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De Backer D, Khanna AK. The Ideal Mean Arterial Pressure Target Debate: Heterogeneity Obscures Conclusions. Crit Care Med 2024; 52:1495-1498. [PMID: 39145710 DOI: 10.1097/ccm.0000000000006331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest University Health Sciences, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
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Kotani Y, D'Andria Ursoleo J, Murru CP, Landoni G. Blood Pressure Management for Hypotensive Patients in Intensive Care and Perioperative Cardiovascular Settings. J Cardiothorac Vasc Anesth 2024; 38:2089-2099. [PMID: 38918089 DOI: 10.1053/j.jvca.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 06/27/2024]
Abstract
Blood pressure is a critical physiological parameter, particularly in the context of cardiac intensive care and perioperative settings. As a primary indicator of organ perfusion, the maintenance of adequate blood pressure is imperative for the assurance of sufficient tissue oxygen delivery. Among critically ill and major surgery patients, the continuous monitoring of blood pressure is performed as a standard practice for patients. Nonetheless, uncertainties remain regarding blood pressure goals, and there is no consensus regarding blood pressure targets. This review describes the determinants of blood pressure, examine the influence of blood pressure on organ perfusion, and synthesize the current clinical evidence from various intensive care and perioperative settings to provide a concise guidance for daily clinical practice.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Pia Murru
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Coloretti I, Tosi M, Biagioni E, Busani S, Girardis M. Management of Sepsis in the First 24 Hours: Bundles of Care and Individualized Approach. Semin Respir Crit Care Med 2024; 45:503-509. [PMID: 39208854 DOI: 10.1055/s-0044-1789185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Early diagnosis and prompt management are essential to enhance the outcomes of patients with sepsis and septic shock. Over the past two decades, evidence-based guidelines have guided appropriate treatment and recommended the implementation of a bundle strategy to deliver fundamental treatments within the initial hours of care. Shortly after its introduction, the implementation of a bundle strategy has led to a substantial decrease in mortality rates across various health care settings. The primary advantage of these bundles is their universality, making them applicable to all patients with sepsis. However, this same quality also represents their primary disadvantage as it fails to account for the significant heterogeneity within the septic patient population. Recently, the individualization of treatments included in the bundle has been suggested as a potential strategy for further improving the prognosis of patients with sepsis. New strategies for the early identification of microorganisms and their resistance patterns, advanced knowledge of antibiotic kinetics in critically ill patients, more conservative fluid therapy in specific patient populations, and early use of alternative vasopressors to catecholamines, as well as tailored source control based on patient conditions and site of infection, are potential approaches to personalize initial care for specific subgroups of patients. These innovative methodologies have the potential to improve the management of septic shock. However, their implementation in clinical practice should be guided by solid evidence. Therefore, it is imperative that future research evaluate the safety, efficacy, and cost-effectiveness of these strategies.
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Affiliation(s)
- Irene Coloretti
- Anaesthesia and Intensive Care Department, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martina Tosi
- Anaesthesia and Intensive Care Department, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Emanuela Biagioni
- Anaesthesia and Intensive Care Department, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Busani
- Anaesthesia and Intensive Care Department, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Girardis
- Anaesthesia and Intensive Care Department, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
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Okamoto K, Fukushima H, Kawaguchi M, Tsuruya K. Low-Dose Continuous Kidney Replacement Therapy and Mortality in Critically Ill Patients With Acute Kidney Injury: A Retrospective Cohort Study. Am J Kidney Dis 2024; 84:145-153.e1. [PMID: 38490319 DOI: 10.1053/j.ajkd.2024.01.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/07/2024] [Accepted: 01/20/2024] [Indexed: 03/17/2024]
Abstract
RATIONALE & OBJECTIVE Continuous kidney replacement therapy (CKRT) is preferred when available for hemodynamically unstable acute kidney injury (AKI) patients in the intensive care unit (ICU). The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend a delivered CKRT dose of 20-25mL/kg/h; however, in Japan the doses are typically below this recommendation due to government health insurance system restrictions. This study investigated the association between mortality and dose of CKRT. STUDY DESIGN Single-center retrospective cohort study. SETTING & PARTICIPANTS Critically ill patients with AKI treated with CKRT at a tertiary Japanese university hospital between January 1, 2012, and December 31, 2021. EXPOSURE Delivered CKRT doses below or above the median. OUTCOME 90-day mortality after CKRT initiation. ANALYTICAL APPROACH Multivariable Cox regression analysis and Kaplan-Meier analysis. RESULTS The study population consisted of 494 patients. The median age was 72 years, and 309 patients (62.6%) were men. Acute tubular injury was the leading cause of AKI, accounting for 81.8%. The median delivered CKRT dose was 13.2mL/kg/h. Among the study participants, 456 (92.3%) received delivered CKRT doses below 20mL/kg/h, and 204 (41.3%) died within 90 days after CKRT initiation. Multivariable Cox regression analysis revealed increased mortality in the below-median group (HR, 1.73 [95% CI, 1.19-2.51], P=0.004). Additionally, a significant, inverse, nonlinear association between 90-day mortality and delivered CKRT dose was observed using delivered CKRT dose as a continuous variable. LIMITATIONS Single-center, retrospective, observational study. CONCLUSIONS A lower delivered CKRT dose was independently associated with higher 90-day mortality among critically ill patients who mostly received dosing below the current KDIGO recommendations. PLAIN-LANGUAGE SUMMARY The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend delivering a continuous kidney replacement therapy (CKRT) dose of 20-25mL/kg/h. However, it is not clear if it is safe to use delivered CKRT doses below this recommendation. In this study, over 90% of the patients received CKRT with a delivered dose below the KDIGO recommendation. We divided these patients into 2 groups based on the median delivered CKRT dose. Our findings show that a delivered CKRT dose below the median was associated with increased risk of death within 90 days. These findings show that a lower delivered CKRT dose was independently associated with higher 90-day mortality among critically ill patients who mostly received dosing below current KDIGO recommendations.
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Affiliation(s)
- Keisuke Okamoto
- Department of Nephrology, Nara Medical University, Nara, Japan.
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University, Nara, Japan
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Yuriditsky E, Bakker J. What every intensivist should know about…Systolic arterial pressure targets in shock. J Crit Care 2024; 82:154790. [PMID: 38816174 DOI: 10.1016/j.jcrc.2024.154790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/10/2023] [Accepted: 12/17/2023] [Indexed: 06/01/2024]
Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA.
| | - Jan Bakker
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Grossman School of Medicine, New York, USA; Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, USA; Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
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Moll V, Khanna AK, Kurz A, Huang J, Smit M, Swaminathan M, Minear S, Parr KG, Prabhakar A, Zhao M, Malbrain MLNG. Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion. Perioper Med (Lond) 2024; 13:72. [PMID: 38997752 PMCID: PMC11245849 DOI: 10.1186/s13741-024-00416-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/09/2024] [Indexed: 07/14/2024] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.
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Affiliation(s)
- Vanessa Moll
- Department of Anesthesiology, Division of Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Andrea Kurz
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Anesthesiology, Emergency Medicine and Intensive Care Medicine, Medical University Graz, Graz, Austria
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Marije Smit
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Steven Minear
- Department of Anesthesiology, Cleveland Clinic Florida, Weston Hospital, Weston, FL, USA
| | - K Gage Parr
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Amit Prabhakar
- Department of Anesthesiology, Division of Critical Care Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Manxu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University Lublin, Lublin, Poland.
- Medical Data Management, Medaman, Geel, Belgium.
- International Fluid Academy, Lovenjoel, Belgium.
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Horiguchi D, Shin S, Pepino JA, Peterson JT, Kehoe IE, Goldstein JN, Lee J, Kwon BK, Hahn JO, Reisner AT. Hypotension During Vasopressor Infusion Occurs in Predictable Clusters: A Multicenter Analysis. J Intensive Care Med 2024; 39:683-692. [PMID: 38282376 DOI: 10.1177/08850666241226893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Background: Published evidence indicates that mean arterial pressure (MAP) below a goal range (hypotension) is associated with worse outcomes, though MAP management failures are common. We sought to characterize hypotension occurrences in ICUs and consider the implications for MAP management. Methods: Retrospective analysis of 3 hospitals' cohorts of adult ICU patients during continuous vasopressor infusion. Two cohorts were general, mixed ICU patients and one was exclusively acute spinal cord injury patients. "Hypotension-clusters" were defined where there were ≥10 min of cumulative hypotension over a 60-min period and "constant hypotension" was ≥10 continuous minutes. Trend analysis was performed (predicting future MAP using 14 min of preceding MAP data) to understand which hypotension-clusters could likely have been predicted by clinician awareness of MAP trends. Results: In cohorts of 155, 66, and 16 ICU stays, respectively, the majority of hypotension occurred within the hypotension-clusters. Failures to keep MAP above the hypotension threshold were notable in the bottom quartiles of each cohort, with hypotension durations of 436, 167, and 468 min, respectively, occurring within hypotension-clusters per day. Mean arterial pressure trend analysis identified most hypotension-clusters before any constant hypotension occurred (81.2%-93.6% sensitivity, range). The positive predictive value of hypotension predictions ranged from 51.4% to 72.9%. Conclusions: Across 3 cohorts, most hypotension occurred in temporal clusters of hypotension that were usually predictable from extrapolation of MAP trends.
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Affiliation(s)
- Daisuke Horiguchi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Nihon Kohden Innovation Center, LLC, Cambridge, MA, USA
| | - Sungtae Shin
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Jeremy A Pepino
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffrey T Peterson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Iain E Kehoe
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital, Boston MA, USA
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jin-Oh Hahn
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Körner A, Sailer B, Sari-Yavuz S, Haeberle HA, Mirakaj V, Bernard A, Rosenberger P, Koeppen M. Explainable Boosting Machine approach identifies risk factors for acute renal failure. Intensive Care Med Exp 2024; 12:55. [PMID: 38874694 PMCID: PMC11178719 DOI: 10.1186/s40635-024-00639-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/02/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Risk stratification and outcome prediction are crucial for intensive care resource planning. In addressing the large data sets of intensive care unit (ICU) patients, we employed the Explainable Boosting Machine (EBM), a novel machine learning model, to identify determinants of acute kidney injury (AKI) in these patients. AKI significantly impacts outcomes in the critically ill. METHODS An analysis of 3572 ICU patients was conducted. Variables such as average central venous pressure (CVP), mean arterial pressure (MAP), age, gender, and comorbidities were examined. This analysis combined traditional statistical methods with the EBM to gain a detailed understanding of AKI risk factors. RESULTS Our analysis revealed chronic kidney disease, heart failure, arrhythmias, liver disease, and anemia as significant comorbidities influencing AKI risk, with liver disease and anemia being particularly impactful. Surgical factors were also key; lower GI surgery heightened AKI risk, while neurosurgery was associated with a reduced risk. EBM identified four crucial variables affecting AKI prediction: anemia, liver disease, and average CVP increased AKI risk, whereas neurosurgery decreased it. Age was a progressive risk factor, with risk escalating after the age of 50 years. Hemodynamic instability, marked by a MAP below 65 mmHg, was strongly linked to AKI, showcasing a threshold effect at 60 mmHg. Intriguingly, average CVP was a significant predictor, with a critical threshold at 10.7 mmHg. CONCLUSION Using an Explainable Boosting Machine enhance the precision in AKI risk factors in ICU patients, providing a more nuanced understanding of known AKI risks. This approach allows for refined predictive modeling of AKI, effectively overcoming the limitations of traditional statistical models.
