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Liang Q, Xu X, Ding S, Wu J, Huang M. Prediction of successful weaning from renal replacement therapy in critically ill patients based on machine learning. Ren Fail 2024; 46:2319329. [PMID: 38416516 PMCID: PMC10903749 DOI: 10.1080/0886022x.2024.2319329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/10/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Predicting the successful weaning of acute kidney injury (AKI) patients from renal replacement therapy (RRT) has emerged as a research focus, and we successfully built predictive models for RRT withdrawal in patients with severe AKI by machine learning. METHODS This retrospective single-center study utilized data from our general intensive care unit (ICU) Database, focusing on patients diagnosed with severe AKI who underwent RRT. We evaluated RRT weaning success based on patients being free of RRT in the subsequent week and their overall survival. Multiple logistic regression (MLR) and machine learning algorithms were adopted to construct the prediction models. RESULTS A total of 976 patients were included, with 349 patients successfully weaned off RRT. Longer RRT duration (7.0 vs. 9.6 d, p = 0.002, OR = 0.94), higher serum cystatin C levels (1.2 vs. 3.2 mg/L, p < 0.001, OR = 0.46), and the presence of septic shock (28.1% vs. 41.5%, p < 0.001, OR = 0.63) were associated with reduced likelihood of RRT weaning. Conversely, a positive furosemide stress test (FST) (60.2% vs. 40.7%, p < 0.001, OR = 2.75) and higher total urine volume 3 d before RRT withdrawal (755 vs. 125 mL/d, p < 0.001, OR = 2.12) were associated with an increased likelihood of successful weaning from RRT. Next, we demonstrated that machine learning models, especially Random Forest and XGBoost, achieving an AUROC of 0.95. The XGBoost model exhibited superior accuracy, yielding an AUROC of 0.849. CONCLUSION High-risk factors for unsuccessful RRT weaning in severe AKI patients include prolonged RRT duration. Machine learning prediction models, when compared to models based on multivariate logistic regression using these indicators, offer distinct advantages in predictive accuracy.
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Affiliation(s)
- Qiqiang Liang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Xin Xu
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Shuo Ding
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Jin Wu
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
| | - Man Huang
- General Intensive Care Unit, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, PR China
- Key Laboratory of Multiple Organ Failure, China National Ministry of Education, Hangzhou, PR China
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2
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Coupland LA, Pai KG, Pye SJ, Butorac MT, Miller JJ, Crispin PJ, Rabbolini DJ, Stewart AHL, Aneman A. Protracted fibrinolysis resistance following cardiac surgery with cardiopulmonary bypass: A prospective observational study of clinical associations and patient outcomes. Acta Anaesthesiol Scand 2024; 68:772-780. [PMID: 38497568 DOI: 10.1111/aas.14409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Surgery on cardiopulmonary bypass (CPB) elicits a pleiomorphic systemic host response which, when severe, requires prolonged intensive care support. Given the substantial cross-talk between inflammation, coagulation, and fibrinolysis, the aim of this hypothesis-generating observational study was to document the kinetics of fibrinolysis recovery post-CPB using ClotPro® point-of-care viscoelastometry. Tissue plasminogen activator-induced clot lysis time (TPA LT, s) was correlated with surgical risk, disease severity, organ dysfunction and intensive care length of stay (ICU LOS). RESULTS In 52 patients following CPB, TPA LT measured on the first post-operative day (D1) correlated with surgical risk (EuroScore II, Spearman's rho .39, p < .01), time on CPB (rho = .35, p = .04), disease severity (APACHE II, rho = .52, p < .001) and organ dysfunction (SOFA, rho = .51, p < .001) scores, duration of invasive ventilation (rho = .46, p < .01), and renal function (eGFR, rho = -.65, p < .001). In a generalized linear regression model containing TPA LT, CPB run time and markers of organ function, only TPA LT was independently associated with the ICU LOS (odds ratio 1.03 [95% CI 1.01-1.05], p = .01). In a latent variables analysis, the association between TPA LT and the ICU LOS was not mediated by renal function and thus, by inference, variation in the clearance of intraoperative tranexamic acid. CONCLUSIONS This observational hypothesis-generating study in patients undergoing cardiac surgery with cardiopulmonary bypass demonstrated an association between the severity of fibrinolysis resistance, measured on the first post-operative day, and the need for extended postoperative ICU level support. Further examination of the role of persistent fibrinolysis resistance on the clinical outcomes in this patient cohort is warranted through large-scale, well-designed clinical studies.
