly differ between survivors and non-survivors (8.5 ± 1.1 vs 7.9 ± 1.7 mmHg, P=0.079).ConclusionsThe incidence of intra-abdominal hypertension in critically ill obstetric patients was lower than previously defined for mixed Intensive Care Unit populations, with an association with the pregnant state. Normalization of intra-abdominal pressure after delivery was associated with better survival. There was no correlation between intra-abdominal pressure and organ function or mortality.     

Myoglobin clearance by continuous venous-venous haemofiltration in rhabdomyolysis with acute kidney injury: A case series

BackgroundClearance of circulating myoglobin is a critical measure to prevent further damage in patients with rhabdomyolysis (RM) and acute kidney injury (AKI). Continuous venous-venous haemofiltration has emerged to be a novel approach for this purpose. The objective of present study is to evaluate the efficacy and safety of CVVH in myoglobin clearance for patients with RM complicated with AKI.MethodWe prospectively analysed 15 patients with acute RM and AKI due to crush syndrome (n = 7), bee stings (n = 5), polymyositis (n = 2) and heroin poisoning (n = 1). All of them presented oliguria with high serum myoglobin and creatine kinase concentration. They were treated by CVVH for at least 48 h until the conditions turned to be stable, then replaced by intermittent renal replacement therapy (intermittent haemofiltration or haemodialysis). Meanwhile intravascular volume expansion, urinary alkalinisation, and forced diuresis were administered. During the procedure, serum and effluent concentrations of myoglobin and creatinine were measured simultaneously at 2, 6, 12 and 24 h.ResultThe mean sieving coefficients for myoglobin were 0.28 ± 0.06, 0.21 ± 0.06, 0.15 ± 0.02 and 0.11 ± 0.02 during 2, 6, 12 and 24 h of CVVH intervention, whilst mean clearance of myoglobin was 14.3 ± 3.1 ml/min during 2 h and reduced to 11.5 ± 3.2, 7.5 ± 0.9, 5.6 ± 1.0 ml/min during 6, 12 and 24 h. In contrast to myoglobin, the sieving coefficient for creatinine remained stable at 0.95 ± 0.25, 1.02 ± 0.12, 0.89 ± 0.32, 0.98 ± 0.27 during 24 h of CVVH. In all of the 15 patients, serum myoglobin and creatine kinase were dramatically decreased in 24 h (?56.2 and ?32.1%), 3 days (?72.9 and ?50.3%) and in 7 days (?97.6 and ?96.7%). Seven patients (46.7%) complicated with hypophosphatemia during CVVH intervention improved in natural course after the cessation of CVVH. After 16 ± 12 days, all of 15 patients came to polyuria stage and finally, discharged with normal renal function after 31 ± 15 days.ConclusionOur study showed CVVH can be employed to clear myoglobin effectively in patients with RM and AKI and presented oliguria. This indicate that CVVH would be better than other modes of renal replement treatment in acute RM with AKI because of the additional benefit of myoglobin removal, but large sample randomised controlled trials are still required to confirm it.     

Complicaciones durante la intubación traqueal repetida en la unidad de cuidados intensivos. Estudio prospectivo,observacional comparando primera intubación y reintubación

Background of the studyThe goal of the study was to compare the incidence of complications, technical difficulty of intubation and physiologic pre-intubation status between the first intubation and reintubation performed on the same patient in an ICU.Materials and methodsThe study was approved by the ethics committee of Galicia (Santiago-Lugo, code No. 2015-012). Due to the observational, noninterventional, and noninvasive design of this study, the need for written consent was waived by the ethics committee of Galicia. Patients requiring tracheal intubation and reintubation in the ICU were included in this prospective observational study. Main endpoint was to compare the incidence of complications, physiologic pre-intubation status, and the rate of technical difficulty of intubation between the first intubation and reintubation performed on the same patient in an ICU.Results and discussion504 patients were intubated in our ICU during the study period, and 82 (16%) required reintubation. There was no difference between the first intubation and reintubation regarding number of total complication (35% vs 33%; P = .86), hypotension (24% vs 24%; P = 1), hypoxia (26% vs 26%; P = 1), esophageal intubation (1% vs 1%; P = 1), and bronchoaspiration (2% vs 1%; P = .86). Physiologic pre-intubation status and technical difficulty of intubation did not differ between the first intubation and reintubation.ConclusionsIn our ICU patients requiring tracheal reintubation, incidence of complications, physiologic pre-intubation status, and technical difficulty of intubation did not differ between the first intubation and reintubation.     

Noninvasive proportional assist ventilation may be useful in weaning patients who failed spontaneous breathing trial

BackgroundEndotracheal mechanical ventilation (ETMV) is accompanied with a high morbidity and mortality in intensive care unit (ICU) patients. The aim of this prospective randomized controlled study was to evaluate the effectiveness of noninvasive proportional assist ventilation (PAV) as a method of weaning in patients who could not tolerate spontaneous breathing trial (SBT).Patients and methodsAmong 112 patients presented with acute respiratory failure (ARF) admitted to Zagazig university surgical ICU, 42 patients of them failed a 2 h-SBT after they met simple criteria for weaning. Conventional invasive synchronized intermittent mandatory ventilation (SIMV) was used as the control weaning technique in 21 patients (SIMV group), and noninvasive PAV was applied immediately after extubation in the remaining 21 patients (PAV group).ResultsThere was no significant difference regarding the main clinical, functional characteristics, and the physiologic parameters of the two weaning groups at the time of their admission. Gas exchange at 1-h post-randomisation was significantly improved in both groups. The duration of ventilatory support was significantly shorter in the PAV group (12.8 + 8.3 days vs 22.3 + 13.3 days in the conventional group; P < 0.05). Weaning success was significantly higher in the PAV group (18 patients“85%” vs 11 patients “52 %” in the conventional group P < 0.05). ICU survival was higher, while, reintubation rate was lower in PAV (three patients “14%” vs 10 patients “47%” in the conventional group; P < 0.05). The rate of tracheostomy was significantly lower in the PAV group (one patient “4%” vs seven patients “33%” in the conventional group; P < 0.05). The incidence of VAP was higher in the conventional group (eight patients “38%” vs one patient “4%”in the PAV group; P < 0.05).ConclusionNoninvasive PAV could be considered as an effective and safe method of weaning in patients who cannot tolerate 2 h-SBT.