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Roedl K, Fuhrmann V. [Liver diseases in the intensive care unit]. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01157-5. [PMID: 38937335 DOI: 10.1007/s00063-024-01157-5] [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: 05/22/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024]
Abstract
The frequency of liver diseases in the intensive care unit has increased significantly in recent years and is now observed in up to 20% of critically ill patients. The occurrence of liver disease is associated with significantly increased morbidity and mortality. Two groups of liver diseases in the intensive care unit can be distinguished. First, the group of "primary hepatic dysfunctions", which includes primary acute liver failure as well as acute-on-chronic liver failure in patients with pre-existing liver cirrhosis. The second group of "secondary or acquired liver diseases" includes cholestatic liver diseases, as well as hypoxic liver injury and mixed forms, as well as other rarer liver diseases. Due to the diversity of liver diseases and the very different triggers, sufficient knowledge of the underlying changes (including hemodynamic changes, inflammatory states or drug-related) is essential. Early recognition, diagnosis, and treatment of the underlying disease are essential for all liver dysfunction in critically ill patients in the intensive care unit. This review article aims to take a closer look at liver diseases in the intensive care unit and provides insight into diagnostics and treatment options.
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Affiliation(s)
- Kevin Roedl
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Valentin Fuhrmann
- Abteilung für Innere Medizin und Gastroenterologie, Heilig-Geist-Krankenhaus, Köln, Deutschland
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Delignette MC, Stevic N, Lebossé F, Bonnefoy-Cudraz E, Argaud L, Cour M. Acute liver failure after out-of-hospital cardiac arrest: An observational study. Resuscitation 2024; 197:110136. [PMID: 38336284 DOI: 10.1016/j.resuscitation.2024.110136] [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: 11/01/2023] [Revised: 01/18/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
RATIONALE Apart from hypoxic hepatitis (HH), the hepatic consequences of out-of-hospital cardiac arrest (OHCA) have been little studied. This cohort study aimed to investigate the characteristics of liver dysfunction resulting from OHCA and its association with outcomes. METHODS Among the conventional static liver function tests used to define acute liver failure (ALF), we determined which one correlated more closely with the reference indocyanine green (ICG) clearance test in a series of OHCA patients from the CYRUS trial (NCT01595958). Subsequently, we assessed whether ALF, in addition to HH (i.e., acute liver injury), was an independent risk factor for death in a large cohort of OHCA patients admitted to two intensive care units between 2007 and 2017. RESULTS ICG clearance, available for 22 patients, was impaired in 17 (77.3%) cases. Prothrombin time (PT) ratio was the only static liver function test that correlated significantly (r = -0.66, p < 0.01) with ICG clearance and was therefore used to define ALF, with the usual cutoff of < 50%. Of the 418 patients included in the analysis (sex ratio: 1.4; median age: 64 [53-75] years; non-shockable rhythm: 73%), 67 (16.0%) presented with ALF, and 61 (14.6%) had HH at admission. On day 28, 337 (80.6%) patients died. Following multivariate analysis, ALF at admission, OHCA occurring at home, absence of bystander, non-cardiac cause of OHCA, low-flow duration ≥ 20 min, and SOFA score excluding liver subscore at admission were independently associated with day 28 mortality. CONCLUSIONS ALF occurred frequently after OHCA and, unlike HH, was independently associated with day 28 mortality.
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Affiliation(s)
- Marie-Charlotte Delignette
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
| | - Neven Stevic
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; INSERM U1060 CarMeN, IRIS, Lyon, France.
| | - Fanny Lebossé
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Institut d'Hépatologie de Lyon, Lyon, France; INSERM U1052, Centre de Recherche en Cancérologie de Lyon (CRCL), Lyon, France.
| | - Eric Bonnefoy-Cudraz
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Louis Pradel, Unité de Soins Intensifs Cardiologiques, Bron, France.
| | - Laurent Argaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; INSERM U1060 CarMeN, IRIS, Lyon, France.
| | - Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; INSERM U1060 CarMeN, IRIS, Lyon, France.
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Laurikkala J, Ameloot K, Reinikainen M, Palmers PJ, De Deyne C, Bert F, Dupont M, Janssens S, Dens J, Hästbacka J, Jakkula P, Loisa P, Birkelund T, Wilkman E, Vaara ST, Skrifvars MB. The effect of higher or lower mean arterial pressure on kidney function after cardiac arrest: a post hoc analysis of the COMACARE and NEUROPROTECT trials. Ann Intensive Care 2023; 13:113. [PMID: 37987871 PMCID: PMC10663425 DOI: 10.1186/s13613-023-01210-0] [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: 06/25/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND We aimed to study the incidence of acute kidney injury (AKI) in out-of-hospital cardiac arrest (OHCA) patients treated according to low-normal or high-normal mean arterial pressure (MAP) targets. METHODS A post hoc analysis of the COMACARE (NCT02698917) and Neuroprotect (NCT02541591) trials that randomized patients to lower or higher targets for the first 36 h of intensive care. Kidney function was defined using the Kidney Disease Improving Global Outcome (KDIGO) classification. We used Cox regression analysis to identify factors associated with AKI after OHCA. RESULTS A total of 227 patients were included: 115 in the high-normal MAP group and 112 in the low-normal MAP group. Eighty-six (38%) patients developed AKI during the first five days; 40 in the high-normal MAP group and 46 in the low-normal MAP group (p = 0.51). The median creatinine and daily urine output were 85 μmol/l and 1730 mL/day in the high-normal MAP group and 87 μmol/l and 1560 mL/day in the low-normal MAP group. In a Cox regression model, independent AKI predictors were no bystander cardiopulmonary resuscitation (p < 0.01), non-shockable rhythm (p < 0.01), chronic hypertension (p = 0.03), and time to the return of spontaneous circulation (p < 0.01), whereas MAP target was not an independent predictor (p = 0.29). CONCLUSION Any AKI occurred in four out of ten OHCA patients. We found no difference in the incidence of AKI between the patients treated with lower and those treated with higher MAP after CA. Higher age, non-shockable initial rhythm, and longer time to ROSC were associated with shorter time to AKI. CLINICAL TRIAL REGISTRATION COMACARE (NCT02698917), NEUROPROTECT (NCT02541591).
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Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland.
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ferdinande Bert
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joseph Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Departement de Cardiologie/Soins Intensifs Adultes, CHC-Montlégia, Liège, Belgique
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Suvi T Vaara
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 9, 00290 HUS, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Harnisch LO, Brockmöller J, Hapke A, Sindern J, Bruns E, Evertz R, Toischer K, Danner BC, Mielke D, Rohde V, Abboud T. Oral Drug Absorption and Drug Disposition in Critically Ill Cardiac Patients. Pharmaceutics 2023; 15:2598. [PMID: 38004576 PMCID: PMC10674156 DOI: 10.3390/pharmaceutics15112598] [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: 09/21/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: In critically ill cardiac patients, parenteral and enteral food and drug administration routes may be used. However, it is not well known how drug absorption and metabolism are altered in this group of adult patients. Here, we analyze drug absorption and metabolism in patients after cardiogenic shock using the pharmacokinetics of therapeutically indicated esomeprazole. (2) Methods: The pharmacokinetics of esomeprazole were analyzed in a consecutive series of patients with cardiogenic shock and controls before and after elective cardiac surgery. Esomeprazole was administered orally or with a nasogastric tube and once as an intravenous infusion. (3) Results: The maximum plasma concentration and AUC of esomeprazole were, on average, only half in critically ill patients compared with controls (p < 0.005) and remained lower even seven days later. Interestingly, esomeprazole absorption was also markedly compromised on day 1 after elective surgery. The metabolites of esomeprazole showed a high variability between patients. The esomeprazole sulfone/esomeprazole ratio reflecting CYP3A4 activity was significantly lower in critically ill patients even up to day 7, and this ratio was negatively correlated with CRP values (p = 0.002). The 5'-OH-esomeprazole and 5-O-desmethyl-esomeprazol ratios reflecting CYP2C19 activity did not differ significantly between critically ill and control patients. (4) Conclusions: Gastrointestinal drug absorption can be significantly reduced in critically ill cardiac patients compared with elective patients with stable cardiovascular disease. The decrease in bioavailability indicates that, under these conditions, any vital medication should be administered intravenously to maintain high levels of medications. After shock, hepatic metabolism via the CYP3A4 enzyme may be reduced.