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Affiliation(s)
- Lucy A Coupland
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
- Ingham Institute for Applied Medical Research, New South Wales, Australia
| | - Kieran G Pai
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
| | - Sidney J Pye
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Mark T Butorac
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
| | - Jennene J Miller
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Philip J Crispin
- Haematology Department, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- The Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - David J Rabbolini
- Kolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony H L Stewart
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Anders Aneman
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
- Ingham Institute for Applied Medical Research, New South Wales, Australia
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Kalaiselvan J, Magoon R, Kashav RC, Jose J. Vasoactive-Inotropic Scoring in Cardiac Surgery: Both Concept and Context Matter! Ann Card Anaesth 2024; 27:287-288. [PMID: 38963374 DOI: 10.4103/aca.aca_23_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/13/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
- Jaffrey Kalaiselvan
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Ramesh C Kashav
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
| | - Jes Jose
- Department of Cardiac Anesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
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Singh S, Sharma R, Singh J, Jain K, Kaur G, Gupta V, Gautam PL. Clinical Outcomes and Determinants of Survival in Patients with Hematologic Malignancies Admitted to Intensive Care Units with Critical Illness. Indian J Hematol Blood Transfus 2024; 40:423-431. [PMID: 39011248 PMCID: PMC11246339 DOI: 10.1007/s12288-024-01757-3] [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: 08/26/2023] [Accepted: 03/15/2024] [Indexed: 07/17/2024] Open
Abstract
Outcomes of patients with hematologic malignancies requiring ICU care for critical illness are suboptimal and represent a major unmet need in this population. We present data from a dedicated haematology oncology setting including 63 patients with a median age of 60 years admitted to the ICU for critical illness with organ dysfunction. The most common underlying diagnosis was multiple myeloma (30%) followed by acute myeloid leukemia (25%). Chemotherapy had been initiated for 90.7% patients before ICU admission. The most common indication for ICU care was respiratory failure (36.5%) and shock (17.5%) patients. Evidence of sepsis was present in 44 (69%) patients. After shifting to ICU, 32 (50%) patients required inotropic support and 18 (28%) required invasive mechanical ventilation. After a median of 5 days of ICU stay, 43.1% patients had died, most commonly due to multiorgan dysfunction. Risk of mortality was higher with involvement of more than two major organs (p = .001), underlying AML (p = .001), need for mechanical ventilation (p = .001) and high inotrope usage (p = .004). Neutropenia was not associated with mortality. Our study indicates high rates of short term mortality and defines prognostic factors which can be used to prognosticate patients and establish goals of care. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-024-01757-3.
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Affiliation(s)
- Suvir Singh
- Department of Clinical Hematology and Stem Cell Transplantation, Bone Marrow Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab 141001 India
| | - Rintu Sharma
- Department of Clinical Hematology and Stem Cell Transplantation, Bone Marrow Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab 141001 India
| | - Jagdeep Singh
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Kunal Jain
- Department of Medical Oncology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Gurkirat Kaur
- Department of Cardiac Anaesthesia, Hero DMC Heart Institute, Dayanand Medical College and Hospital, Ludhiana, India
| | - Vivek Gupta
- Department of Cardiac Anaesthesia, Hero DMC Heart Institute, Dayanand Medical College and Hospital, Ludhiana, India
| | - P. L. Gautam
- Department of Critical Care Medicine, Dayanand Medical College and Hospital, Ludhiana, India
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Celegen K, Celegen M. A Retrospective Analysis of Risk Factors and Impact of Acute Kidney Injury in Critically Ill Children. KLINISCHE PADIATRIE 2024; 236:229-239. [PMID: 36848938 DOI: 10.1055/a-1996-1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious clinical condition in critically ill children and is associated with worse outcomes. A few pediatric studies focused on the risk factors of AKI. We aimed to identify the incidence, risk factors, and outcomes of AKI in the pediatric intensive care unit (PICU). PATIENTS AND METHODS All the patients admitted to PICU over a period of 20 months were included. We compared both groups the risk factors between AKI and non-AKI. RESULTS A total of 63 patients (17.5%) of the 360 patients developed AKI during PICU stay. The presence of comorbidity, diagnosis of sepsis, increased PRISM III score, and positive renal angina index were found to be risk factors for AKI on admission. Thrombocytopenia, multiple organ failure syndrome, the requirement of mechanical ventilation, use of inotropic drugs, intravenous iodinated contrast media, and exposure to an increased number of nephrotoxic drugs were independent risk factors during the hospital stay. The patients with AKI had a lower renal function on discharge and had worse overall survival. CONCLUSIONS AKI is prevalent and multifactorial in critically sick children. The risk factors of AKI may be present on admission and during the hospital stay. AKI is related to prolonged mechanical ventilation days, longer PICU stays, and a higher mortality rate. Based on the presented results early prediction of AKI and consequent modification of nephrotoxic medication may generate positive effects on the outcome of critically ill children.