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Affiliation(s)
- Andreas Körner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Benjamin Sailer
- Medical Data Integration Center, University Hospital Tübingen, Tübingen, Germany
| | - Sibel Sari-Yavuz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Helene A Haeberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Valbona Mirakaj
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Alice Bernard
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Michael Koeppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
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Nakanishi T, Tsuji T, Tamura T, Fujiwara K, Sobue K. Development and Validation of a Prediction Model for Acute Hypotensive Events in Intensive Care Unit Patients. J Clin Med 2024; 13:2786. [PMID: 38792329 PMCID: PMC11122431 DOI: 10.3390/jcm13102786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Persistent hypotension in the intensive care unit (ICU) is associated with increased mortality. Predicting acute hypotensive events can lead to timely intervention. We aimed to develop a prediction model of acute hypotensive events in patients admitted to the ICU. Methods: We included adult patients admitted to the Nagoya City University (NCU) Hospital ICU between January 2018 and December 2021 for model training and internal validation. The MIMIC-III database was used for external validation. A hypotensive event was defined as a mean arterial pressure < 60 mmHg for at least 5 min in 10 min. The input features were age, sex, and time-series data for vital signs. We compared the area under the receiver-operating characteristic curve (AUROC) of three machine-learning algorithms: logistic regression, the light gradient boosting machine (LightGBM), and long short-term memory (LSTM). Results: Acute hypotensive events were found in 1325/1777 (74.6%) and 2691/5266 (51.1%) of admissions in the NCU and MIMIC-III cohorts, respectively. In the internal validation, the LightGBM model had the highest AUROC (0.835), followed by the LSTM (AUROC 0.834) and logistic regression (AUROC 0.821) models. Applying only blood pressure-related features, the LSTM model achieved the highest AUROC (0.843) and consistently showed similar results in external and internal validation. Conclusions: The LSTM model using only blood pressure-related features had the highest AUROC with comparable performance in external validation.
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Affiliation(s)
- Toshiyuki Nakanishi
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
- Department of Materials Process Engineering, Nagoya University, Furo-cho, Chikusa-ku, Nagoya 464-8603, Japan
| | - Tatsuya Tsuji
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Tetsuya Tamura
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
| | - Koichi Fujiwara
- Department of Materials Process Engineering, Nagoya University, Furo-cho, Chikusa-ku, Nagoya 464-8603, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan
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Jouffroy R, Djossou F, Neviere R, Jaber S, Vivien B, Heming N, Gueye P. The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization. Ann Intensive Care 2024; 14:58. [PMID: 38625453 PMCID: PMC11019190 DOI: 10.1186/s13613-024-01282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/26/2024] [Indexed: 04/17/2024] Open
Abstract
This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique - Hôpitaux de Paris, Boulogne Billancourt, France.
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM - Paris Saclay University, Paris, France.
- EA 7329 - Institut de Recherche Médicale et d'Épidémiologie du Sport - Institut National du Sport, de l'Expertise et de la Performance, Paris, France.
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique - Hôpitaux de Paris, and Paris Saclay University, Saclay, France.
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Guyane and Laboratoire Ecosystèmes Amazoniens et Pathologie Tropicale EA 3593, Centre Hospitalier de Cayenne, Université de Guyane, Cayenne, France
| | - Rémi Neviere
- Service des Explorations Fonctionnelles Centre Hospitalier Universitaire de Martinique et UR5_3 PC2E Pathologie Cardiaque, toxicité Environnementale et Envenimations (ex EA7525, Université des Antilles, Antilles, France
| | - Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, University of Montpellier, INSERM U1046, Centre Hospitalier Universitaire Montpellier, Montpellier, 34295, France
| | - Benoît Vivien
- Service d'Anesthésie Réanimation, SAMU de Paris, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital, Laboratory of Infection & Inflammation - U1173, School of Medicine Simone Veil, FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), APHP University Versailles Saint Quentin - University Paris Saclay, University Versailles Saint Quentin - University Paris Saclay, INSERM, Garches, Garches, 92380, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, University of the Antilles, French West Indies, Antilles, France
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Jiang Z, Li S, Wang L, Yu F, Zeng Y, Li H, Li J, Zhang Z, Zuo J. A comparison of invasive arterial blood pressure measurement with oscillometric non-invasive blood pressure measurement in patients with sepsis. J Anesth 2024; 38:222-231. [PMID: 38305914 DOI: 10.1007/s00540-023-03304-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/25/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE This study aimed to compare non-invasive oscillometric blood pressure (NIBP) measurement with invasive arterial blood pressure (IBP) measurement in patients with sepsis. METHODS We conducted a retrospective study to evaluate the agreement between IBP and NIBP using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Paired blood pressure measurements of mean arterial pressure (MAP), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were compared using Bland-Altman analysis and paired Student's t test. We also focus on the effect of norepinephrine (NE) on the agreement between the two methods and the association between blood pressure and mortality during intensive care unit (ICU) stay. RESULTS A total of 96,673 paired blood pressure measurements from 6060 unique patients were analyzed in the study. In Bland-Altman analysis, the bias (± SD, 95% limits of agreement) was 6.21 mmHg (± 12.05 mmHg, - 17.41 to 29.83 mmHg) for MAP, 0.39 mmHg (± 19.25 mmHg, - 37.34 to 38.12 mmHg) for SBP, and 0.80 mmHg (± 12.92 mmHg, - 24.52 to 26.12 mmHg) for DBP between the two techniques. Similarly, large limits of agreement were shown in different groups of NE doses. NE doses significantly affected the agreement between IBP and NIBP. SBP between the two methods gave an inconsistent assessment of patients' risk of ICU mortality. CONCLUSION IBP and NIBP were not interchangeable in septic patients. Clinicians should be aware that non-invasive MAP was clinically and significantly underestimated invasive MAP.
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Affiliation(s)
- Ziqing Jiang
- Candidate of Master's Degree, The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Shaoying Li
- Candidate of Master's Degree, The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Lin Wang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Feng Yu
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Yanping Zeng
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Hongbo Li
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Jun Li
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Zhanfeng Zhang
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China
| | - Junling Zuo
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, 16 Jichang Road, Baiyun District, Guangzhou, Guangdong Province, China.
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Schuurmans J, van Rossem BTB, Rellum SR, Tol JTM, Kurucz VC, van Mourik N, van der Ven WH, Veelo DP, Schenk J, Vlaar APJ. Hypotension during intensive care stay and mortality and morbidity: a systematic review and meta-analysis. Intensive Care Med 2024; 50:516-525. [PMID: 38252288 PMCID: PMC11018652 DOI: 10.1007/s00134-023-07304-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024]
Abstract
PURPOSE The aim of this study is to provide a summary of the existing literature on the association between hypotension during intensive care unit (ICU) stay and mortality and morbidity, and to assess whether there is an exposure-severity relationship between hypotension exposure and patient outcomes. METHODS CENTRAL, Embase, and PubMed were searched up to October 2022 for articles that reported an association between hypotension during ICU stay and at least one of the 11 predefined outcomes. Two independent reviewers extracted the data and assessed the risk of bias. Results were gathered in a summary table and studies designed to investigate the hypotension-outcome relationship were included in the meta-analyses. RESULTS A total of 122 studies (176,329 patients) were included, with the number of studies varying per outcome between 0 and 82. The majority of articles reported associations in favor of 'no hypotension' for the outcomes mortality and acute kidney injury (AKI), and the strength of the association was related to the severity of hypotension in the majority of studies. Using meta-analysis, a significant association was found between hypotension and mortality (odds ratio: 1.45; 95% confidence interval (CI) 1.12-1.88; based on 13 studies and 34,829 patients), but not for AKI. CONCLUSION Exposure to hypotension during ICU stay was associated with increased mortality and AKI in the majority of included studies, and associations for both outcomes increased with increasing hypotension severity. The meta-analysis reinforced the descriptive findings regarding mortality but did not yield similar support for AKI.
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Affiliation(s)
- Jaap Schuurmans
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Benthe T B van Rossem
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Santino R Rellum
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Johan T M Tol
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Vincent C Kurucz
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Niels van Mourik
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ward H van der Ven
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Denise P Veelo
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Jimmy Schenk
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Epidemiology and Data Science, Amsterdam Public Health, Meibergdreef 9, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Amsterdam UMC location University of Amsterdam, Intensive Care, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Meibergdreef 9, Amsterdam, The Netherlands
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Kwon H, Sohn CH, Kim SM, Kim YJ, Ryoo SM, Ahn S, Seo DW, Kim WY. Comparison of Modified Shock Index and Shock Index for Predicting Massive Transfusion in Women with Primary Postpartum Hemorrhage: A Retrospective Study. Med Sci Monit 2024; 30:e943286. [PMID: 38437191 PMCID: PMC10921966 DOI: 10.12659/msm.943286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/11/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The modified shock index (MSI) is calculated as the ratio of heart rate (HR) to mean arterial pressure (MAP) and has been used to predict the need for massive transfusion (MT) in trauma patients. This retrospective study from a single center aimed to compare the MSI with the traditional shock index (SI) to predict the need for MT in 612 women diagnosed with primary postpartum hemorrhage (PPH) at the Emergency Department (ED) between January 2004 and August 2023. MATERIAL AND METHODS The patients were divided into the MT group and the non-MT group. The predictive power of MSI and SI was compared using the areas under the receiver operating characteristic curve (AUC). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated. RESULTS Out of 612 patients, 105 (17.2%) required MT. The MT group had higher median values than the non-MT group for MSI (1.58 vs 1.07, P<0.001) and SI (1.22 vs 0.80, P<0.001). The AUC for MSI, with a value of 0.811 (95% confidence interval [CI], 0.778-0.841), did not demonstrate a significant difference compared to the AUC for SI, which was 0.829 (95% CI, 0.797-0.858) (P=0.066). The optimal cutoff values for MSI and SI were 1.34 and 1.07, respectively. The specificity and PPV for MT were 77.1% and 40.2% for MSI, and 83.2% and 45.9% for SI. CONCLUSIONS Both MSI and SI were effective in predicting MT in patients with primary PPH. However, MSI did not demonstrate superior performance to SI.
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Huang Y, Gao Y, Quan S, Pan H, Wang Y, Dong Y, Ye L, Wu M, Zhou A, Ruan X, Wang B, Chen J, Zheng C, Xu H, Lu Y, Pan J. DEVELOPMENT AND INTERNAL-EXTERNAL VALIDATION OF THE ACCI-SOFA MODEL FOR PREDICTING IN-HOSPITAL MORTALITY OF PATIENTS WITH SEPSIS-3 IN THE ICU: A MULTICENTER RETROSPECTIVE COHORT STUDY. Shock 2024; 61:367-374. [PMID: 38407987 DOI: 10.1097/shk.0000000000002311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
ABSTRACT Objective: To achieve a better prediction of in-hospital mortality, the Sequential Organ Failure Assessment (SOFA) score needs to be adjusted and combined with comorbidities. This study aims to enhance the prediction of SOFA score for in-hospital mortality in patients with Sepsis-3. Methods: This study adjusted the maximum SOFA score within the first 3 days (Max Day3 SOFA) in relation to in-hospital mortality using logistic regression and incorporated the age-adjusted Charlson Comorbidity Index (aCCI) as a continuous variable to build the age-adjusted Charlson Comorbidity Index-Sequential Organ Failure Assessment (aCCI-SOFA) model. The outcome was in-hospital mortality. We developed, internally validated, and externally validated the aCCI-SOFA model using cohorts of Sepsis-3 patients from the MIMIC-IV, MIMIC-III (CareVue), and the FAHWMU cohort. The predictive performance of the model was assessed through discrimination and calibration, which was assessed using the area under the receiver operating characteristic and calibration curves, respectively. The overall predictive effect was evaluated using the Brier score. Measurements and main results: Compared with the Max Day3 SOFA, the aCCI-SOFA model showed significant improvement in area under the receiver operating characteristic with all cohorts: development cohort (0.81 vs 0.75, P < 0.001), internal validation cohort (0.81 vs 0.76, P < 0.001), MIMIC-III (CareVue) cohort (0.75 vs 0.68, P < 0.001), and FAHWMU cohort (0.72 vs 0.67, P = 0.001). In sensitivity analysis, it was suggested that the application of aCCI-SOFA in early nonseptic shock patients had greater clinical value, with significant differences compared with the original SOFA scores in all cohorts ( P < 0.05). Conclusion: For septic patients in intensive care unit, the aCCI-SOFA model exhibited superior predictive performance. The application of aCCI-SOFA in early nonseptic shock patients had greater clinical value.