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Affiliation(s)
- Lars-Olav Harnisch
- Department of Anesthesiology, University of Göttingen Medical Center, 37075 Göttingen, Germany
| | - Jürgen Brockmöller
- Department of Clinical Pharmacology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (J.B.); (E.B.)
| | - Anne Hapke
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
- Department of Otorhinolaryngology-Head and Neck Surgery, RWTH Aachen University Hospital, 52074 Aachen, Germany
| | - Juliane Sindern
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
- Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Ellen Bruns
- Department of Clinical Pharmacology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (J.B.); (E.B.)
| | - Ruben Evertz
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (R.E.); (K.T.)
| | - Karl Toischer
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, 37075 Göttingen, Germany; (R.E.); (K.T.)
| | - Bernhard C. Danner
- Department of Cardiac, Thoracic and Vascular Surgery, University of Göttingen Medical Center, 37075 Göttingen, Germany;
| | - Dorothee Mielke
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
| | - Tammam Abboud
- Department of Neurosurgery, University of Göttingen Medical Center, 37075 Göttingen, Germany; (A.H.); (D.M.); (V.R.); (T.A.)
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The Influence of Ultra-Low Tidal Volume Ventilation during Cardiopulmonary Resuscitation on Renal and Hepatic End-Organ Damage in a Porcine Model. Biomedicines 2023; 11:biomedicines11030899. [PMID: 36979878 PMCID: PMC10045409 DOI: 10.3390/biomedicines11030899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/28/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
The optimal ventilation strategy during cardiopulmonary resuscitation (CPR) has eluded scientists for years. This porcine study aims to validate the hypothesis that ultra-low tidal volume ventilation (tidal volume 2–3 mL kg−1; ULTVV) minimizes renal and hepatic end-organ damage when compared to standard intermittent positive pressure ventilation (tidal volume 8–10 mL kg−1; IPPV) during CPR. After induced ventricular fibrillation, the animals were ventilated using an established CPR protocol. Upon return of spontaneous circulation (ROSC), the follow-up was 20 h. After sacrifice, kidney and liver samples were harvested and analyzed histopathologically using an Endothelial, Glomerular, Tubular, and Interstitial (EGTI) scoring system for the kidney and a newly developed scoring system for the liver. Of 69 animals, 5 in the IPPV group and 6 in the ULTVV group achieved sustained ROSC and were enlisted, while 4 served as the sham group. Creatinine clearance was significantly lower in the IPPV-group than in the sham group (p < 0.001). The total EGTI score was significantly higher for ULTVV than for the sham group (p = 0.038). Aminotransferase levels and liver score showed no significant difference between the intervention groups. ULTVV may be advantageous when compared to standard ventilation during CPR in the short-term ROSC follow-up period.
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Lazzarin T, Tonon CR, Martins D, Fávero EL, Baumgratz TD, Pereira FWL, Pinheiro VR, Ballarin RS, Queiroz DAR, Azevedo PS, Polegato BF, Okoshi MP, Zornoff L, Rupp de Paiva SA, Minicucci MF. Post-Cardiac Arrest: Mechanisms, Management, and Future Perspectives. J Clin Med 2022; 12:jcm12010259. [PMID: 36615059 PMCID: PMC9820907 DOI: 10.3390/jcm12010259] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiac arrest is an important public health issue, with a survival rate of approximately 15 to 22%. A great proportion of these deaths occur after resuscitation due to post-cardiac arrest syndrome, which is characterized by the ischemia-reperfusion injury that affects the role body. Understanding physiopathology is mandatory to discover new treatment strategies and obtain better results. Besides improvements in cardiopulmonary resuscitation maneuvers, the great increase in survival rates observed in recent decades is due to new approaches to post-cardiac arrest care. In this review, we will discuss physiopathology, etiologies, and post-resuscitation care, emphasizing targeted temperature management, early coronary angiography, and rehabilitation.
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Sun R, Wang X, Jiang H, Yan Y, Dong Y, Yan W, Luo X, Miu H, Qi L, Huang Z. Prediction of 30-day mortality in heart failure patients with hypoxic hepatitis: Development and external validation of an interpretable machine learning model. Front Cardiovasc Med 2022; 9:1035675. [PMID: 36386374 PMCID: PMC9649827 DOI: 10.3389/fcvm.2022.1035675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to explore the impact of hypoxic hepatitis (HH) on survival in heart failure (HF) patients and to develop an effective machine learning model to predict 30-day mortality risk in HF patients with HH. Methods In the Medical Information Mart for Intensive Care (MIMIC)-III and IV databases, clinical data and survival situations of HF patients admitted to the intensive care unit (ICU) were retrospectively collected. Propensity Score Matching (PSM) analysis was used to balance baseline differences between HF patients with and without HH. Kaplan Meier analysis and multivariate Cox analysis were used to determining the effect of HH on the survival of CF patients. For developing a model that can predict 30-day mortality in CF patients with HH, the feature recurrence elimination (RFE) method was applied to feature selection, and seven machine learning algorithms were employed to model construction. After training and hyper-parameter optimization (HPO) of the model through cross-validation in the training set, a performance comparison was performed through internal and external validation. To interpret the optimal model, Shapley Additive Explanations (SHAP) were used along with the Local Interpretable Model-agnostic Explanations (LIME) and the Partial Dependence Plot (PDP) techniques. Results The incidence of HH was 6.5% in HF patients in the MIMIC cohort. HF patients with HH had a 30-day mortality rate of 33% and a 1-year mortality rate of 51%, and HH was an independent risk factor for increased short-term and long-term mortality risk in HF patients. After RFE, 21 key features (21/56) were selected to build the model. Internal validation and external validation suggested that Categorical Boosting (Catboost) had a higher discriminatory capability than the other models (internal validation: AUC, 0.832; 95% CI, 0.819–0.845; external validation: AUC, 0.757 95% CI, 0.739–0.776), and the simplified Catboost model (S-Catboost) also had good performance in both internal validation and external validation (internal validation: AUC, 0.801; 95% CI, 0.787–0.813; external validation: AUC, 0.729, 95% CI, 0.711–0.745). Conclusion HH was associated with increased mortality in HF patients. Machine learning methods had good performance in identifying the 30-day mortality risk of HF with HH. With interpretability techniques, the transparency of machine learning models has been enhanced to facilitate user understanding of the prediction results.