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Affiliation(s)
- Kubra Celegen
- Division of Pediatric Nephrology, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
- Pediatric Nephrology, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
| | - Mehmet Celegen
- Pediatric Intensive Care, Afyonkarahisar Health Sciences University, Afyonkarahisar, Turkey
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6
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Zhang D, Li L, Huang W, Hu C, Zhu W, Hu B, Li J. Vasoactive-Inotropic Score as a Promising Predictor of Acute Kidney Injury in Adult Patients Requiring Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:586-593. [PMID: 38324707 PMCID: PMC11210947 DOI: 10.1097/mat.0000000000002158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Acute kidney injury (AKI) is a common complication in patients supported by extracorporeal membrane oxygenation (ECMO). Vasoactive-Inotropic Score (VIS) serves as an indicator of the extent of cardiovascular drug support provided. Our objective is to assess the relationship between the VIS and ECMO-associated AKI (EAKI). This single-center retrospective study extracted adult patients treated with ECMO between August 2016 and September 2022 from an intensive care unit (ICU) in a university hospital. A total of 126 patients requiring ECMO support were included in the study, of which 76% developed AKI. Multivariate logistic regression analysis identified VIS-max Day1 (odds ratio [OR]: 1.025, 95% confidence interval [CI]: 1.007-1.044, p = 0.006), VIS-max Day2 (OR: 1.038, 95% CI: 1.007-1.069, p = 0.015), VIS-mean Day1 (OR: 1.048, 95% CI: 1.013-1.084, p = 0.007), and VIS-mean Day2 (OR: 1.059, 95% CI: 1.014-1.107, p = 0.010) as independent risk factors for EAKI. VIS-max Day1 showing the best predictive effect (Area under the receiver operating characteristic curve (AUROC): 0.80, sensitivity: 71.87%, specificity: 80.00%) for EAKI with a cutoff value of 33.33. Surprisingly, VIS-mean Day2 was also excellent at predicting 7 day mortality (AUROC: 0.77, sensitivity: 87.50%, specificity: 56.38%) with a cutoff value of 8.67. In conclusion, VIS could independently predict EAKI and 7 day mortality in patients with ECMO implantation, which may help clinicians to recognize the poor prognosis in time for early intervention.
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Affiliation(s)
- Dandan Zhang
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Lu Li
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Weipeng Huang
- Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chang Hu
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Weiwei Zhu
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Bo Hu
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
| | - Jianguo Li
- From the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, China
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7
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Magoon R. IABP use and outcomes in cardiac valvular surgery: a closer look! Gen Thorac Cardiovasc Surg 2024; 72:498-499. [PMID: 38594583 DOI: 10.1007/s11748-024-02029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/31/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Rohan Magoon
- Department of Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, 110001, India.
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS), Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, 110001, India.