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Affiliation(s)
| | | | | | - Hao Pan
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
| | | | | | | | | | | | | | | | | | - Chenfei Zheng
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, PR China
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15
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Tang J, Zhong Z, Nijiati M, Wu C. Systemic inflammation response index as a prognostic factor for patients with sepsis-associated acute kidney injury: a retrospective observational study. J Int Med Res 2024; 52:3000605241235758. [PMID: 38518195 PMCID: PMC10960344 DOI: 10.1177/03000605241235758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/12/2024] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVE To assess the association between the systemic inflammation response index (SIRI) and the prognosis in patients with sepsis-associated acute kidney injury (SA-AKI). METHODS In this observational study, adult patients with SA-AKI were categorized into three groups based on SIRI tertiles. Survival outcomes were compared across the three groups using Kaplan-Meier survival curves. Various Cox proportional hazards regression models were developed to determine the association between the SIRI and mortality in patients with SA-AKI. Subgroup analyses were also performed to explore the association between different SIRI tertiles and all-cause mortality. RESULTS After adjusting for several confounders, the second SIRI tertile (2.5 < SIRI < 7.6) was found to be an independent risk factor for 30-day mortality [hazard ratio (95% confidence interval): 1.19 (1.01-1.40)], 90-day mortality [1.22 (1.06-1.41)], and 365-day mortality [1.24 (1.09-1.40)]. Furthermore, high SIRI values were associated with increased risks of 30-day, 90-day, and 365-day mortality in patients with SA-AKI across all three models. The third tertile showed a significant association with adverse outcomes in most subgroups. CONCLUSIONS The SIRI serves as a comprehensive biomarker for predicting all-cause mortality of critically ill patients with SA-AKI.
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Affiliation(s)
- Jia Tang
- Graduate School of Xinjiang Medical University, Urumqi, China
| | - Zhenguang Zhong
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Muyesai Nijiati
- Xinjiang Emergency Center, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Changdong Wu
- Xinjiang Emergency Center, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
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Dong S, Wang Q, Wang S, Zhou C, Wang H. Hypotension prediction index for the prevention of hypotension during surgery and critical care: A narrative review. Comput Biol Med 2024; 170:107995. [PMID: 38325215 DOI: 10.1016/j.compbiomed.2024.107995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/17/2023] [Accepted: 01/13/2024] [Indexed: 02/09/2024]
Abstract
Surgeons and anesthesia clinicians commonly face a hemodynamic disturbance known as intraoperative hypotension (IOH), which has been linked to more severe postoperative outcomes and increases mortality rates. Increased occurrence of IOH has been positively associated with mortality and incidence of myocardial infarction, stroke, and organ dysfunction hypertension. Hence, early detection and recognition of IOH is meaningful for perioperative management. Currently, when hypotension occurs, clinicians use vasopressor or fluid therapy to intervene as IOH develops but interventions should be taken before hypotension occurs; therefore, the Hypotension Prediction Index (HPI) method can be used to help clinicians further react to the IOH process. This literature review evaluates the HPI method, which can reliably predict hypotension several minutes before a hypotensive event and is beneficial for patients' outcomes.
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Affiliation(s)
- Siwen Dong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Qing Wang
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
| | - Shuai Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Congcong Zhou
- Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China; Biosensor National Special Laboratory, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou 310027, China
| | - Hongwei Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China; Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China.
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Coloretti I, Genovese A, Teixeira JP, Cherian A, Ferrer R, Landoni G, Leone M, Girardis M, Nielsen ND. Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:13. [PMID: 38383521 PMCID: PMC10882873 DOI: 10.1186/s44158-024-00150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.
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Affiliation(s)
- Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy.
| | - Andrea Genovese
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Anusha Cherian
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, India
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Giovanni Landoni
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc Leone
- Anesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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18
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Joosten A, Rinehart J, Cannesson M, Coeckelenbergh S, Pochard J, Vicaut E, Duranteau J. Control of mean arterial pressure using a closed-loop system for norepinephrine infusion in severe brain injury patients: the COMAT randomized controlled trial. J Clin Monit Comput 2024; 38:25-30. [PMID: 38310591 PMCID: PMC11330589 DOI: 10.1007/s10877-023-01119-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/15/2023] [Indexed: 02/06/2024]
Abstract
Brain injury patients require precise blood pressure (BP) management to maintain cerebral perfusion pressure (CPP) and avoid intracranial hypertension. Nurses have many tasks and norepinephrine titration has been shown to be suboptimal. This can lead to limited BP control in patients that are in critical need of cerebral perfusion optimization. We have designed a closed-loop vasopressor (CLV) system capable of maintaining mean arterial pressure (MAP) in a narrow range and we aimed to assess its performance when treating severe brain injury patients. Within the first 48 h of intensive care unit (ICU) admission, 18 patients with a severe brain injury underwent either CLV or manual norepinephrine titration. In both groups, the objective was to maintain MAP in target (within ± 5 mmHg of a predefined target MAP) to achieve optimal CPP. Fluid administration was standardized in the two groups. The primary objective was the percentage of time patients were in target. Secondary outcomes included time spent over and under target. Over the four-hour study period, the mean percentage of time with MAP in target was greater in the CLV group than in the control group (95.8 ± 2.2% vs. 42.5 ± 27.0%, p < 0.001). Severe undershooting, defined as MAP < 10 mmHg of target value was lower in the CLV group (0.2 ± 0.3% vs. 7.4 ± 14.2%, p < 0.001) as was severe overshooting defined as MAP > 10 mmHg of target (0.0 ± 0.0% vs. 22.0 ± 29.0%, p < 0.001). The CLV system can maintain MAP in target better than nurses caring for severe brain injury patients.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, Ronald Reagan Medical Center, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA.
| | - Joseph Rinehart
- Department of Anesthesiology & Perioperative Care, University of California Irvine, California, CA, 92868, USA
| | - Maxime Cannesson
- Department of Anesthesiology & Perioperative Medicine, David Geffen School of Medicine, Ronald Reagan Medical Center, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Sean Coeckelenbergh
- Department of Anesthesiology, Université Paris-Saclay, Hôpital Paul-Brousse, Assistance Publique Hôpitaux de Paris, Villejuif, France
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Jonas Pochard
- Department of Intensive Care, Université Paris-Saclay, Hôpital Bicetre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicetre, France
| | - Eric Vicaut
- Unité de Recherche Clinique, Lariboisière University Hospital, Paris 7 Diderot University, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jacques Duranteau
- Department of Intensive Care, Université Paris-Saclay, Hôpital Bicetre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicetre, France
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De Backer D, Deutschman CS, Hellman J, Myatra SN, Ostermann M, Prescott HC, Talmor D, Antonelli M, Pontes Azevedo LC, Bauer SR, Kissoon N, Loeches IM, Nunnally M, Tissieres P, Vieillard-Baron A, Coopersmith CM. Surviving Sepsis Campaign Research Priorities 2023. Crit Care Med 2024; 52:268-296. [PMID: 38240508 DOI: 10.1097/ccm.0000000000006135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To identify research priorities in the management, epidemiology, outcome, and pathophysiology of sepsis and septic shock. DESIGN Shortly after publication of the most recent Surviving Sepsis Campaign Guidelines, the Surviving Sepsis Research Committee, a multiprofessional group of 16 international experts representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, convened virtually and iteratively developed the article and recommendations, which represents an update from the 2018 Surviving Sepsis Campaign Research Priorities. METHODS Each task force member submitted five research questions on any sepsis-related subject. Committee members then independently ranked their top three priorities from the list generated. The highest rated clinical and basic science questions were developed into the current article. RESULTS A total of 81 questions were submitted. After merging similar questions, there were 34 clinical and ten basic science research questions submitted for voting. The five top clinical priorities were as follows: 1) what is the best strategy for screening and identification of patients with sepsis, and can predictive modeling assist in real-time recognition of sepsis? 2) what causes organ injury and dysfunction in sepsis, how should it be defined, and how can it be detected? 3) how should fluid resuscitation be individualized initially and beyond? 4) what is the best vasopressor approach for treating the different phases of septic shock? and 5) can a personalized/precision medicine approach identify optimal therapies to improve patient outcomes? The five top basic science priorities were as follows: 1) How can we improve animal models so that they more closely resemble sepsis in humans? 2) What outcome variables maximize correlations between human sepsis and animal models and are therefore most appropriate to use in both? 3) How does sepsis affect the brain, and how do sepsis-induced brain alterations contribute to organ dysfunction? How does sepsis affect interactions between neural, endocrine, and immune systems? 4) How does the microbiome affect sepsis pathobiology? 5) How do genetics and epigenetics influence the development of sepsis, the course of sepsis and the response to treatments for sepsis? CONCLUSIONS Knowledge advances in multiple clinical domains have been incorporated in progressive iterations of the Surviving Sepsis Campaign guidelines, allowing for evidence-based recommendations for short- and long-term management of sepsis. However, the strength of existing evidence is modest with significant knowledge gaps and mortality from sepsis remains high. The priorities identified represent a roadmap for research in sepsis and septic shock.
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Affiliation(s)
- Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
- Sepsis Research Lab, the Feinstein Institutes for Medical Research, Manhasset, NY
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Ignacio-Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Leinster, Dublin, Ireland
| | | | - Pierre Tissieres
- Pediatric Intensive Care, Neonatal Medicine and Pediatric Emergency, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Vieillard-Baron
- Service de Medecine Intensive Reanimation, Hopital Ambroise Pare, Universite Paris-Saclay, Le Kremlin-Bicêtre, France
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20
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Xing Z, Cai L, Wu Y, Shen P, Fu X, Xu Y, Wang J. Development and validation of a nomogram for predicting in-hospital mortality of patients with cervical spine fractures without spinal cord injury. Eur J Med Res 2024; 29:80. [PMID: 38287435 PMCID: PMC10823604 DOI: 10.1186/s40001-024-01655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/10/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The incidence of cervical spine fractures is increasing every day, causing a huge burden on society. This study aimed to develop and verify a nomogram to predict the in-hospital mortality of patients with cervical spine fractures without spinal cord injury. This could help clinicians understand the clinical outcome of such patients at an early stage and make appropriate decisions to improve their prognosis. METHODS This study included 394 patients with cervical spine fractures from the Medical Information Mart for Intensive Care III database, and 40 clinical indicators of each patient on the first day of admission to the intensive care unit were collected. The independent risk factors were screened using the Least Absolute Shrinkage and Selection Operator regression analysis method, a multi-factor logistic regression model was established, nomograms were developed, and internal validation was performed. A receiver operating characteristic (ROC) curve was drawn, and the area under the ROC curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to evaluate the discrimination of the model. Moreover, the consistency between the actual probability and predicted probability was reflected using the calibration curve and Hosmer-Lemeshow (HL) test. A decision curve analysis (DCA) was performed, and the nomogram was compared with the scoring system commonly used in clinical practice to evaluate the clinical net benefit. RESULTS The nomogram indicators included the systolic blood pressure, oxygen saturation, respiratory rate, bicarbonate, and simplified acute physiology score (SAPS) II. The results showed that our model had satisfactory predictive ability, with an AUC of 0.907 (95% confidence interval [CI] = 0.853-0.961) and 0.856 (95% CI = 0.746-0.967) in the training set and validation set, respectively. Compared with the SAPS-II system, the NRI values of the training and validation sets of our model were 0.543 (95% CI = 0.147-0.940) and 0.784 (95% CI = 0.282-1.286), respectively. The IDI values of the training and validation sets were 0.064 (95% CI = 0.004-0.123; P = 0.037) and 0.103 (95% CI = 0.002-0.203; P = 0.046), respectively. The calibration plot and HL test results confirmed that our model prediction results showed good agreement with the actual results, where the HL test values of the training and validation sets were P = 0.8 and P = 0.95, respectively. The DCA curve revealed that our model had better clinical net benefit than the SAPS-II system. CONCLUSION We explored the in-hospital mortality of patients with cervical spine fractures without spinal cord injury and constructed a nomogram to predict their prognosis. This could help doctors assess the patient's status and implement interventions to improve prognosis accordingly.