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Affiliation(s)
- Run Sun
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Xue Wang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Haiyan Jiang
- Medical School of Nantong University, Nantong University, Nantong, China
- Health Management Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Yan Yan
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Yansong Dong
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
| | - Wenxiao Yan
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Xinye Luo
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Hua Miu
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Lei Qi
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
- *Correspondence: Lei Qi,
| | - Zhongwei Huang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
- Zhongwei Huang,
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Perez Ruiz de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M. Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care 2022; 26:289. [PMID: 36163253 PMCID: PMC9511746 DOI: 10.1186/s13054-022-04163-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/10/2022] [Indexed: 01/11/2023] Open
Abstract
AbstractOrgan dysfunction or overt failure is a commonplace event in the critically ill affecting up to 70% of patients during their stay in the ICU. The outcome depends on the resolution of impaired organ function, while a domino-like deterioration of organs other than the primarily affected ones paves the way for increased mortality. “Acute Liver Failure” was defined in the 1970s as a rare and potentially reversible severe liver injury in the absence of prior liver disease with hepatic encephalopathy occurring within 8 weeks. Dysfunction of the liver in general reflects a critical event in “Multiple Organ Dysfunction Syndrome” due to immunologic, regulatory and metabolic functions of liver parenchymal and non-parenchymal cells. Dysregulation of the inflammatory response, persistent microcirculatory (hypoxic) impairment or drug-induced liver injury are leading problems that result in “secondary liver failure,” i.e., acquired liver injury without underlying liver disease or deterioration of preexisting (chronic) liver disease (“Acute-on-Chronic Liver Failure”). Conventional laboratory markers, such as transaminases or bilirubin, are limited to provide insight into the complex facets of metabolic and immunologic liver dysfunction. Furthermore, inhomogeneous definitions of these entities lead to widely ranging estimates of incidence. In the present work, we review the different definitions to improve the understanding of liver dysfunction as a perpetrator (and therapeutic target) of multiple organ dysfunction syndrome in critical care.
Graphic Abstract
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9
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Widmer J, Eden J, Carvalho MF, Dutkowski P, Schlegel A. Machine Perfusion for Extended Criteria Donor Livers: What Challenges Remain? J Clin Med 2022; 11:jcm11175218. [PMID: 36079148 PMCID: PMC9457017 DOI: 10.3390/jcm11175218] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Based on the renaissance of dynamic preservation techniques, extended criteria donor (ECD) livers reclaimed a valuable eligibility in the transplantable organ pool. Being more vulnerable to ischemia, ECD livers carry an increased risk of early allograft dysfunction, primary non-function and biliary complications and, hence, unveiled the limitations of static cold storage (SCS). There is growing evidence that dynamic preservation techniques—dissimilar to SCS—mitigate reperfusion injury by reconditioning organs prior transplantation and therefore represent a useful platform to assess viability. Yet, a debate is ongoing about the advantages and disadvantages of different perfusion strategies and their best possible applications for specific categories of marginal livers, including organs from donors after circulatory death (DCD) and brain death (DBD) with extended criteria, split livers and steatotic grafts. This review critically discusses the current clinical spectrum of livers from ECD donors together with the various challenges and posttransplant outcomes in the context of standard cold storage preservation. Based on this, the potential role of machine perfusion techniques is highlighted next. Finally, future perspectives focusing on how to achieve higher utilization rates of the available donor pool are highlighted.
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Affiliation(s)
- Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50139 Florence, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Correspondence:
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10
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Gall E, Lafont A, Varenne O, Dumas F, Cariou A, Picard F. Balancing thrombosis and bleeding after out-of-hospital cardiac arrest related to acute coronary syndrome: A literature review. Arch Cardiovasc Dis 2021; 114:667-679. [PMID: 34565694 DOI: 10.1016/j.acvd.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/29/2022]
Abstract
Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P2Y12 inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.
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Affiliation(s)
- Emmanuel Gall
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alexandre Lafont
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Olivier Varenne
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Florence Dumas
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alain Cariou
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France.
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11
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van Reeven M, Gilbo N, Monbaliu D, van Leeuwen OB, Porte RJ, Ysebaert D, van Hoek B, Alwayn IPJ, Meurisse N, Detry O, Coubeau L, Cicarelli O, Berrevoet F, Vanlander A, IJzermans JNM, Polak WG. Evaluation of Liver Graft Donation After Euthanasia. JAMA Surg 2021; 155:917-924. [PMID: 32777007 DOI: 10.1001/jamasurg.2020.2479] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The option of donating organs after euthanasia is not well known. Assessment of the results of organ transplants with grafts donated after euthanasia is essential to justify the use of this type of organ donation. Objectives To assess the outcomes of liver transplants (LTs) with grafts donated after euthanasia (donation after circulatory death type V [DCD-V]), and to compare them with the results of the more commonly performed LTs with grafts from donors with a circulatory arrest after the withdrawal of life-supporting treatment (type III [DCD-III]). Design, Setting, and Participants This retrospective multicenter cohort study analyzed medical records and LT data for most transplant centers in the Netherlands and Belgium. All LTs with DCD-V grafts performed from the start of the donation after euthanasia program (September 2012 for the Netherlands, and January 2005 for Belgium) through July 1, 2018, were included in the analysis. A comparative cohort of patients who received DCD-III grafts was also analyzed. All patients in both cohorts were followed up for at least 1 year. Data analysis was performed from September 2019 to December 2019. Exposures Liver transplant with either a DCD-V graft or DCD-III graft. Main Outcomes and Measures Primary outcomes were recipient and graft survival rates at years 1, 3, and 5 after the LT. Secondary outcomes included postoperative complications (early allograft dysfunction, hepatic artery thrombosis, and nonanastomotic biliary strictures) within the first year after the LT. Results Among the cohort of 47 LTs with DCD-V grafts, 25 organ donors (53%) were women and the median (interquartile range [IQR]) age was 51 (44-59) years. Among the cohort of 542 LTs with DCD-III grafts, 335 organ donors (62%) were men and the median (IQR) age was 49 (37-57) years. Median (IQR) follow-up was 3.8 (2.1-6.3) years. In the DCD-V cohort, 30 recipients (64%) were men, and the median (IQR) age was 56 (48-64) years. Recipient survival in the DCD-V cohort was 87% at 1 year, 73% at 3 years, and 66% at 5 years after LT. Graft survival among recipients was 74% at 1 year, 61% at 3 years, and 57% at 5 years after LT. These survival rates did not differ statistically significantly from those in the DCD-III cohort. Incidence of postoperative complications did not differ between the groups. For example, the occurrence of early allograft dysfunction after the LT was found to be 13 (31%) in the DCD-V cohort and 219 (45%) in the DCD-III cohort. The occurrence of nonanastomotic biliary strictures after the LT was found to be 7 (15%) in the DCD-V cohort and 83 (15%) in the DCD-III cohort. Conclusions and Relevance The findings of this cohort study suggest that LTs with DCD-V grafts yield similar outcomes as LTs with DCD-III grafts; therefore, grafts donated after euthanasia may be a justifiable option for increasing the organ donor pool. However, grafts from these donations should be considered high-risk grafts that require an optimal donor selection process and logistics.