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8
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Monaco F, Guarracino F, Vendramin I, Lei C, Zhang H, Lomivorotov V, Osinsky R, Efremov S, Gürcü ME, Mazzeffi M, Pasyuga V, Kotani Y, Biondi-Zoccai G, D'Ascenzo F, Romagnoli E, Nigro Neto C, Do Nascimento VTNDS, Ti LK, Lorsomradee S, Farag A, Bukamal N, Brizzi G, Lobreglio R, Belletti A, Arangino C, Paternoster G, Bonizzoni MA, Tucciariello MT, Kroeller D, Di Prima AL, Mantovani LF, Ajello V, Gerli C, Porta S, Ferrod F, Giardina G, Santonocito C, Ranucci M, Lembo R, Pisano A, Morselli F, Nakhnoukh C, Oriani A, Pieri M, Scandroglio AM, Kırali K, Likhvantsev V, Longhini F, Yavorovskiy A, Bellomo R, Landoni G, Zangrillo A. Acute normovolemic hemodilution in cardiac surgery: rationale and design of a multicenter randomized trial. Contemp Clin Trials 2024; 143:107605. [PMID: 38866095 DOI: 10.1016/j.cct.2024.107605] [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: 01/31/2024] [Revised: 05/12/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Igor Vendramin
- Division of Cardiac Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; Department of Medicine, University of Udine, Udine, Italy
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Vladimir Lomivorotov
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia; Penn State Milton S. Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine, Hershey, PA, USA
| | - Roman Osinsky
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia
| | - Sergey Efremov
- Saint Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Mustafa Emre Gürcü
- Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Vadim Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russian Federation
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | | | - Fabrizio D'Ascenzo
- Cardiovascular and Thoracic Department, A.O.U. Città della Salute e della Scienza, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via Pineta Sacchetti, 217, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Campus di Roma, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | | | | | | | - Ahmed Farag
- King Abdullah Medical City - Holy Capital (KAMC-HC), Makkah, Saudi Arabia
| | - Nazar Bukamal
- Cardiothoracic ICU and Anesthesia Department, Mohammed Bin Khalifa Specialist Cardiac Center, Awali 183261, Bahrain
| | - Giulia Brizzi
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Arangino
- Department of Cardiothoracic Anesthesia and Intensive Care, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Gianluca Paternoster
- Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Matteo Aldo Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Daniel Kroeller
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Valentina Ajello
- Department of Cardio Thoracic anesthesia and Intensive Care, Hospital Tor Vergata Roma, Italy
| | - Chiara Gerli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Porta
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Federica Ferrod
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Giuseppe Giardina
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Santonocito
- Anaesthesia and Intensive Care Medicine III, Policlinico University Hospital, Catania, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Pisano
- Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy
| | - Federica Morselli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Nakhnoukh
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kaan Kırali
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valery Likhvantsev
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russian Federation; Department of Anesthesiology and Resuscitation, First Moscow State Medical University, Moscow, Russian Federation
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy
| | - Andrey Yavorovskiy
- I.M. Sechenov First Moscow State Medical University, Ministry of Public Health of Russia, Moscow, Russia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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9
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Krishnan AV, Freniere V, Sahni R, Vargas Chaves DP, Krishnan SS, Savva D, Krishnan US. Safety and Tolerability of Continuous Inhaled Iloprost Therapy for Severe Pulmonary Hypertension in Neonates and Infants. CHILDREN (BASEL, SWITZERLAND) 2024; 11:703. [PMID: 38929282 PMCID: PMC11201391 DOI: 10.3390/children11060703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
This is a single-center retrospective study to assess the safety and tolerability of continuous inhaled iloprost use as rescue therapy for refractory pulmonary hypertension (PH) in critically ill neonates and infants. A retrospective chart review was performed on 58 infants and data were collected at baseline, 1, 6, 12, 24, 48 and 72 h of iloprost initiation. Primary outcomes were change in heart rate (HR), fraction of inspired oxygen (FiO2), mean airway pressures (MAP), blood pressure (BP) and oxygenation index (OI). Secondary outcomes were need for extracorporeal membrane oxygenation (ECMO) and death. 51 patients treated for >6 h were analyzed in 2 age groups, neonate (≤28 days: n = 32) and infant (29-365 days: n = 19). FiO2 (p < 0.001) and OI (p = 0.01) decreased, while there were no significant changes in MAP, BP and HR. Of the fifteen patients placed on ECMO, seven were bridged off ECMO on iloprost and eight died. Twenty-four out of fifty-one patients (47%) recovered without requiring ECMO, while twelve (23%) died. Iloprost as add-on therapy for refractory PH in critically ill infants in the NICU has an acceptable tolerability and safety profile. Large prospective multicenter studies using iloprost in the neonatal ICU are necessary to validate these results.