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Affiliation(s)
- Zhibin Xing
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lingli Cai
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yuxuan Wu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Pengfei Shen
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaochen Fu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yiwen Xu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jing Wang
- The First Affiliated Hospital of Jinan University, Guangzhou, China.
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21
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Myatra SN, Jagiasi BG, Singh NP, Divatia JV. Role of artificial intelligence in haemodynamic monitoring. Indian J Anaesth 2024; 68:93-99. [PMID: 38406336 PMCID: PMC10893816 DOI: 10.4103/ija.ija_1260_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 12/28/2023] [Accepted: 01/08/2024] [Indexed: 02/27/2024] Open
Abstract
This narrative review explores the evolving role of artificial intelligence (AI) in haemodynamic monitoring, emphasising its potential to revolutionise patient care. The historical reliance on invasive procedures for haemodynamic assessments is contrasted with the emerging non-invasive AI-driven approaches that address limitations and risks associated with traditional methods. Developing the hypotension prediction index and introducing CircEWSTM and CircEWS-lite TM showcase AI's effectiveness in predicting and managing circulatory failure. The crucial aspects include the balance between AI and healthcare professionals, ethical considerations, and the need for regulatory frameworks. The use of AI in haemodynamic monitoring will keep growing with ongoing research, better technology, and teamwork. As we navigate these advancements, it is crucial to balance AI's power and healthcare professionals' essential role. Clinicians must continue to use their clinical acumen to ensure that patient outliers or system problems do not compromise the treatment of the condition and patient safety.
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Affiliation(s)
- Sheila N. Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Bharat G. Jagiasi
- Director of Critical Care Department, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Neeraj P. Singh
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V. Divatia
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Guo J, Cheng H, Wang Z, Qiao M, Li J, Lyu J. Factor analysis based on SHapley Additive exPlanations for sepsis-associated encephalopathy in ICU mortality prediction using XGBoost - a retrospective study based on two large database. Front Neurol 2023; 14:1290117. [PMID: 38162445 PMCID: PMC10755941 DOI: 10.3389/fneur.2023.1290117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Sepsis-associated encephalopathy (SAE) is strongly linked to a high mortality risk, and frequently occurs in conjunction with the acute and late phases of sepsis. The objective of this study was to construct and verify a predictive model for mortality in ICU-dwelling patients with SAE. Methods The study selected 7,576 patients with SAE from the MIMIC-IV database according to the inclusion criteria and randomly divided them into training (n = 5,303, 70%) and internal validation (n = 2,273, 30%) sets. According to the same criteria, 1,573 patients from the eICU-CRD database were included as an external test set. Independent risk factors for ICU mortality were identified using Extreme Gradient Boosting (XGBoost) software, and prediction models were constructed and verified using the validation set. The receiver operating characteristic (ROC) and the area under the ROC curve (AUC) were used to evaluate the discrimination ability of the model. The SHapley Additive exPlanations (SHAP) approach was applied to determine the Shapley values for specific patients, account for the effects of factors attributed to the model, and examine how specific traits affect the output of the model. Results The survival rate of patients with SAE in the MIMIC-IV database was 88.6% and that of 1,573 patients in the eICU-CRD database was 89.1%. The ROC of the XGBoost model indicated good discrimination. The AUCs for the training, test, and validation sets were 0.908, 0.898, and 0.778, respectively. The impact of each parameter on the XGBoost model was depicted using a SHAP plot, covering both positive (acute physiology score III, vasopressin, age, red blood cell distribution width, partial thromboplastin time, and norepinephrine) and negative (Glasgow Coma Scale) ones. Conclusion A prediction model developed using XGBoost can accurately predict the ICU mortality of patients with SAE. The SHAP approach can enhance the interpretability of the machine-learning model and support clinical decision-making.
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Affiliation(s)
- Jiayu Guo
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- School of Public Health, Shannxi University of Chinese Medicine, Xianyang, China
| | - Hongtao Cheng
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- School of Nursing, Jinan University, Guangzhou, Guangdong, China
| | - Zicheng Wang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Mengmeng Qiao
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- School of Public Health, Shannxi University of Chinese Medicine, Xianyang, China
| | - Jing Li
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- School of Public Health, Shannxi University of Chinese Medicine, Xianyang, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, Guangdong, China
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Wieruszewski PM, Sevransky JE, Roberts RJ. Is It Time to Reconsider the Concept of "Salvage Therapy" in Refractory Shock? Crit Care Med 2023; 51:1821-1824. [PMID: 37971337 DOI: 10.1097/ccm.0000000000006003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta GA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA
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24
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Holder AL, Khanna AK, Scott MJ, Rossetti SC, Rinehart JB, Linn DD, Weichert J, Dellinger RP. A Delphi Process to Identify Relevant Outcomes That May Be Associated With a Predictive Analytic Tool to Detect Hemodynamic Deterioration in the Intensive Care Unit. Cureus 2023; 15:e50169. [PMID: 38186415 PMCID: PMC10771798 DOI: 10.7759/cureus.50169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background The critical care literature has seen an increase in the development and validation of tools using artificial intelligence for early detection of patient events or disease onset in the intensive care unit (ICU). The hemodynamic stability index (HSI) was found to have an AUC of 0.82 in predicting the need for hemodynamic intervention in the ICU. Future studies using this tool may benefit from targeting those outcomes that are more relevant to clinicians and most achievable. Methods A three-round Delphi study was conducted with a panel of 10 critical care physicians and three nurses in the United States to identify outcomes that may be most relevant and achievable with the HSI when evaluated for use in the ICU. To achieve criteria for relevance, at least 65% of panelists had to rate an outcome as a 4 or 5 on a 5-point scale. Results Nineteen of 24 outcomes that may be associated with the HSI achieved consensus for relevance. The Kemeny-Young approach was used to develop a matrix depicting the distribution of outcomes considering both relevance and achievability. "Reduces time spent in hemodynamic instability" and "reduces times to recognition of hemodynamic instability" were the highest-ranking outcomes considering both relevance and achievability. Conclusion This Delphi study was a feasible method to identify relevant outcomes that may be associated with an appropriate predictive analytic tool in the ICU. These findings can provide insight to researchers looking to study such tools to impact outcomes relevant to critical care practitioners. Future studies should test these tools in the ICU that target the most clinically relevant and achievable outcomes, such as time spent hemodynamically unstable or time until actionable nursing assessment or treatment.
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Affiliation(s)
- Andre L Holder
- Critical Care Medicine, Emory University School of Medicine, Atlanta, USA
| | - Ashish K Khanna
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael J Scott
- Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - Sarah C Rossetti
- Biomedical Informatics and Nursing, Columbia University Medical Center, New York, USA
| | | | - Dustin D Linn
- Hospital Patient Monitoring, Philips Research North America, Cambridge, USA
| | - Jochen Weichert
- Clinical Development, Philips Research Netherlands BV, Eindhoven, NLD
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Matsuura R, Komaru Y, Hamasaki Y, Nangaku M, Doi K. BENEFIT OF HIGHER BLOOD PRESSURE TARGET IN SEVERE ACUTE KIDNEY INJURY TREATED BY CONTINUOUS RENAL REPLACEMENT THERAPY. Shock 2023; 60:534-538. [PMID: 37625112 DOI: 10.1097/shk.0000000000002207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
ABSTRACT Introduction : The optimal target of mean arterial pressure (MAP) during continuous renal replacement therapy (CRRT) is unknown. Method : We retrospectively collected the hourly MAP data in acute kidney injury patients requiring CRRT who admitted to the intensive care unit in the University of Tokyo hospital during 2011-2019. Patients who died within 48 h of CRRT start and whose average value of hourly MAPs during the first 48 h was <65 mm Hg were excluded. When the average value of MAP was ≤75 mm Hg or >75 mm Hg, patients were allocated to the low or high target group. We estimated the effect of MAP on mortality and RRT independence at 90 days, using multivariable the Cox regression model and Fine and Gray model. Result : Of the 275 patients we analyzed, 95 patients were in the low group. There are no differences in sex, baseline kidney function, and disease severity. At 90 days, the low target group had higher mortality with 38 deaths (40.0%) compared with 57 deaths (31.7%) in the high target group ( P < 0.05). The adjusted hazard ratio of the low target group (≤75 mm Hg) for mortality was 1.72 (95% CI, 1.08-2.74). In addition, the low target group had a lower rate of RRT independence, with 60 patients (63.2%) compared with 136 patients (75.6%) in the high target group ( P < 0.05). The multivariable analysis revealed that the adjusted hazard ratio of the low target group for RRT independence was 0.74 (95% CI, 0.54-1.01). Conclusion : This study found the association with low MAP and mortality. The association with low MAP and delayed renal recovery was not revealed.
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Affiliation(s)
- Ryo Matsuura
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yohei Komaru
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshifumi Hamasaki
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan
| | - Masaomi Nangaku
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
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Stulberg EL, Harris BRE, Zheutlin AR, Delic A, Sheibani N, Anadani M, Yaghi S, Petersen NH, de Havenon A. Association of Blood Pressure Variability With Death and Discharge Destination Among Critically Ill Patients With and Without Stroke. Neurology 2023; 101:e1145-e1157. [PMID: 37487742 PMCID: PMC10513881 DOI: 10.1212/wnl.0000000000207599] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 05/15/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES It is unclear whether blood pressure variability's (BPV) association with worse outcomes is unique to patients with stroke or a risk factor among all critically ill patients. We (1) determined whether BPV differed between patients with stroke and nonstroke patients, (2) examined BPV's associations with in-hospital death and favorable discharge destination in patients with stroke and nonstroke patients, and (3) assessed how minimum mean arterial pressure (MAP)-a correlate of illness severity and cerebral perfusion-affects these associations. METHODS This is a retrospective analysis of adult intensive care unit patients hospitalized between 2001 and 2012 from the Medical Information Mart for Intensive Care III database. Confounder-adjusted logistic regressions determined associations between BPV, measured as SD and average real variability (ARV), and (1) in-hospital death and (2) favorable discharge, with testing of minimum MAP for effect modification. RESULTS BPV was higher in patients with stroke (N = 2,248) compared with nonstroke patients (N = 9,085) (SD mean difference 2.3, 95% CI 2.1-2.6, p < 0.01). After adjusting for minimum tertile of MAP and other confounders, higher SD remained significantly associated (p < 0.05) with higher odds of in-hospital death for patients with acute ischemic strokes (AISs, odds ratio [OR] 2.7, 95% CI 1.5-4.8), intracerebral hemorrhage (ICH, OR 2.6, 95% CI 1.6-4.3), subarachnoid hemorrhage (SAH, OR 3.4, 95% CI 1.2-9.3), and pneumonia (OR 1.9, 95% CI 1.1-3.3) and lower odds of favorable discharge destination in patients with ischemic stroke (OR 0.3, 95% CI 0.2-0.6) and ICH (OR 0.4, 95% CI 0.3-0.6). No interaction was found between minimum MAP tertile with SD (p > 0.05). Higher ARV was not significantly associated with increased risk of death in any condition when adjusting for illness severity but portended worse discharge destination in those with AIS (OR favorable discharge 0.4, 95% CI 0.3-0.7), ICH (OR favorable discharge 0.5, 95% CI 0.3-0.7), sepsis (OR favorable discharge 0.8, 95% CI 0.6-1.0), and pneumonia (OR favorable discharge 0.5, 95% CI 0.4-0.8). DISCUSSION BPV is higher and generally associated with worse outcomes among patients with stroke compared with nonstroke patients. BPV in patients with AIS and patients with ICH may be a marker of central autonomic network injury, although clinician-driven blood pressure goals likely contribute to the association between BPV and outcomes.