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Affiliation(s)
- Marjolein van Reeven
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicholas Gilbo
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepato-Pancreato-Biliary and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepato-Pancreato-Biliary and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk Ysebaert
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian P J Alwayn
- Division of Transplant Surgery, Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicolas Meurisse
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Laurent Coubeau
- Department of Abdominal Surgery and Transplantation, University Hospitals Saint-Luc, Brussels, Belgium
| | - Olga Cicarelli
- Department of Abdominal Surgery and Transplantation, University Hospitals Saint-Luc, Brussels, Belgium
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium
| | - Jan N M IJzermans
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
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12
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Jozwiak M, Bougouin W, Geri G, Grimaldi D, Cariou A. Post-resuscitation shock: recent advances in pathophysiology and treatment. Ann Intensive Care 2020; 10:170. [PMID: 33315152 PMCID: PMC7734609 DOI: 10.1186/s13613-020-00788-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/02/2020] [Indexed: 12/28/2022] Open
Abstract
A post-resuscitation shock occurs in 50–70% of patients who had a cardiac arrest. It is an early and transient complication of the post-resuscitation phase, which frequently leads to multiple-organ failure and high mortality. The pathophysiology of post-resuscitation shock is complex and results from the whole-body ischemia–reperfusion process provoked by the sequence of circulatory arrest, resuscitation manoeuvers and return of spontaneous circulation, combining a myocardial dysfunction and sepsis features, such as vasoplegia, hypovolemia and endothelial dysfunction. Similarly to septic shock, the hemodynamic management of post-resuscitation shock is based on an early and aggressive hemodynamic management, including fluid administration, vasopressors and/or inotropes. Norepinephrine should be considered as the first-line vasopressor in order to avoid arrhythmogenic effects of other catecholamines and dobutamine is the most established inotrope in this situation. Importantly, the optimal mean arterial pressure target during the post-resuscitation shock still remains unknown and may probably vary according to patients. Mechanical circulatory support by extracorporeal membrane oxygenation can be necessary in the most severe patients, when the neurological prognosis is assumed to be favourable. Other symptomatic treatments include protective lung ventilation with a target of normoxia and normocapnia and targeted temperature management by avoiding the lowest temperature targets. Early coronary angiogram and coronary reperfusion must be considered in ST-elevation myocardial infarction (STEMI) patients with preserved neurological prognosis although the timing of coronary angiogram in non-STEMI patients is still a matter of debate. Further clinical research is needed in order to explore new therapeutic opportunities regarding inflammatory, hormonal and vascular dysfunction.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du faubourg Saint Jacques, 75014, Paris, France. .,Université de Paris, Paris, France.
| | - Wulfran Bougouin
- Service de Médecine Intensive Réanimation, Hôpital Privé Jacques Cartier, Ramsay Générale de Santé, Massy, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, Hôpital Universitaire Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France.,Université Paris-Saclay, Paris, France.,INSERM UMR1018, Centre de Recherche en Epidémiologie Et Santé Des Populations, Villejuif, France.,AfterROSC Network Group, Paris, France
| | - David Grimaldi
- Service de Soins Intensifs CUB-Erasme, Université Libre de Bruxelles (ULB), Bruxelles, Belgium.,AfterROSC Network Group, Paris, France
| | - Alain Cariou
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27, rue du faubourg Saint Jacques, 75014, Paris, France.,Université de Paris, Paris, France.,INSERM U970, Paris-Cardiovascular-Research-Center, Paris, France.,Paris Sudden-Death-Expertise-Centre, Paris, France.,AfterROSC Network Group, Paris, France
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13
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Lu Z, Ma G, Chen L. De-Ritis Ratio Is Associated with Mortality after Cardiac Arrest. DISEASE MARKERS 2020; 2020:8826318. [PMID: 33204363 PMCID: PMC7657697 DOI: 10.1155/2020/8826318] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/15/2020] [Accepted: 10/19/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of our study was to explore the associations of the aspartate transaminase/alanine transaminase (De-Ritis) ratio with outcomes after cardiac arrest (CA). METHODS This retrospective study included 374 consecutive adult cardiac arrest patients. Information on the study population was obtained from the Dryad Digital Repository. Patients were divided into tertiles based on their De-Ritis ratio. The logistic regression hazard analysis was used to assess the independent relationship between the De-Ritis ratio and mortality. The Kaplan-Meier method and log-rank test were used to estimate the survival of different groups. Receiver operating characteristic (ROC) curve analysis was utilized to compare the prognostic ability of biomarkers. A model combining the De-Ritis ratio was established, and its performance was evaluated using the Akaike information criterion (AIC). RESULTS Of the 374 patients who were included in the study, 194 patients (51.9%) died in the intensive care unit (ICU), 213 patients (57.0%) died during hospitalization, and 226 patients (60.4%) had an unfavorable neurologic outcome. Logistic regression analysis including potentially confounding factors showed that the De-Ritis ratio was independently associated with mortality, yielding a more than onefold risk of ICU mortality (OR 1.455; 95% CI 1.088-1.946; p = 0.011) and hospital mortality (OR 1.378; 95% CI 1.031-1.842; p = 0.030). Discriminatory performance assessed by ROC curves showed an area under the curve of 0.611 (95% CI 0.553-0.668) for ICU mortality and 0.625 (0.567-0.682) for hospital mortality. Further, the likelihood ratio test (LRT) analysis showed that the model combining the De-Ritis ratio had a smaller AIC and higher likelihood ratio χ 2 score than the model without the De-Ritis ratio. The Kaplan-Meier curves showed that the CA patients in the De-Ritis ratio tertile 3 group clearly had a significantly higher incidence of ICU mortality (log - rank = 0.007). CONCLUSION An elevated De-Ritis ratio on admission was significantly associated with ICU mortality and hospital mortality after CA. Assessment of the De-Ritis ratio might help identify groups at high risk for mortality.
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Affiliation(s)
- Zhengri Lu
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Genshan Ma
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Lijuan Chen
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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14
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The Impact of Hypoxic Hepatitis on Clinical Outcomes after Extracorporeal Cardiopulmonary Resuscitation. J Clin Med 2020; 9:jcm9092994. [PMID: 32948044 PMCID: PMC7565649 DOI: 10.3390/jcm9092994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/18/2022] Open
Abstract
Although there have been several reports regarding the association between hypoxic hepatic injury and clinical outcomes in patients who underwent conventional cardiopulmonary resuscitation (CPR), limited data are available in the setting of extracorporeal CPR (ECPR). Patients who received ECPR due to either in- or out-of-hospital cardiac arrest from May 2004 through December 2018 were eligible. Hypoxic hepatitis (HH) was defined as an increased aspartate aminotransferase or alanine aminotransferase level to more than 20 times the upper normal range. The primary outcome was in-hospital mortality. In addition, we assessed poor neurological outcome defined as a Cerebral Performance Categories score of 3 to 5 at discharge and the predictors of HH occurrence. Among 365 ECPR patients, 90 (24.7%) were identified as having HH. The in-hospital mortality and poor neurologic outcomes in the HH group were significantly higher than those of the non-HH group (72.2% vs. 54.9%, p = 0.004 and 77.8% vs. 63.6%, p = 0.013, respectively). As indicators of hepatic dysfunction, patients with hypoalbuminemia (albumin < 3 g/dL) or coagulopathy (international normalized ratio > 1.5) had significantly higher mortalities than those of their counterparts (p = 0.005 and p < 0.001, respectively). In multivariable logistic regression, age and acute kidney injury requiring continuous renal replacement therapy were predictors for development of HH (p = 0.046 and p < 0.001 respectively). Furthermore age, arrest due to ischemic heart disease, initial shockable rhythm, out-of-hospital cardiac arrest, lowflow time, continuous renal replacement therapy, and HH were significant predictors for in-hospital mortality. HH was a frequent complication and associated with poor clinical outcomes in ECPR patients.