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Affiliation(s)
- Amit V. Krishnan
- Department of Pediatrics (Cardiology), Columbia University Irving Medical Center, New York, NY 10932, USA;
| | - Victoria Freniere
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY 10065, USA; (V.F.); (D.S.)
| | - Rakesh Sahni
- Department of Pediatrics (Neonatology), Columbia University Irving Medical Center, New York, NY 10032, USA; (R.S.); (D.P.V.C.)
| | - Diana P. Vargas Chaves
- Department of Pediatrics (Neonatology), Columbia University Irving Medical Center, New York, NY 10032, USA; (R.S.); (D.P.V.C.)
| | | | - Dimitrios Savva
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY 10065, USA; (V.F.); (D.S.)
| | - Usha S. Krishnan
- Department of Pediatrics (Cardiology), Columbia University Irving Medical Center, New York, NY 10932, USA;
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10
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Grand J, Hassager C, Schmidt H, Mølstrøm S, Nyholm B, Obling LER, Meyer MAS, Illum E, Josiassen J, Beske RP, Høigaard Frederiksen H, Dahl JS, Møller JE, Kjaergaard J. Impact of Blood Pressure Targets in Patients With Heart Failure Undergoing Postresuscitation Care: A Subgroup Analysis From a Randomized Controlled Trial. Circ Heart Fail 2024; 17:e011437. [PMID: 38847097 DOI: 10.1161/circheartfailure.123.011437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/04/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND To assess the effect of targeting higher or lower blood pressure during postresucitation intensive care among comatose patients with out-of-hospital cardiac arrest with a history of heart failure. METHODS The BOX trial (Blood Pressure and Oxygenation Targets After Out-of-Hospital Cardiac Arrest) was a randomized, controlled, double-blinded, multicenter study comparing titration of vasopressors toward a mean arterial pressure (MAP) of 63 versus 77 mm Hg during postresuscitation intensive care. Patients with a history of heart failure were included in this substudy. Pulmonary artery catheters were inserted shortly after admission. History of heart failure was assessed through chart review of all included patients. The primary outcome was cardiac index during the first 72 hours. Secondary outcomes were left ventricular ejection fraction, heart rate, stroke volume, renal replacement therapy and all-cause mortality at 365 days. RESULTS A total of 134 patients (17% of the BOX cohort) had a history of heart failure (patients with left ventricular ejection fraction, ≤40%: 103 [77%]) of which 71 (53%) were allocated to a MAP of 77 mm Hg. Cardiac index at intensive care unit arrival was 1.77±0.11 L/min·m-2 in the MAP63-group and 1.78±0.17 L/min·m-2 in the MAP77, P=0.92. During the next 72 hours, the mean difference was 0.15 (95% CI, -0.04 to 0.35) L/min·m-2; Pgroup=0.22. Left ventricular ejection fraction and stroke volume was similar between the groups. Patients allocated to MAP77 had significantly elevated heart rate (mean difference 6 [1-12] beats/min, Pgroup=0.03). Vasopressor usage was also significantly increased (P=0.006). At 365 days, 69 (51%) of the patients had died. The adjusted hazard ratio for 365 day mortality was 1.38 (0.84-2.27), P=0.20 and adjusted odds ratio for renal replacement therapy was 2.73 (0.84-8.89; P=0.09). CONCLUSIONS In resuscitated patients with out-of-hospital cardiac arrest with a history of heart failure, allocation to a higher blood pressure target resulted in significantly increased heart rate in the higher blood pressure-target group. However, no certain differences was found for cardiac index, left ventricular ejection fraction or stroke volume. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03141099.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
- Department of Cardiology, Copenhagen University Hospital Amager-Hvidovre, Denmark (J.G.)
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (C.H., J.K.)
| | - Henrik Schmidt
- Department of Anaesthesiology and Intensive Care (H.S., S.M., H.H.F.), Odense University Hospital, Denmark
| | - Simon Mølstrøm
- Department of Anaesthesiology and Intensive Care (H.S., S.M., H.H.F.), Odense University Hospital, Denmark
| | - Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
| | - Laust E R Obling
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
| | - Martin A S Meyer
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
| | - Emma Illum
- Department of Cardiology (E.I., J.S.D., J.E.M.), Odense University Hospital, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark (E.I., J.S.D., J.E.M.)
| | - Jakob Josiassen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
| | - Rasmus P Beske
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
| | | | - Jordi S Dahl
- Department of Cardiology (E.I., J.S.D., J.E.M.), Odense University Hospital, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark (E.I., J.S.D., J.E.M.)
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
- Department of Cardiology (E.I., J.S.D., J.E.M.), Odense University Hospital, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark (E.I., J.S.D., J.E.M.)