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Affiliation(s)
- Eric Lee Stulberg
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT.
| | - Benjamin Robert Edward Harris
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Alexander Robert Zheutlin
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Alen Delic
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Nazanin Sheibani
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Mohammad Anadani
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Shadi Yaghi
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Nils H Petersen
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
| | - Adam de Havenon
- From the Department of Neurology (E.L.S., A.D., A.H.), and Department of Internal Medicine (B.R.E.H., A.R.Z.), University of Utah School of Medicine, Salt Lake City; Department of Neurology (N.S.), Tufts University Medical Center, Boston, MA; Department of Neurology (M.A.), Medical University of South Carolina, Charleston; Department of Neurology (S.Y.), Brown University Alpert School of Medicine, Providence, RI; and Department of Neurology (N.H.P., A.H.), Yale University School of Medicine, New Haven, CT
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Zhou HX, Yang CF, Wang HY, Teng Y, He HY. Should we initiate vasopressors earlier in patients with septic shock: A mini systemic review. World J Crit Care Med 2023; 12:204-216. [PMID: 37745258 PMCID: PMC10515096 DOI: 10.5492/wjccm.v12.i4.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
Abstract
Septic shock treatment remains a major challenge for intensive care units, despite the recent prominent advances in both management and outcomes. Vasopressors serve as a cornerstone of septic shock therapy, but there is still controversy over the timing of administration. Specifically, it remains unclear whether vasopressors should be used early in the course of treatment. Here, we provide a systematic review of the literature on the timing of vasopressor administration. Research was systematically identified through PubMed, Embase and Cochrane searching according to PRISMA guidelines. Fourteen studies met the eligibility criteria and were included in the review. The pathophysiological basis for early vasopressor use was classified, with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII. We found that mortality was 28.1%-47.7% in the early vasopressors group, and 33.6%-54.5% in the control group. We also investigated the issue of vasopressor responsiveness. Furthermore, we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use. Based on the literature review, we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.
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Affiliation(s)
- Hang-Xiang Zhou
- Department of Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
| | - Chun-Fu Yang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou Province, China
| | - He-Yan Wang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
- School of Basic Medicine, Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou Province, China
| | - Yin Teng
- Department of Thoracic Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Hang-Yong He
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing 100020, China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Beijing 100020, China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Chao-Yang Hospital, Beijing 100020, China
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Suh GJ, shin TG, Kwon WY, Kim K, Jo YH, Choi SH, Chung SP, Kim WY. Hemodynamic management of septic shock: beyond the Surviving Sepsis Campaign guidelines. Clin Exp Emerg Med 2023; 10:255-264. [PMID: 37439141 PMCID: PMC10579730 DOI: 10.15441/ceem.23.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023] Open
Abstract
Although the Surviving Sepsis Campaign guidelines provide standardized and generalized guidance, they are less individualized. This review focuses on recent updates in the hemodynamic management of septic shock. Monitoring and intervention for septic shock should be personalized according to the phase of shock. In the salvage phase, fluid resuscitation and vasopressors should be given to provide life-saving tissue perfusion. During the optimization phase, tissue perfusion should be optimized. In the stabilization and de-escalation phases, minimal fluid infusion and safe fluid removal should be performed, respectively, while preserving organ perfusion. There is controversy surrounding the use of restrictive versus liberal fluid strategies after initial resuscitation. Fluid administration after initial resuscitation should depend upon the patient's fluid responsiveness and requires individualized management. A number of dynamic tests have been proposed to monitor fluid responsiveness, which can help clinicians decide whether to give fluid or not. The optimal timing for the initiation of vasopressor agents is unknown. Recent data suggest that early vasopressor initiation should be considered. Inotropes can be considered in patients with decreased cardiac contractility associated with impaired tissue perfusion despite adequate volume status and arterial blood pressure. Venoarterial extracorporeal membrane oxygenation should be considered for refractory septic shock with severe cardiac systolic dysfunction.
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Affiliation(s)
- Gil Joon Suh
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Tae Gun shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - You Hwan Jo
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung-Hyuk Choi
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - for the Korean Shock Society Investigators
- Department of Emergency Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Research Center for Disaster Medicine, Seoul National University Medical Research Center, Seoul, Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Emergency Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Jouffroy R, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. Prehospital pulse pressure and mortality of septic shock patients cared for by a mobile intensive care unit. BMC Emerg Med 2023; 23:97. [PMID: 37626302 PMCID: PMC10464421 DOI: 10.1186/s12873-023-00864-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Septic shock medical treatment relies on a bundle of care including antibiotic therapy and hemodynamic optimisation. Hemodynamic optimisation consists of fluid expansion and norepinephrine administration aiming to optimise cardiac output to reach a mean arterial pressure of 65mmHg. In the prehospital setting, direct cardiac output assessment is difficult because of the lack of invasive and non-invasive devices. This study aims to assess the relationship between 30-day mortality and (i) initial pulse pressure (iPP) as (ii) pulse pressure variation (dPP) during the prehospital stage among patients cared for SS by a prehospital mobile intensive care unit (MICU). METHODS From May 09th, 2016 to December 02nd, 2021, septic shock patients requiring MICU intervention were retrospectively analysed. iPP was calculated as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the first contact between the patient and the MICU team prior to any treatment and, dPP as the difference between the final PP (the difference between SBP and DBP at the end of the prehospital stage) and iPP divided by prehospital duration. To consider cofounders, the propensity score method was used to assess the relationship between (i) iPP < 40mmHg, (ii) positive dPP and 30-day mortality. RESULTS Among the 530 patients analysed, pulmonary, digestive, and urinary infections were suspected among 43%, 25% and 17% patients, respectively. The 30-day overall mortality rate reached 31%. Cox regression analysis showed an association between 30-day mortality and (i) iPP < 40mmHg; aHR of 1.61 [1.03-2.51], and (ii) a positive dPP; aHR of 0.56 [0.36-0.88]. CONCLUSION The current study reports an association between 30-day mortality rate and iPP < 40mmHg and a positive dPP among septic shock patients cared for by a prehospital MICU. A negative dPP could be helpful to identify septic shock with higher risk of poor outcome despite prehospital hemodynamic optimization.
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Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique Hôpitaux Paris and Paris Saclay University, 9 avenue Charles De Gaulle, Boulogne-Billancourt, 92100, France.
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France.
- Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM, Paris Saclay University, Villejuif, France.
- Institut de Recherche bioMédicale et d'Epidémiologie du Sport - EA7329, INSEP - Paris University, Paris, France.
- EA 7525 Université des Antilles, Fort de France, France.
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital - Assistance Publique - Hôpitaux Paris, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, Paris - Assistance Publique - Hôpitaux Paris, Paris, 75013, France
| | - Josiane Boularan
- SAMU 31, Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux Paris, Paris, France
| | - Papa Gueye
- EA 7525 Université des Antilles, Fort de France, France
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- EA 7525 University of the Antilles, Martinique, France
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Zhao H, Qin L, Wang R, Qu D, Li S. FOXO1 regulates NLRP3 inflammasome proteins in LPS-induced cardiotoxicity. Am J Transl Res 2023; 15:5446-5456. [PMID: 37692952 PMCID: PMC10492091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/15/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE Forkhead box protein O1 (FOXO1) has been shown to regulate multiple proteins in various cardiovascular disease processes. However, the effect of FOXO1 on lipopolysaccharide (LPS)-induced cardiotoxicity remains unknown. The aim of this study was to explore the impact of FOXO1 on LPS-induced cardiotoxicity. METHODS Rat-derived H9c2 cells were subjected to LPS, and the manipulation of FOXO1 was achieved through overexpression and knockdown using the adeno-associated virus system and siRNA, respectively. Western blotting and quantitative real-time polymerase chain reaction were utilized to examine the inhibitory effect of FOXO1. Cell viability was examined utilizing Cell Counting Kit-8 assay. The changes of apoptosis were examined utilizing Annexin V-FITC/PI method. The levels of pro-inflammatory cytokines, including interleukin (IL)-1β, IL-18, and tumor necrosis factor-α in the H9c2 cells were measured using ELISA kits. Reactive oxygen species (ROS) generation was quantified using the 2'-7'dichlorofluorescin diacetate assay kit. RESULTS In H9c2 cells treated with LPS, FOXO1 expression was downregulated in a dose-dependent and time-dependent manner. Overexpression of FOXO1 attenuated LPS-induced apoptosis, oxidative stress injury, and cardiomyocyte inflammation, while FOXO1 inhibition aggravated these processes. Additionally, FOXO1 was found to regulate LPS-related myocardial injury by downregulating the expression of NLR family pyrin domain-containing 3 (NLRP3). CONCLUSION FOXO1 overexpression attenuated apoptosis, ROS generation, and inflammation, whereas FOXO1 inhibition aggravated LPS-induced cardiomyocyte injury via the NLRP3 inflammasome signaling pathway.
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Affiliation(s)
- Hui Zhao
- Department of Cardiology, Tianjin Fifth Central HospitalTianjin, China
| | - Lingcun Qin
- Department of Cardiology, Gucheng County Hospital of Hebei ProvinceHengshui, Hebei, China
| | - Ruyi Wang
- The Second Ward of Department of Cardiology, Binzhou Central HospitalBinzhou, Shandong, China
| | - Dejie Qu
- Department of Emergency, Jinan Lingang HospitalJinan, Shandong, China
| | - Suting Li
- Department of Internal Medicine, BinZhou PolytechnicBinzhou, Shandong, China
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Rajkumar KP, Hicks MH, Marchant B, Khanna AK. Blood Pressure Goals in Critically Ill Patients. Methodist Debakey Cardiovasc J 2023; 19:24-37. [PMID: 37547901 PMCID: PMC10402811 DOI: 10.14797/mdcvj.1260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/08/2023] [Indexed: 08/08/2023] Open
Abstract
Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.