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15
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Roedl K, Jarczak D, Blohm R, Winterland S, Müller J, Fuhrmann V, Westermann D, Söffker G, Kluge S. Epidemiology of intensive care unit cardiac arrest: Characteristics, comorbidities, and post-cardiac arrest organ failure - A prospective observational study. Resuscitation 2020; 156:92-98. [PMID: 32920114 DOI: 10.1016/j.resuscitation.2020.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/18/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Critically ill patients in intensive care units can frequently suffer from cardiac arrest (ICU-CA), the incidence of ICU-CA is associated with high mortality. Most studies on ICU-CA focused on risk factors and intra-arrest determinants. However, there is a lack of data on organ failure after ICU-CA and its clinical implications for outcome. This study aimed to investigate ICU-CA incidence, outcome and the occurrence of organ failure after ICU-CA. METHODS We conducted a prospective observational study over a 1-year at 12 intensive care units of a tertiary care university hospital. We included all consecutive adult patients suffering cardiac arrest (CA) during the ICU stay. Incidence, clinical and neurological outcome, as well as organ failure and support were assessed. RESULTS Out of 7690 patients, 176 (2%) with ICU-CA were identified during the study period. Male patients comprised 63% and the median age was 70 (58-78) years. The median ICU stay before ICU-CA was 3 (1-8) days. The initial cardiac rhythm was shockable (VT/VF) in 23% of patients; defibrillation during CPR was performed in 19%. The presumed cause of CA was cardiac in 24%, and sustained ROSC was observed in 80% of patients. Before CA 57% (n = 100) of patients were sedated, 63% (n = 110) mechanically ventilated, 70% needed vasopressor therapy and renal replacement therapy was necessary in 27% (n = 48) of patients. Organ failure after ICU-CA was common, 70% suffered from post-CA cardiac failure, renal replacement therapy was newly initiated in 26% of patients and liver failure occurred in 24% of patients. Mortality at ICU-discharge and at hospital discharge was 66 % and 68 %, respectively. Multivariate regression analysis identified the SOFA score [HR 1.09, 95% CI (0.92-3.18); p < 0.05] and liver failure [HR 2.44, 95% CI (1.39-4.26); p < 0.001] after ICU-CA as independent predictors of mortality. CONCLUSION The incidence of ICU-CA is rare in critically ill patients. Organ failure before and after ICU-CA is common; liver failure incidence and severity of illness after ICU-CA are independent predictors of mortality and should be considered in further decisions on ICU therapy.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Rasmus Blohm
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Sarah Winterland
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jakob Müller
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Tabea Hospital Hamburg, Hamburg, Germany.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Dirk Westermann
- Department of Interventional and General Cardiology, University Heart Center Hamburg, Hamburg, Germany.
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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16
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Nee J, Schroeder T, Vornholt F, Schaeuble J, Leithner C, Stockmann M, Storm C. Dynamic determination of functional liver capacity with the LiMAx test in post-cardiac arrest patients undergoing targeted temperature management-A prospective trial. Acta Anaesthesiol Scand 2020; 64:501-507. [PMID: 31828754 DOI: 10.1111/aas.13523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Transiently increased transaminases is a common finding after cardiac arrest but little is known about the functional liver capacity (LiMAx) during the post-cardiac arrest syndrome and treatment in the intensive care unit (ICU). The aim of this trial was to evaluate liver function capacity in post-cardiac arrest survivors undergoing targeted temperature management (TTM) in ICU. METHODS Thirty-two post-cardiac arrest survivors were prospectively included with all patients undergoing TTM at 33°C for 24 hours. Blood samples were collected, and LiMAx testing was performed at days 1, 2, 5, and 10 post-cardiac arrest. LiMAx is a non-invasive, in vivo, dynamic breath test determining cytochrome P450 1A2 (CYP1A2) capacity using intravenous (IV) 13 C-methacetin, thus reflecting maximum liver function capacity. Static liver parameters were determined and compared to LiMAx values. RESULTS A typical pattern of transiently, mildly increased transaminases was demonstrated without fulfilling the criteria for hypoxic hepatitis (HH). CYP1A2 activity was reduced with slow normalization over 10 days (lowest median 48 hours after cardiac arrest: 228.5 (25-75 percentile 105.2-301.7 μg/kg/h, P < .05). Parameters reflecting the liver synthetic function were not impaired, as assessed by, in standard laboratory testing. CONCLUSION Liver functional capacity is impaired in patients after cardiac arrest undergoing TTM at 33°C. More data are needed to determine if liver functional capacity may add relevant information, especially in the context of pharmacotherapy, to individualize post-cardiac arrest care.
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Affiliation(s)
- Jens Nee
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Tim Schroeder
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Florian Vornholt
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Julian Schaeuble
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Christoph Leithner
- Department of Neurology Charité Universitätsmedizin Berlin Berlin Germany
| | - Martin Stockmann
- Department of General, Visceral and Vascular Surgery Evangelisches Krankenhaus Paul Gerhard Stift Lutherstadt Wittenberg Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine Charité Universitätsmedizin Berlin Berlin Germany
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17
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Postresuscitation Care after Out-of-hospital Cardiac Arrest: Clinical Update and Focus on Targeted Temperature Management. Anesthesiology 2020; 131:186-208. [PMID: 31021845 DOI: 10.1097/aln.0000000000002700] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Out-of-hospital cardiac arrest is a major cause of mortality and morbidity worldwide. With the introduction of targeted temperature management more than a decade ago, postresuscitation care has attracted increased attention. In the present review, we discuss best practice hospital management of unconscious out-of-hospital cardiac arrest patients with a special focus on targeted temperature management. What is termed post-cardiac arrest syndrome strikes all organs and mandates access to specialized intensive care. All patients need a secured airway, and most patients need hemodynamic support with fluids and/or vasopressors. Furthermore, immediate coronary angiography and percutaneous coronary intervention, when indicated, has become an essential part of the postresuscitation treatment. Targeted temperature management with controlled sedation and mechanical ventilation is the most important neuroprotective strategy to take. Targeted temperature management should be initiated as quickly as possible, and according to international guidelines, it should be maintained at 32° to 36°C for at least 24 h, whereas rewarming should not increase more than 0.5°C per hour. However, uncertainty remains regarding targeted temperature management components, warranting further research into the optimal cooling rate, target temperature, duration of cooling, and the rewarming rate. Moreover, targeted temperature management is linked to some adverse effects. The risk of infection and bleeding is moderately increased, as is the risk of hypokalemia and magnesemia. Circulation needs to be monitored invasively and any deviances corrected in a timely fashion. Outcome prediction in the individual patient is challenging, and a self-fulfilling prophecy poses a real threat to early prognostication based on clinical assessment alone. Therefore, delayed and multimodal prognostication is now considered a key element of postresuscitation care. Finally, modern postresuscitation care can produce good outcomes in the majority of patients but requires major diagnostic and therapeutic resources and specific training. Hence, recent international guidelines strongly recommend the implementation of regional prehospital resuscitation systems with integrated and specialized cardiac arrest centers.