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Affiliation(s)
- Karuna Puttur Rajkumar
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Megan Henley Hicks
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Bryan Marchant
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Ashish K. Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
- Outcomes Research Consortium, Cleveland, Ohio, US
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Tong X, Xue X, Duan C, Liu A. Early administration of multiple vasopressors is associated with better survival in patients with sepsis: a propensity score-weighted study. Eur J Med Res 2023; 28:249. [PMID: 37481578 PMCID: PMC10362716 DOI: 10.1186/s40001-023-01229-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/14/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND The association between the timing of administration of multiple vasopressors and patient outcomes has not been investigated. METHODS This study used data from the MIMIC-IV database. Patients with sepsis who were administered two or more vasopressors were included. The principal exposure was the last norepinephrine dose when adding a second vasopressor. The cohort was divided into early (last norepinephrine dose < 0.25 μg/kg/min) and normal (last norepinephrine dose ≥ 0.25 μg/kg/min) groups. The primary outcome was 28-day mortality. Multivariable Cox analyses, propensity score matching, stabilized inverse probability of treatment weighting (sIPTW), and restricted cubic spline (RCS) curves were used. RESULTS Overall, 1,437 patients who received multiple vasopressors were included. Patients in the early group had lower 28-day mortality (HR: 0.76; 95% CI: 0.65-0.89; p < 0.001) than those in the single group, with similar results in the propensity score-matched (HR: 0.80; 95% CI: 0.68-0.94; p = 0.006) and sIPTW (HR: 0.75; 95% CI: 0.63-0.88; p < 0.001) cohorts. RCS curves showed that the risk of 28-day mortality increased as the last norepinephrine dose increased. CONCLUSIONS The timing of secondary vasopressor administration is strongly associated with the outcomes of patients with sepsis.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Chuanzhi Duan
- Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Neurosurgery Center, Southern Medical University, Guangdong, China
- Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangdong, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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Jouffroy R, Gueye P, Djossou F, Vivien B. Usefulness of Prehospital Care for Patients with Septic Shock: Experience and Evidence-Based Medicine Are Mounting. PREHOSP EMERG CARE 2023; 27:767-768. [PMID: 37307225 DOI: 10.1080/10903127.2023.2225093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Romain Jouffroy
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique - Hôpitaux de Paris, Paris Saclay University, Gif-sur-Yvette, France
| | - Papa Gueye
- SAMU 972 Centre Hospitalier Universitaire de Hôpital de Martinique, Université des Antilles, Pointe-à-Pitre, Guadeloupe
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Guyane and Laboratoire Ecosystèmes Amazoniens et Pathologie Tropicale, Université de Guyane, Cayenne, French Guiana
| | - Benoît Vivien
- SAMU de Paris, Service d'Anesthésie Réanimation, Hôpital Universitaire Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
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Gao Q, Lin Y, Xu R, Zhang Y, Luo F, Chen R, Li P, Nie S, Li Y, Su L. Association between mean arterial pressure and clinical outcomes among patients with heart failure. ESC Heart Fail 2023. [PMID: 37177860 PMCID: PMC10375101 DOI: 10.1002/ehf2.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/12/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Mean arterial pressure (MAP) is widely used for evaluating organ perfusion, but its impact on clinical outcomes in patients with heart failure (HF) remains poorly understood. The aim of this study is to investigate the relationship between MAP and all-cause mortality and readmission in patients with HF. METHODS AND RESULTS We retrospectively analysed data from PhysioNet, involving 2005 patients with HF admitted to Zigong Fourth People's Hospital between 2016 and 2019. The primary outcomes were composite outcomes of all-cause mortality and readmission at 3 and 6 months. The secondary outcomes were readmission at 3 and 6 months. Multivariate-adjusted Cox regression models, restricted cubic spline curves (RCS), and propensity score matching (PSM) were used to explore the relationship between MAP and clinical outcomes. Among 2005 patients with HF [≥70 years, 1460 (72.8%); male, 843 (42.0%)], the incidence of primary outcome at 3 months was 33.4% (223/668), 24.4% (163/668), and 22.7% (152/669), and at 6 months, it was 47.5% (317/668), 38.5% (257/668), and 38.0% (254/669) across MAP tertiles [from Tertile 1 (T1) to Tertile 3 (T3)], respectively. The RCS showed an 'L-shaped' relationship between MAP and primary or secondary endpoints. Multivariate-adjusted Cox models showed that a higher MAP was significantly associated with a lower risk of composite endpoints at 3 months [adjusted hazard ratio (aHR) 0.75, 95% confidence interval (CI) 0.61-0.92, P = 0.006, Tertile 2 (T2); aHR 0.69, 95% CI 0.56-0.86, P = 0.001, T3] and 6 months (aHR 0.79, 95% CI 0.67-0.93, P = 0.005, T2; aHR 0.77, 95% CI 0.64-0.91, P = 0.003, T3) compared with T1. After 1:1 PSM, the effect of maintaining a relatively higher MAP was slightly attenuated. Threshold analyses indicated that per 10 mmHg increase in MAP, there was a 21% and 14% decrease in composite endpoints at 3 and 6 months, respectively (aHR 0.79, 95% CI 0.69-0.91, P = 0.001), and 6 months (aHR 0.86, 95% CI 0.77-0.97, P = 0.013) in patients with MAP ≤ 93 mmHg. The associations were consistent in readmission (secondary outcomes), various subgroups, and sensitivity analysis. CONCLUSIONS A higher MAP was associated with a lower risk of a composite of all-cause mortality and readmission. Maintaining a relatively higher MAP could potentially improve the clinical prognosis for patients with HF.
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Affiliation(s)
- Qi Gao
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Yuxin Lin
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Ruqi Xu
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Yuping Zhang
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Fan Luo
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Ruixuan Chen
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Pingping Li
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Sheng Nie
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Yanqin Li
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
| | - Licong Su
- Division of Nephrology, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, 1838 N Guangzhou Ave, Guangzhou, 510515, China
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Wieruszewski PM, Bellomo R, Busse LW, Ham KR, Zarbock A, Khanna AK, Deane AM, Ostermann M, Wunderink RG, Boldt DW, Kroll S, Greenfeld CR, Hodges T, Chow JH. Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: an exploratory post-hoc analysis of the ATHOS-3 clinical trial. Crit Care 2023; 27:175. [PMID: 37147690 PMCID: PMC10163684 DOI: 10.1186/s13054-023-04446-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/17/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND High dose vasopressors portend poor outcome in vasodilatory shock. We aimed to evaluate the impact of baseline vasopressor dose on outcomes in patients treated with angiotensin II (AT II). METHODS Exploratory post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial data. The ATHOS-3 trial randomized 321 patients with vasodilatory shock, who remained hypotensive (mean arterial pressure of 55-70 mmHg) despite receiving standard of care vasopressor support at a norepinephrine-equivalent dose (NED) > 0.2 µg/kg/min, to receive AT II or placebo, both in addition to standard of care vasopressors. Patients were grouped into low (≤ 0.25 µg/kg/min; n = 104) or high (> 0.25 µg/kg/min; n = 217) NED at the time of study drug initiation. The primary outcome was the difference in 28-day survival between the AT II and placebo subgroups in those with a baseline NED ≤ 0.25 µg/kg/min at the time of study drug initiation. RESULTS Of 321 patients, the median baseline NED in the low-NED subgroup was similar in the AT II (n = 56) and placebo (n = 48) groups (median of each arm 0.21 µg/kg/min, p = 0.45). In the high-NED subgroup, the median baseline NEDs were also similar (0.47 µg/kg/min AT II group, n = 107 vs. 0.45 µg/kg/min placebo group, n = 110, p = 0.75). After adjusting for severity of illness, those randomized to AT II in the low-NED subgroup were half as likely to die at 28-days compared to placebo (HR 0.509; 95% CI 0.274-0.945, p = 0.03). No differences in 28-day survival between AT II and placebo groups were found in the high-NED subgroup (HR 0.933; 95% CI 0.644-1.350, p = 0.71). Serious adverse events were less frequent in the low-NED AT II subgroup compared to the placebo low-NED subgroup, though differences were not statistically significant, and were comparable in the high-NED subgroups. CONCLUSIONS This exploratory post-hoc analysis of phase 3 clinical trial data suggests a potential benefit of AT II introduction at lower doses of other vasopressor agents. These data may inform design of a prospective trial. TRIAL REGISTRATION The ATHOS-3 trial was registered in the clinicaltrials.gov repository (no. NCT02338843). Registered 14 January 2015.
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Affiliation(s)
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - Kealy R Ham
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, University Münster, Munster, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Boldt
- Department of Anesthesiology and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Stew Kroll
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | | | - Tony Hodges
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, 2700 M St. NW, 7Th Floor, Room 709, Washington, DC, 20037, USA.
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Schuurmans J, van Nieuw Amerongen AR, Terwindt LE, Schenk J, Veelo DP, Vlaar APJ, van der Ster BJP. Feasibility of continuous non-invasive finger blood pressure monitoring in adult patients admitted to an intensive care unit: A retrospective cohort study. Heart Lung 2023; 61:51-58. [PMID: 37148815 DOI: 10.1016/j.hrtlng.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Arterial catheters are often used for blood pressure monitoring in the intensive care unit (ICU), but they can cause complications. Non-invasive continuous finger blood pressure monitors could serve as an alternative. However, failure to obtain finger blood pressure signals is reported in up to 12% of ICU patients. OBJECTIVES Our primary objective was to identify the success rate of finger blood pressure monitoring in ICU patients. Secondary objectives were to assess whether patient admission characteristics could be used to identify patients unsuitable for non-invasive blood pressure monitoring and to determine the quality of non-invasive blood pressure waveforms. METHODS Retrospective observational study conducted in a cohort of 499 ICU patients. When available, the signal quality of the first hour of finger measurement was determined using an open-source waveform algorithm. RESULTS Finger blood pressure signals were obtained in 94% of patients. These patients had a high quality blood pressure waveform for 84% of the measurement time. Patients without a finger blood pressure signal significantly more frequently had a history of kidney and vascular disease, were more often treated with inotropic agents, had lower hemoglobin levels, and had higher arterial lactate levels. CONCLUSIONS Finger blood pressure signals were obtained in nearly all ICU patients. Significant differences in baseline characteristics between patients with and without finger blood pressure signals were found, but they were not clinically relevant. The characteristics studied could therefore not be used to identify patients unsuitable for finger blood pressure monitoring.
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Affiliation(s)
- Jaap Schuurmans
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Lotte Elisabeth Terwindt
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands
| | - Jimmy Schenk
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands; Department of Epidemiology and Data Science, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Denise Petra Veelo
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands.
| | - Alexander Petrus Johannes Vlaar
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Björn Jacob Petrus van der Ster
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands
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Rellum SR, Schuurmans J, Schenk J, van der Ster BJP, van der Ven WH, Geerts BF, Hollmann MW, Cherpanath TGV, Lagrand WK, Wynandts P, Paulus F, Driessen AHG, Terwindt LE, Eberl S, Hermanns H, Veelo DP, Vlaar APJ. Effect of the machine learning-derived Hypotension Prediction Index (HPI) combined with diagnostic guidance versus standard care on depth and duration of intraoperative and postoperative hypotension in elective cardiac surgery patients: HYPE-2 - study protocol of a randomised clinical trial. BMJ Open 2023; 13:e061832. [PMID: 37130670 PMCID: PMC10163508 DOI: 10.1136/bmjopen-2022-061832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
INTRODUCTION Hypotension is common during cardiac surgery and often persists postoperatively in the intensive care unit (ICU). Still, treatment is mainly reactive, causing a delay in its management. The Hypotension Prediction Index (HPI) can predict hypotension with high accuracy. Using the HPI combined with a guidance protocol resulted in a significant reduction in the severity of hypotension in four non-cardiac surgery trials. This randomised trial aims to evaluate the effectiveness of the HPI in combination with a diagnostic guidance protocol on reducing the occurrence and severity of hypotension during coronary artery bypass grafting (CABG) surgery and subsequent ICU admission. METHODS AND ANALYSIS This is a single-centre, randomised clinical trial in adult patients undergoing elective on-pump CABG surgery with a target mean arterial pressure of 65 mm Hg. One hundred and thirty patients will be randomly allocated in a 1:1 ratio to either the intervention or control group. In both groups, a HemoSphere patient monitor with embedded HPI software will be connected to the arterial line. In the intervention group, HPI values of 75 or above will initiate the diagnostic guidance protocol, both intraoperatively and postoperatively in the ICU during mechanical ventilation. In the control group, the HemoSphere patient monitor will be covered and silenced. The primary outcome is the time-weighted average of hypotension during the combined study phases. ETHICS AND DISSEMINATION The medical research ethics committee and the institutional review board of the Amsterdam UMC, location AMC, the Netherlands, approved the trial protocol (NL76236.018.21). No publication restrictions apply, and the study results will be disseminated through a peer-reviewed journal. TRIAL REGISTRATION NUMBER The Netherlands Trial Register (NL9449), ClinicalTrials.gov (NCT05821647).
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Affiliation(s)
- Santino R Rellum
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Jaap Schuurmans
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Jimmy Schenk
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Ward H van der Ven
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Bart F Geerts
- Medical affairs, Healthplus.ai B.V, Amsterdam, Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Wim K Lagrand
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Paul Wynandts
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Antoine H G Driessen
- Department of Cardiothoracic Surgery, Heart Centre, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Lotte E Terwindt
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Susanne Eberl
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Henning Hermanns
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Denise P Veelo
- Department of Anesthesiology, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
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Colomina-Climent F, Latour-Pérez J. Effectiveness and safety of continuous plasma filtration adsorption (CPFA) treatment in patients with septic shock. Med Intensiva 2023; 47:296-298. [PMID: 36274034 DOI: 10.1016/j.medine.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/27/2022] [Accepted: 08/04/2022] [Indexed: 04/29/2023]
Affiliation(s)
- F Colomina-Climent
- Servicio de Medicina Intensiva, Hospital Universitario de San Juan, Alicante, Spain; Colaborador Honorario, Departamento de Medicina Clínica, Universidad Miguel Hernández de Elche, Spain.
| | - J Latour-Pérez
- Colaborador Honorario, Departamento de Medicina Clínica, Universidad Miguel Hernández de Elche, Spain; Servicio de Medicina Intensiva, Hospital General Universitario de Elche, Elche, Spain
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Kotani Y, Pruna A, Turi S, Borghi G, Lee TC, Zangrillo A, Landoni G, Pasin L. Propofol and survival: an updated meta-analysis of randomized clinical trials. Crit Care 2023; 27:139. [PMID: 37046269 PMCID: PMC10099692 DOI: 10.1186/s13054-023-04431-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/05/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Propofol is one of the most widely used hypnotic agents in the world. Nonetheless, propofol might have detrimental effects on clinically relevant outcomes, possibly due to inhibition of other interventions' organ protective properties. We performed a systematic review and meta-analysis of randomized controlled trials to evaluate if propofol reduced survival compared to any other hypnotic agent in any clinical setting. METHODS We searched eligible studies in PubMed, Google Scholar, and the Cochrane Register of Clinical Trials. The following inclusion criteria were used: random treatment allocation and comparison between propofol and any comparator in any clinical setting. The primary outcome was mortality at the longest follow-up available. We conducted a fixed-effects meta-analysis for the risk ratio (RR). Using this RR and 95% confidence interval, we estimated the probability of any harm (RR > 1) through Bayesian statistics. We registered this systematic review and meta-analysis in PROSPERO International Prospective Register of Systematic Reviews (CRD42022323143). RESULTS We identified 252 randomized trials comprising 30,757 patients. Mortality was higher in the propofol group than in the comparator group (760/14,754 [5.2%] vs. 682/16,003 [4.3%]; RR = 1.10; 95% confidence interval, 1.01-1.20; p = 0.03; I2 = 0%; number needed to harm = 235), corresponding to a 98.4% probability of any increase in mortality. A statistically significant mortality increase in the propofol group was confirmed in subgroups of cardiac surgery, adult patients, volatile agent as comparator, large studies, and studies with low mortality in the comparator arm. CONCLUSIONS Propofol may reduce survival in perioperative and critically ill patients. This needs careful assessment of the risk versus benefit of propofol compared to other agents while planning for large, pragmatic multicentric randomized controlled trials to provide a definitive answer.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60-20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Alessandro Pruna
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60-20132, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60-20132, Milan, Italy
| | - Giovanni Borghi
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60-20132, Milan, Italy
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60-20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, San Raffaele Hospital, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60-20132, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Laura Pasin
- Anesthesia and Intensive Care Unit, Padua University Hospital, Padua, Italy
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Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock. Anesthesiol Clin 2023; 41:1-25. [PMID: 36871993 DOI: 10.1016/j.anclin.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.
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He L, Liang S, Liang Y, Fang M, Li J, Deng J, Fang H, Li Y, Jiang X, Chen C. Defining a postoperative mean arterial pressure threshold in association with acute kidney injury after cardiac surgery: a prospective observational study. Intern Emerg Med 2023; 18:439-448. [PMID: 36577909 DOI: 10.1007/s11739-022-03187-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022]
Abstract
Acute kidney injury (AKI) is a common but fatal complication after cardiac surgery. In the absence of effective treatments, the identification and modification of risk factors has been a major component of disease management. However, the optimal blood pressure target for preventing cardiac surgery-associated acute kidney injury (CSA-AKI) remains unclear. We sought to determine the effect of postoperative mean arterial pressure (MAP) in CSA-AKI. It is hypothesized that longer periods of hypotension after cardiac surgery are associated with an increased risk of AKI. This prospective cohort study was conducted on adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between October 2018 and May 2020. The primary outcome is the occurrence of CSA-AKI. MAP and its duration in the ranges of less than 65, 65 to 74, and 75 to 84 mmHg within 24 h after surgery were recorded. The association between postoperative MAP and CSA-AKI was examined by using logistic regression. Among the 353 patients enrolled, 217 (61.5%) had a confirmed diagnosis of CSA-AKI. Each 1 h epoch of postoperative MAP less than 65 mmHg was associated with an adjusted odds ratio of 1.208 (95% CI, 1.007 to 1.449; P = 0.042), and each 1 h epoch of postoperative MAP between 65 and 74 mmHg was associated with an adjusted odds ratio of 1.144 (95% CI, 1.026 to 1.275; P = 0.016) for CSA-AKI. A potentially modifiable risk factor, postoperative MAP less than 75 mmHg for 1 h or more is associated with an increased risk of CSA-AKI.
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Affiliation(s)
- Linling He
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
- Shantou University Medical College, Shantou, 515000, China
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Silin Liang
- Department of Critical Care Medicine, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of South University of Science and Technology, Shenzhen, 518020, China
| | - Yu Liang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Miaoxian Fang
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
| | - Jiaxin Li
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
| | - Jia Deng
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Department of Critical Care Medicine, The Second Hospital of Dalian Medical University, Dalian, 116023, China
| | - Heng Fang
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Ying Li
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China
| | - Xinyi Jiang
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Chunbo Chen
- Department of Intensive Care Unit of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080, China.
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China.
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- Department of Emergency Medicine, Maoming People's Hospital, 101 Weimin Road, Maoming, 525000, China.
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Bauer SR, Sacha GL, Siuba MT, Wang L, Wang X, Scheraga RG, Vachharajani V. Vasopressin Response and Clinical Trajectory in Septic Shock Patients. J Intensive Care Med 2023; 38:273-279. [PMID: 36062611 PMCID: PMC10236982 DOI: 10.1177/08850666221118282] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In septic shock, vasopressors aim to improve tissue perfusion and prevent persistent organ dysfunction, a characteristic of chronic critical illness (CCI). Adjunctive vasopressin is often used to decrease catecholamine dosage, but the association of vasopressin response with subsequent patient outcomes is unclear. We hypothesized vasopressin response is associated with favorable clinical trajectory. METHODS We included patients with septic shock receiving vasopressin as a catecholamine adjunct in this retrospective cohort study. We defined vasopressin response as a lowering of the catecholamine dose required to maintain mean arterial pressure ≥65 mm Hg, 6 h after vasopressin initiation. Clinical trajectories were adjudicated as early death (ED; death before day 14), CCI (ICU stay ≥14 days with persistent organ dysfunction), or rapid recovery (RR; not meeting ED or CCI criteria). Trajectories were placed on an ordinal scale with ED the worst outcome, CCI next, and RR the best outcome. The association of vasopressin response with clinical trajectory was assessed with multivariable ordinal logistic regression. RESULTS In total 938 patients were included; 426 (45.4%) were vasopressin responders. The most frequent trajectory was ED (49.8%), 29.7% developed CCI, and 20.5% had rapid recovery. In survivors to ICU day 14 (those without ED), 59.2% had CCI and 40.8% experienced RR. Compared with vasopressin non-responders, vasopressin responders less frequently experienced ED (42.5% vs. 55.9%) and more frequently experienced RR (24.6% vs. 17.0%; P < 0.01). After controlling for confounders, vasopressin response was independently associated with higher odds of developing a better clinical trajectory (OR 1.63; 95% CI 1.26-2.10). Medical patients most frequently developed ED and survivors more commonly developed CCI than RR; surgical patients developed the three trajectories with similar frequency (P < 0.01). CONCLUSIONS Vasopressin responsive status was associated with improved clinical trajectory in septic shock patients. Early vasopressin response is a potential novel prognostic marker for short-term clinical trajectory.
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Affiliation(s)
- Seth R. Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH,
USA
- Cleveland Clinic Lerner College of Medicine, Case Western
Reserve University, Cleveland, OH, USA
| | | | - Matthew T. Siuba
- Cleveland Clinic Lerner College of Medicine, Case Western
Reserve University, Cleveland, OH, USA
- Department of Critical Care Medicine, Respiratory
Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lu Wang
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH,
USA
- Department of Quantitative Health Sciences, Lerner Research
Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Cleveland Clinic Lerner College of Medicine, Case Western
Reserve University, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Lerner Research
Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rachel G. Scheraga
- Cleveland Clinic Lerner College of Medicine, Case Western
Reserve University, Cleveland, OH, USA
- Department of Critical Care Medicine, Respiratory
Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vidula Vachharajani
- Cleveland Clinic Lerner College of Medicine, Case Western
Reserve University, Cleveland, OH, USA
- Department of Critical Care Medicine, Respiratory
Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research
Institute, Cleveland Clinic, Cleveland, OH, USA
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Khanna AK, Kinoshita T, Natarajan A, Schwager E, Linn DD, Dong J, Ghosh E, Vicario F, Maheshwari K. Association of systolic, diastolic, mean, and pulse pressure with morbidity and mortality in septic ICU patients: a nationwide observational study. Ann Intensive Care 2023; 13:9. [PMID: 36807233 PMCID: PMC9941378 DOI: 10.1186/s13613-023-01101-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/21/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Intensivists target different blood pressure component values to manage intensive care unit (ICU) patients with sepsis. We aimed to evaluate the relationship between individual blood pressure components and organ dysfunction in critically ill septic patients. METHODS In this retrospective observational study, we evaluated 77,328 septic patients in 364 ICUs in the eICU Research Institute database. Primary exposure was the lowest cumulative value of each component; mean, systolic, diastolic, and pulse pressure, sustained for at least 120 min during ICU stay. Primary outcome was ICU mortality and secondary outcomes were composite outcomes of acute kidney injury or death and myocardial injury or death during ICU stay. Multivariable logistic regression spline and threshold regression adjusting for potential confounders were conducted to evaluate associations between exposures and outcomes. Sensitivity analysis was conducted in 4211 patients with septic shock. RESULTS Lower values of all blood pressures components were associated with a higher risk of ICU mortality. Estimated change-points for the risk of ICU mortality were 69 mmHg for mean, 100 mmHg for systolic, 60 mmHg for diastolic, and 57 mmHg for pulse pressure. The strength of association between blood pressure components and ICU mortality as determined by slopes of threshold regression were mean (- 0.13), systolic (- 0.11), diastolic (- 0.09), and pulse pressure (- 0.05). Equivalent non-linear associations between blood pressure components and ICU mortality were confirmed in septic shock patients. We observed a similar relationship between blood pressure components and secondary outcomes. CONCLUSION Blood pressure component association with ICU mortality is the strongest for mean followed by systolic, diastolic, and weakest for pulse pressure. Critical care teams should continue to follow MAP-based resuscitation, though exploratory analysis focusing on blood pressure components in different sepsis phenotypes in critically ill ICU patients is needed.