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18
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Mouliade C, Dépret F, Rosenbaum B, Mallet V. L’hépatite hypoxique : ce que le réanimateur doit savoir. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’hépatite hypoxique est secondaire à une inadéquation entre les besoins hépatiques en oxygène et les apports sanguins. Elle est caractérisée par une augmentation rapide et transitoire de l’activité des transaminases sériques, prédominant souvent sur l’aspartate aminotransférase, chez un patient avec une ou plusieurs comorbidité(s), en particulier cardiaque(s). Le diagnostic est clinicobiologique et ne nécessite pas, en général, d’examen d’imagerie ou d’anatomopathologie. La lésion histologique sous-jacente est une nécrose de la zone centrale du lobule hépatique. L’hépatite hypoxique est souvent associée à une insuffisance rénale aiguë. Les facteurs de risque sont les cardiopathies favorisant la congestion hépatique, les hypoxémies, les altérations de lamicrocirculation hépatique, telles qu’on les observe au cours de la cirrhose. La prise en charge repose sur la correction de l’événement aigu et la restauration d’une perfusion et d’une oxygénation hépatique appropriées. Le pronostic est sombre avec une mortalité proche de 50 % et dépend essentiellement du délai de prise en charge de l’événement causal. Il est classique d’observer un syndrome de cholestase après une hépatite hypoxique résolutive. La lésion sous-jacente, encore mal comprise, est probablement une ischémie des petites voies biliaires intrahépatiques qui peut conduire, parfois, à des cholangites sclérosantes secondaires. L’objectif de cet article est de fournir au réanimateur l’ensemble des outils lui permettant d’identifier les situations à risque d’hépatite hypoxique et d’en faire le diagnostic le plus précocement possible afin de mettre en œuvre les mesures nécessaires.
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19
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Kasper P, Tacke F, Steffen HM, Michels G. [Hepatic dysfunction in patients with cardiogenic shock]. Med Klin Intensivmed Notfmed 2019; 114:665-676. [PMID: 31538212 DOI: 10.1007/s00063-019-00618-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 01/16/2023]
Abstract
Cardiogenic shock is a life-threatening condition that is frequently associated with acute hepatic dysfunction. Due to low cardiac output resulting in end-organ hypoperfusion and hypoxia, different types of liver dysfunction can develop, such as hypoxic hepatitis or acute liver failure. A very serious and late sequela is the secondary sclerosing cholangitis in critically patients. Clinical management of acute hepatic dysfunction involves the stabilization of cardiac output to improve hepatic perfusion and the optimization of liver oxygenation. However, despite maximum efforts in supportive treatment, the outcome of patients with cardiogenic shock and concomitant hepatic dysfunction remains poor.
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Affiliation(s)
- Philipp Kasper
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Mitte und Campus Virchow-Klinikum, Berlin, Deutschland
| | - Hans-Michael Steffen
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Guido Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Köln, Deutschland
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20
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Roedl K, Spiel AO, Nürnberger A, Horvatits T, Drolz A, Hubner P, Warenits AM, Sterz F, Herkner H, Fuhrmann V. Hypoxic liver injury after in- and out-of-hospital cardiac arrest: Risk factors and neurological outcome. Resuscitation 2019; 137:175-182. [PMID: 30831218 DOI: 10.1016/j.resuscitation.2019.02.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/24/2019] [Accepted: 02/24/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypoxic liver injury (HLI) is a frequent and life-threatening complication in critically ill patients that occurs in up to ten percent of critically ill patients. However, there is a lack of data on HLI following cardiac arrest and its clinical implications on outcome. Aim of this study was to investigate incidence, outcome and functional outcome of patients with HLI after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). METHODS We conducted an analysis of a cardiac arrest registry data over a 7-year period. All patients with non-traumatic OHCA and IHCA with return of spontaneous circulation (ROSC) treated at the emergency department of a tertiary care hospital were included in the study. HLI was defined according to established criteria. Predictors of HLI, occurrence, clinical and neurological outcome were assessed using multivariable regression. RESULTS Out of 1068 patients after IHCA and OHCA with ROSC, 219 (21%) patients developed HLI. Rate of HLI did not differ significantly in IHCA and OHCA patients. Multivariate regression analysis identified time-to-ROSC [OR 1.18, 95% CI (1.01-1.38); p < 0.05], presence of cardiac failure [OR 2.57, 95% CI (1.65-4.01); p < 0.001] and Charlson comorbidity index [OR 0.83, 95% CI (0.72-0.95); p < 0.01] as independent predictors for occurrence of HLI. Good functional outcome was significantly lower in patients suffering from HLI after 28-days (35% vs. 48%, p < 0.001) and 1-year (34% vs. 44%, p < 0.001). Occurrence of HLI was associated with unfavourable neurological outcome [OR 1.74, 95% CI (1.16-2.61); p < 0.01] in multivariate regression analysis. CONCLUSION New onset of HLI is a frequent finding after IHCA and OHCA. HLI is associated with increased mortality, unfavourable neurological and overall outcome.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Alexander O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Alexander Nürnberger
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Thomas Horvatits
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Andreas Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Pia Hubner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | | | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
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21
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Mangus RS, Schroering JR, Fridell JA, Kubal CA. Impact of Donor Pre-Procurement Cardiac Arrest (PPCA) on Clinical Outcomes in Liver Transplantation. Ann Transplant 2018; 23:808-814. [PMID: 30455411 PMCID: PMC6259573 DOI: 10.12659/aot.910387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Transplantation of liver grafts from deceased donors who experienced cardiac arrest prior to liver procurement is now common. This single-center study analyzed the impact of pre-donation arrest time on clinical outcomes in liver transplantation. Material/Methods Records of all orthotopic liver transplants performed at a single center over a 15-year period were reviewed. Donor records were reviewed and total arrest time was calculated as cumulative minutes. Post-transplant liver graft function was assessed using laboratory values. Graft survival was assessed with Cox regression analysis. Results Records for 1830 deceased donor transplants were reviewed, and 521 donors experienced pre-procurement cardiac arrest (28%). Median arrest time was 21 min (mean 25 min, range 1–120 min). After transplant, the peak alanine aminotransferase and bilirubin levels for liver grafts from donors with arrest were lower compared to those for donors without arrest (p<0.001). Early allograft dysfunction occurred in 25% (arrest) and 28% (no arrest) of patients (p=0.22). There were no differences in risk of early graft loss (3% vs. 3%, p=0.84), length of hospital stay (10 vs. 10 days, p=0.76), and 1-year graft survival (89% vs. 89%, p=0.94). Cox regression analysis comparing 4 groups (no arrest, <20 min, 20–40 min, and >40 min arrest) demonstrated no statistically significant difference in survival at 10 years. Subgroup analysis of 93 donation after cardiac death grafts showed no significant difference for these same outcomes. Conclusions These results support the use of select deceased liver donors who experience pre-donation cardiac arrest. Pre-donation arrest may be associated with less early allograft dysfunction, but had no impact on long-term clinical outcomes. The results for donation after cardiac death donors were similar.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Joel R Schroering
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University, School of Medicine, Indianapolis, IN, USA
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Abstract
Few data are available regarding hypoxic hepatitis (HH) and acute liver failure (ALF) in patients resuscitated from cardiac arrest (CA). The aim of this study was to describe the occurrence of these complications and their association with outcome. All adult patients admitted to the Department of Intensive Care following CA were considered for inclusion in this retrospective study. Exclusion criteria were early death (<24 hours) or missing biological data. We retrieved data concerning CA characteristics and markers of liver function. ALF was defined as a bilirubin >1.2 mg/dL and an international normalized ratio ≥1.5. HH was defined as an aminotransferase level >1000 IU/L. Neurological outcome was assessed at 3 months and an unfavourable neurological outcome was defined as a Cerebral Performance Categories (CPC) score of 3–5. A total of 374 patients (age 62 [52–74] years; 242 male) were included. ALF developed in 208 patients (56%) and HH in 27 (7%); 24 patients developed both conditions. Patients with HH had higher mortality (89% vs. 51% vs. 45%, respectively) and greater rates of unfavourable neurological outcome (93% vs. 60% vs. 59%, respectively) compared to those with ALF without HH (n = 184) and those without ALF or HH (n = 163; p = 0.03). Unwitnessed arrest, non-shockable initial rhythm, lack of bystander cardiopulmonary resuscitation, high adrenaline doses and the development of acute kidney injury were independent predictors of unfavourable neurological outcome; HH (OR: 16.276 [95% CIs: 2.625–81.345; p = 0.003), but not ALF, was also a significant risk-factor for unfavourable outcome. Although ALF occurs frequently after CA, HH is a rare complication. Only HH is significantly associated with poor neurological outcome in this setting.