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Affiliation(s)
- Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, 27106, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
| | - Takahiro Kinoshita
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | | | - Emma Schwager
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | - Dustin D Linn
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | - Junzi Dong
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | - Erina Ghosh
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | - Francesco Vicario
- Philips Research North America, 222 Jacobs St, Cambridge, MA, 02141, USA
| | - Kamal Maheshwari
- Department of General Anesthesia and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
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Deng J, Li L, Feng Y, Yang J. Comprehensive Management of Blood Pressure in Patients with Septic AKI. J Clin Med 2023; 12:jcm12031018. [PMID: 36769666 PMCID: PMC9917880 DOI: 10.3390/jcm12031018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Acute kidney injury (AKI) is one of the serious complications of sepsis in clinical practice, and is an important cause of prolonged hospitalization, death, increased medical costs, and a huge medical burden to society. The pathogenesis of AKI associated with sepsis is relatively complex and includes hemodynamic abnormalities due to inflammatory response, oxidative stress, and shock, which subsequently cause a decrease in renal perfusion pressure and eventually lead to ischemia and hypoxia in renal tissue. Active clinical correction of hypotension can effectively improve renal microcirculatory disorders and promote the recovery of renal function. Furthermore, it has been found that in patients with a previous history of hypertension, small changes in blood pressure may be even more deleterious for kidney function. Therefore, the management of blood pressure in patients with sepsis-related AKI will directly affect the short-term and long-term renal function prognosis. This review summarizes the pathophysiological mechanisms of microcirculatory disorders affecting renal function, fluid management, vasopressor, the clinical blood pressure target, and kidney replacement therapy to provide a reference for the clinical management of sepsis-related AKI, thereby promoting the recovery of renal function for the purpose of improving patient prognosis.
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Affiliation(s)
- Junhui Deng
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Lina Li
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Yuanjun Feng
- Department of Renal Rheumatology, Space Hospital Affiliated to Zunyi Medical University, Zunyi 563002, China
| | - Jurong Yang
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
- Correspondence: or
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Leone M, Einav S, Antonucci E, Depret F, Lakbar I, Martin-Loeches I, Wieruszewski PM, Myatra SN, Khanna AK. Multimodal strategy to counteract vasodilation in septic shock. Anaesth Crit Care Pain Med 2023; 42:101193. [PMID: 36621622 DOI: 10.1016/j.accpm.2023.101193] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/26/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023]
Abstract
Early initiation of a multimodal treatment strategy in the management of vasopressors during septic shock has been advocated to reduce delays in restoring adequate organ perfusion and to mitigate side effects associated with the administration of high-dose catecholamines. We provide a review that summarises the pathophysiology of vasodilation, the physiologic response to the vascular response, and the different drugs used in this situation, focusing on the need to combine early different vasopressors. Fluid loading being insufficient for counteracting vasoplegia, norepinephrine is usually the first-line vasopressor used to restore hemodynamics. Norepinephrine sparing is discussed in further detail through the concomitant use of adrenergic, vasopressinergic, and renin-angiotensin systems and the optimisation of endothelial reactivity with methylene blue. A blueprint for the construction of new studies is outlined to address the question of vasopressor selection and timing in septic shock.
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Affiliation(s)
- Marc Leone
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
| | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - François Depret
- GH St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, St-Louis Hospital, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, North Hospital, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Ignacio Martin-Loeches
- Intensive Care Unit, Trinity Centre for Health Science HRB-Wellcome Trust, St James's Hospital, Dublin, Ireland
| | | | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland, OH, USA
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Heimark S, Bøtker-Rasmussen KG, Stepanov A, Haga ØG, Gonzalez V, Seeberg TM, Fadl Elmula FEM, Waldum-Grevbo B. Accuracy of non-invasive cuffless blood pressure in the intensive care unit: Promises and challenges. Front Med (Lausanne) 2023; 10:1154041. [PMID: 37138759 PMCID: PMC10150697 DOI: 10.3389/fmed.2023.1154041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/14/2023] [Indexed: 05/05/2023] Open
Abstract
Objective Continuous non-invasive cuffless blood pressure (BP) monitoring may reduce adverse outcomes in hospitalized patients if accuracy is approved. We aimed to investigate accuracy of two different BP prediction models in critically ill intensive care unit (ICU) patients, using a prototype cuffless BP device based on electrocardiogram and photoplethysmography signals. We compared a pulse arrival time (PAT)-based BP model (generalized PAT-based model) derived from a general population cohort to more complex and individualized models (complex individualized models) utilizing other features of the BP sensor signals. Methods Patients admitted to an ICU with indication of invasive BP monitoring were included. The first half of each patient's data was used to train a subject-specific machine learning model (complex individualized models). The second half was used to estimate BP and test accuracy of both the generalized PAT-based model and the complex individualized models. A total of 7,327 measurements of 15 s epochs were included in pairwise comparisons across 25 patients. Results The generalized PAT-based model achieved a mean absolute error (SD of errors) of 7.6 (7.2) mmHg, 3.3 (3.1) mmHg and 4.6 (4.4) mmHg for systolic BP, diastolic BP and mean arterial pressure (MAP) respectively. Corresponding results for the complex individualized model were 6.5 (6.7) mmHg, 3.1 (3.0) mmHg and 4.0 (4.0) mmHg. Percentage of absolute errors within 10 mmHg for the generalized model were 77.6, 96.2, and 89.6% for systolic BP, diastolic BP and MAP, respectively. Corresponding results for the individualized model were 83.8, 96.2, and 94.2%. Accuracy was significantly improved when comparing the complex individualized models to the generalized PAT-based model in systolic BP and MAP, but not diastolic BP. Conclusion A generalized PAT-based model, developed from a different population was not able to accurately track BP changes in critically ill ICU patients. Individually fitted models utilizing other cuffless BP sensor signals significantly improved accuracy, indicating that cuffless BP can be measured non-invasively, but the challenge toward generalizable models remains for future research to resolve.
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Affiliation(s)
- Sondre Heimark
- Department of Nephrology, Oslo University Hospital, Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- *Correspondence: Sondre Heimark,
| | | | | | | | - Victor Gonzalez
- Department of Smart Sensors and Microsystems, SINTEF Digital, Oslo, Norway
| | - Trine M. Seeberg
- Aidee Health AS, Oslo, Norway
- Department of Smart Sensors and Microsystems, SINTEF Digital, Oslo, Norway
| | | | - Bård Waldum-Grevbo
- Department of Nephrology, Oslo University Hospital, Ullevål, Oslo, Norway
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Li M, Zhuang Q, Zhao S, Huang L, Hu C, Zhang B, Hou Q. Development and deployment of interpretable machine-learning model for predicting in-hospital mortality in elderly patients with acute kidney disease. Ren Fail 2022; 44:1886-1896. [DOI: 10.1080/0886022x.2022.2142139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Mingxia Li
- Department of Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
| | - Qinghe Zhuang
- School of Computer Science and Engineering, Central South University, Changsha, China
| | - Shuangping Zhao
- Department of Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Changsha, China
- Hunan Provincial Clinical Research Center of Intensive Care Medicine, Changsha, China
| | - Li Huang
- Department of Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
| | - Chenghuan Hu
- Department of Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
| | - Buyao Zhang
- Department of Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
| | - Qinlan Hou
- Department of Critical Care Medicine, Xiangya Hospital Central South University, Changsha, China
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49
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Khan Mamun MMR, Sherif A. Advancement in the Cuffless and Noninvasive Measurement of Blood Pressure: A Review of the Literature and Open Challenges. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 10:bioengineering10010027. [PMID: 36671599 PMCID: PMC9854981 DOI: 10.3390/bioengineering10010027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Hypertension is a chronic condition that is one of the prominent reasons behind cardiovascular disease, brain stroke, and organ failure. Left unnoticed and untreated, the deterioration in a health condition could even result in mortality. If it can be detected early, with proper treatment, undesirable outcomes can be avoided. Until now, the gold standard is the invasive way of measuring blood pressure (BP) using a catheter. Additionally, the cuff-based and noninvasive methods are too cumbersome or inconvenient for frequent measurement of BP. With the advancement of sensor technology, signal processing techniques, and machine learning algorithms, researchers are trying to find the perfect relationships between biomedical signals and changes in BP. This paper is a literature review of the studies conducted on the cuffless noninvasive measurement of BP using biomedical signals. Relevant articles were selected using specific criteria, then traditional techniques for BP measurement were discussed along with a motivation for cuffless measurement use of biomedical signals and machine learning algorithms. The review focused on the progression of different noninvasive cuffless techniques rather than comparing performance among different studies. The literature survey concluded that the use of deep learning proved to be the most accurate among all the cuffless measurement techniques. On the other side, this accuracy has several disadvantages, such as lack of interpretability, computationally extensive, standard validation protocol, and lack of collaboration with health professionals. Additionally, the continuing work by researchers is progressing with a potential solution for these challenges. Finally, future research directions have been provided to encounter the challenges.
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Affiliation(s)
| | - Ahmed Sherif
- School of Computing Sciences and Computer Engineering, The University of Southern Mississippi, Hattiesburg, MS 39406, USA
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Dynamic Arterial Elastance to Predict Mean Arterial Pressure Decrease after Reduction of Vasopressor in Septic Shock Patients. Life (Basel) 2022; 13:life13010028. [PMID: 36675977 PMCID: PMC9862728 DOI: 10.3390/life13010028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
After fluid status optimization, norepinephrine infusion represents the cornerstone of septic shock treatment. De-escalation of vasopressors should be considered with caution, as hypotension increases the risk of mortality. In this prospective observational study including 42 patients, we assess the role of dynamic elastance (EaDyn), i.e., the ratio between pulse pressure variation and stroke volume variation, which can be measured noninvasively by the MostCare monitoring system, to predict a mean arterial pressure (MAP) drop > 10% 30 min after norepinephrine reduction. Patients were divided into responders (MAP falling > 10%) and non-responders (MAP falling < 10%). The receiver-operating-characteristic curve identified an area under the curve of the EaDyn value to predict a MAP decrease > 10% of 0.84. An EaDyn cut-off of 0.84 predicted a MAP drop > 10% with a sensitivity of 0.71 and a specificity of 0.89. In a multivariate logistic regression, EaDyn was significantly and independently associated with MAP decrease (OR 0.001, 95% confidence interval 0.00001−0.081, p < 0.001). The nomogram model for the probability of MAP decrease > 10% showed a C-index of 0.90. In conclusion, in a septic shock cohort, EaDyn correlates well with the risk of decrease of MAP > 10% after norepinephrine reduction.
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