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Peris A, Lazzeri C, Bonizzoli M, Guetti C, Tadini Buoninsegni L, Fulceri G, Ticali PF, Chiostri M, Li Marzi V, Serni S, Migliaccio ML. A metabolic approach during normothermic regional perfusion in uncontrolled donors after circulatory death-A pilot study. Clin Transplant 2018; 32:e13387. [DOI: 10.1111/ctr.13387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/17/2018] [Accepted: 08/16/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Adriano Peris
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
- Tuscany Authority for Transplantation (Centro Regionale Allocazione Organi e Tessuti CRAOT); Florence Italy
| | - Chiara Lazzeri
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Manuela Bonizzoli
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Cristiana Guetti
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Laura Tadini Buoninsegni
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Giorgio Fulceri
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Pier Francesco Ticali
- Department of Emergency Medicine; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Marco Chiostri
- Emergency Department; Intensive Care Unit and Regional ECMO Referral Centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Vincenzo Li Marzi
- Department of Urology; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Sergio Serni
- Department of Urology; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Maria Luisa Migliaccio
- Tuscany Authority for Transplantation (Centro Regionale Allocazione Organi e Tessuti CRAOT); Florence Italy
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Gilje P, Frydland M, Bro-Jeppesen J, Dankiewicz J, Friberg H, Rundgren M, Devaux Y, Stammet P, Al-Mashat M, Jögi J, Kjaergaard J, Hassager C, Erlinge D. The association between plasma miR-122-5p release pattern at admission and all-cause mortality or shock after out-of-hospital cardiac arrest. Biomarkers 2018; 24:29-35. [PMID: 30015516 DOI: 10.1080/1354750x.2018.1499804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Data suggests that the plasma levels of the liver-specific miR-122-5p might both be a marker of cardiogenic shock and a prognostic marker of out-of-hospital cardiac arrest (OHCA). Our aim was to characterize plasma miR-122-5p at admission after OHCA and to assess the association between miR-122-5p and relevant clinical factors such all-cause mortality and shock at admission after OHCA. METHODS In the pilot trial, 10 survivors after OHCA were compared to 10 age- and sex-matched controls. In the main trial, 167 unconscious survivors of OHCA from the Targeted Temperature Management (TTM) trial were included. RESULTS In the pilot trial, plasma miR-122-5p at admission after OHCA was 400-fold elevated compared to controls. In the main trial, plasma miR-122-5p at admission was independently associated with lactate and bystander cardiopulmonary resuscitation. miR-122-5p at admission was not associated with shock at admission (p = 0.14) or all-cause mortality (p = 0.35). Target temperature (33 °C vs 36 °C) was not associated with miR-122-5p levels at any time point. CONCLUSIONS After OHCA, miR-122-5p demonstrated a marked acute increase in plasma and was independently associated with lactate and bystander resuscitation. However, miR-122-5p at admission was not associated with all-cause mortality or shock at admission.
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Affiliation(s)
- Patrik Gilje
- a Department of Cardiology, Clinical Sciences , Lund University , Lund , Sweden
| | - Martin Frydland
- b The Heart Centre, Department of Cardiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - John Bro-Jeppesen
- b The Heart Centre, Department of Cardiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Josef Dankiewicz
- c Department of Intensive and Perioperative Care, Clinical Sciences , Lund University , Lund , Sweden
| | - Hans Friberg
- c Department of Intensive and Perioperative Care, Clinical Sciences , Lund University , Lund , Sweden
| | - Malin Rundgren
- c Department of Intensive and Perioperative Care, Clinical Sciences , Lund University , Lund , Sweden
| | - Yvan Devaux
- d Cardiovascular Research Unit , Luxembourg Institute of Health , Luxembourg , Luxembourg
| | - Pascal Stammet
- e The Medical Department, National Rescue Services , Luxembourg, Luxembourg
| | - Mariam Al-Mashat
- f Department of Clinical Physiology, Clinical Sciences , Lund University , Lund , Sweden
| | - Jonas Jögi
- f Department of Clinical Physiology, Clinical Sciences , Lund University , Lund , Sweden
| | - Jesper Kjaergaard
- b The Heart Centre, Department of Cardiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Christian Hassager
- b The Heart Centre, Department of Cardiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - David Erlinge
- a Department of Cardiology, Clinical Sciences , Lund University , Lund , Sweden
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25
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Mongardon N, Savary G, Geri G, El Bejjani MR, Silvera S, Dumas F, Charpentier J, Pène F, Mira JP, Cariou A. Prognostic value of adrenal gland volume after cardiac arrest: Association of CT-scan evaluation with shock and mortality. Resuscitation 2018; 129:135-140. [PMID: 29852197 DOI: 10.1016/j.resuscitation.2018.05.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/18/2018] [Accepted: 05/26/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Adrenal gland volume is associated with survival in septic shock. As sepsis and post-cardiac arrest syndrome share many pathophysiological features, we assessed the association between adrenal gland volume measured by computerized tomography (CT)-scan and post-cardiac arrest shock and intensive care unit (ICU) mortality, in a large cohort of out-of-hospital cardiac arrest (OHCA) patients. We also investigated the association between adrenal hormonal function and both adrenal gland volume and outcomes. PATIENTS AND METHODS Prospective analysis of CT-scan performed at hospital admission in patients admitted after OHCA (2007-2012). A pair of blinded radiologist calculated manually adrenal gland volume. In a subgroup of patients, plasma cortisol was measured at admission and 60 min after a cosyntropin test. Factors associated with post-cardiac arrest shock and ICU mortality were identified using multivariate logistic regression. RESULTS Among 775 patients admitted during this period after OHCA, 138 patients were included: 72 patients (52.2%) developed a post-cardiac arrest shock, and 98 patients (71.1%) died. In univariate analysis, adrenal gland volume was not different between patients with and without post-cardiac arrest shock: 10.6 and 11.3 cm3, respectively (p = 0.9) and between patients discharged alive or dead: 10.2 and 11.8 cm3, respectively (p = 0.4). Multivariate analysis confirmed that total adrenal gland volume was associated neither with post-cardiac arrest shock nor mortality. Neither baseline cortisol level nor delta between baseline and after cosyntropin test cortisol levels were associated with adrenal volume, post-cardiac arrest shock onset or mortality. CONCLUSION After OHCA, adrenal gland volume is not associated with post-cardiac arrest shock onset or ICU mortality. Adrenal gland volume does not predict adrenal gland hormonal response.
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Affiliation(s)
- Nicolas Mongardon
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Savary
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Guillaume Geri
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France
| | - Marie-Rose El Bejjani
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Stéphane Silvera
- Radiology Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Florence Dumas
- Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Julien Charpentier
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Frédéric Pène
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, 15 rue de l'Ecole de Médecine, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, 56 rue Leblanc, 75015 Paris, France.
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26
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Paul M, Bougouin W, Dumas F, Geri G, Champigneulle B, Guillemet L, Ben Hadj Salem O, Legriel S, Chiche JD, Charpentier J, Mira JP, Sandroni C, Cariou A. Comparison of two sedation regimens during targeted temperature management after cardiac arrest. Resuscitation 2018; 128:204-210. [PMID: 29555261 DOI: 10.1016/j.resuscitation.2018.03.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/15/2018] [Accepted: 03/15/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE Although guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated. METHODS We compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. RESULTS 460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1-9) hours in P2 vs. 17 (IQR 7-60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03-0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods. CONCLUSIONS During TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.
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Affiliation(s)
- Marine Paul
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France
| | - Wulfran Bougouin
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
| | - Florence Dumas
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France; Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, Paris, France
| | - Guillaume Geri
- Medical ICU, Cochin Hospital, AP-HP, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France
| | - Benoit Champigneulle
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Surgical & Trauma Intensive Care Unit, Georges Pompidou European Hospital, APHP, Paris, France
| | | | | | - Stéphane Legriel
- Paris Sudden-Death-Expertise-Center, Paris, France; ICU, Mignot Hospital, Le Chesnay, France
| | - Jean-Daniel Chiche
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France
| | | | - Jean-Paul Mira
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Alain Cariou
- Université Paris-Descartes-Sorbonne-Paris-Cité, UFR de Médecine, Paris, France; Medical ICU, Cochin Hospital, AP-HP, Paris, France; Paris Sudden-Death-Expertise-Center, Paris, France; Paris-Cardiovascular-Research-Center, INSERM U970, Paris, France.
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Dell'Anna AM, Sandroni C, Lamanna I, Belloni I, Donadello K, Creteur J, Vincent JL, Taccone FS. Prognostic implications of blood lactate concentrations after cardiac arrest: a retrospective study. Ann Intensive Care 2017; 7:101. [PMID: 28986863 PMCID: PMC5630540 DOI: 10.1186/s13613-017-0321-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 09/19/2017] [Indexed: 01/12/2023] Open
Abstract
Background Elevated lactate concentration has been associated with increased mortality after out-of-hospital cardiac arrest (CA). We investigated the variables associated with high blood lactate concentrations and explored the relationship between blood lactate and neurological outcome in this setting. Methods This was a retrospective analysis of an institutional database that included all adult (> 18 years) patients admitted to a multidisciplinary Department of Intensive Care between January 2009 and January 2013 after resuscitation from CA. Blood lactate concentrations were collected at hospital admission and 6, 12, 24 and 48 h thereafter. Neurological outcome was evaluated 3 months post-CA using the Cerebral Performance Category (CPC) score: a CPC of 3–5 was used to define a poor outcome. Results Of the 236 patients included, 162 (69%) had a poor outcome. On admission, median lactate concentrations (5.3[2.9–9.0] vs. 2.5[1.5–5.5], p < 0.001) and cardiovascular sequential organ failure assessment (cSOFA) score (3[0–4] vs. 0[0–3], p = 0.003) were higher in patients with poor than in those with favourable outcomes. Lactate concentrations were higher in patients with poor outcomes at all time points. Lactate concentrations were similar in patients with out-of-hospital and in-hospital CA at all time points. After adjustment, high admission lactate was independently associated with a poor neurological outcome (OR 1.18, 95% CI 1.08–1.30; p < 0.001). In multivariable analysis, use of vasopressors and high PaO2 on admission, longer time to return of spontaneous circulation and altered renal function were associated with high admission lactate concentrations. Conclusions High lactate concentrations on admission were an independent predictor of poor neurological recovery post-CA, but the time course was not related to outcome. Prolonged resuscitation, use of vasopressors, high PaO2 and altered renal function were predictors of high lactate concentrations. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0321-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antonio Maria Dell'Anna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.,Department of Anesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Claudio Sandroni
- Department of Anesthesiology and Intensive Care, Catholic University School of Medicine, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Irene Lamanna
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Ilaria Belloni
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Katia Donadello
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.,Anaesthesia and Intensive Care B, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, AOUI-University Hospital Integrated Trust of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Bougouin W, Dumas F, Marijon E, Geri G, Champigneulle B, Chiche JD, Varenne O, Spaulding C, Mira JP, Jouven X, Cariou A. Gender differences in early invasive strategy after cardiac arrest: Insights from the PROCAT registry. Resuscitation 2017; 114:7-13. [DOI: 10.1016/j.resuscitation.2017.02.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 02/07/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
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Nobile L, Taccone FS, Szakmany T, Sakr Y, Jakob SM, Pellis T, Antonelli M, Leone M, Wittebole X, Pickkers P, Vincent JL. The impact of extracerebral organ failure on outcome of patients after cardiac arrest: an observational study from the ICON database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:368. [PMID: 27839517 PMCID: PMC5108077 DOI: 10.1186/s13054-016-1528-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/14/2016] [Indexed: 12/26/2022]
Abstract
Background We used data from a large international database to assess the incidence and impact of extracerebral organ dysfunction on prognosis of patients admitted after cardiac arrest (CA). Methods This was a sub-analysis of the Intensive Care Over Nations (ICON) database, which contains data from all adult patients admitted to one of 730 participating intensive care units (ICUs) in 84 countries from 8–18 May 2012, except admissions for routine postoperative surveillance. For this analysis, patients admitted after CA (defined as those with “post-anoxic coma” or “cardiac arrest” as the reason for ICU admission) were included. Data were collected daily in the ICU for a maximum of 28 days; patients were followed up for outcome data until death, hospital discharge, or a maximum of 60 days in-hospital. Favorable neurological outcome was defined as alive at hospital discharge with a last available neurological Sequential Organ Failure Assessment (SOFA) subscore of 0–2. Results Among the 469 patients admitted after CA, 250 (53 %) had had out-of-hospital CA; 210 (45 %) patients died in the ICU and 357 (76 %) had an unfavorable neurological outcome. Non-survivors had a higher incidence of renal (43 vs. 16 %), cardiovascular (56 vs. 45 %), and respiratory (62 vs. 48 %) failure on admission and during the ICU stay than survivors (all p < 0.05). Similar results were found for patients with unfavorable vs. favorable neurological outcomes. In multivariable analysis, independent predictors of ICU mortality were renal failure on admission, high admission Simplified Acute Physiology Score (SAPS) II, high maximum serum lactate levels within the first 24 h after ICU admission, and development of sepsis. Independent predictors of unfavorable neurological outcome were mechanical ventilation on admission, high admission SAPS II score, and neurological dysfunction on admission. Conclusions In this multicenter cohort, extracerebral organ dysfunction was common in CA patients. Renal failure on admission was the only extracerebral organ dysfunction independently associated with higher ICU mortality. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1528-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leda Nobile
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Tamas Szakmany
- Department of Critical Care, Royal Gwent Hospital, Newport, Wales, UK.,Department of Anaesthetics, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Tommaso Pellis
- Anesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marc Leone
- Department of Anesthesia and Intensive Care, Hôpital Nord, AP-HM Aix Marseille Université, Marseille, France
| | - Xavier Wittebole
- Critical Care Department, Cliniques Universitaires St Luc, UCL, Brussels, Belgium
| | - Peter Pickkers
- Department of Intensive Care, Nijmegen Institute for Infection, Inflammation and Immunity, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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