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (J.G., C.H., B.N., L.E.R.O., M.A.S.M., J.J., R.P.B., J.E.M., J.K.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (C.H., J.K.)
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11
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Goyer I, Lakbar I, Freund Y, Lévy B, Leone M. Norepinephrine dosing in France: Time to move forward! Anaesth Crit Care Pain Med 2024; 43:101397. [PMID: 38821157 DOI: 10.1016/j.accpm.2024.101397] [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: 02/22/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 06/02/2024]
Abstract
Norepinephrine is the first-line vasopressor used in acute cardio-circulatory failure. At the bedside, its dose is critical as it serves to determine the severity of patients, to compare the patients between different studies, and to start specific interventions. Recently, several investigators underlined differences in the expression of norepinephrine doses according to countries and manufacturers. For various reasons, all norepinephrine products are processed to a salt formulation thereby generating a stable and soluble conjugated acid in a slightly acidic solution. Depending on the salt used, the total weight will differ, but the weight of pure norepinephrine base is the same. This results in at-risk situations with large variations in terms of practices, evaluation and treatment. In this technical note, we summarized the evidence and provided a few suggestions to improve the practices at different levels.
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Affiliation(s)
| | - Ines Lakbar
- Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, Montpellier, France
| | - Yonathan Freund
- Sorbonne Université, IMProving Emergency Care FHU, Paris, France, and Emergency Department and Service Mobile d'Urgence et de Réanimation (SMUR), Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Bruno Lévy
- Service de Réanimation Médicale Brabois, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, and Université de Lorraine, Nancy, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France.
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12
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White K, Laupland KB, Bellomo R, Serpa-Neto A. The interaction of net ultrafiltration rate with urine output and fluid balance after continuous renal replacement therapy initiation: A multi-Centre study. J Crit Care 2024; 83:154835. [PMID: 38772126 DOI: 10.1016/j.jcrc.2024.154835] [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: 01/23/2024] [Revised: 04/18/2024] [Accepted: 05/13/2024] [Indexed: 05/23/2024]
Abstract
PURPOSE During continuous renal replacement therapy (CRRT), a high net ultrafiltration rate (NUF) may worsen the decrease in urine output (UO) associated with starting CRRT. However, fluid balance (FB) may modulate this association. We aimed to examine the relationship between NUF, UO and FB at the start of CRRT. METHODS A retrospective cohort study of 1030 CRRT-treated patients admitted to two tertiary ICUs. RESULTS Median age was 60 years (IQR, 48-70), median APACHE III was 94 (IQR, 76-114) and median NUF rate was 0.7 mL/kg/h. In the 24 h after CRRT started, the mean hourly UO decreased from 25.5 mL to 11.9 mL (P < 0.001). Moreover, after adjusting for multiple confounders on multivariable analysis, a higher NUF was not significantly associated with a lower UO (-1.5 mL/kg for every 1 mL/kg/h increase in NUF; 95% CI -3.1 to 0.04; p = 0.064). In addition, pre-CRRT FB did not modulate the above relationship between higher NUF and lower UO. CONCLUSION A higher NUF rate was not significantly associated with a greater immediate and sustained reduction in UO after CRRT commencement. FB before CRRT was also not associated with a greater reduction in UO. These findings do not provide evidence for an effect of NUF on renal function.
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Affiliation(s)
- Kyle White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ary Serpa-Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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13
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Cervera JP, López CAA, Romero RN, Macías JC, Asensio JMN, Mínguez JRL. Implementation of Society for Cardiovascular Angiography and Interventions classification in patients with cardiogenic shock secondary to acute myocardial infarction in a spanish university hospital. Acute Crit Care 2024; 39:257-265. [PMID: 38863356 PMCID: PMC11167420 DOI: 10.4266/acc.2023.01620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Killip-Kimball classification has been used for estimating death risk in patients suffering acute myocardial infarction (AMI). Killip-Kimball stage IV corresponds to cardiogenic shock. However, the Society for Cardiovascular Angiography and Interventions (SCAI) classification provides a more precise tool to classify patients according to shock severity. The aim of this study was to apply this classification to a cohort of Killip IV patients and to analyze the differences in death risk estimation between the two classifications. METHODS A single-center retrospective cohort study of 100 consecutive patients hospitalized for "Killip IV AMI" between 2016 and 2023 was performed to reclassify patients according to SCAI stage. RESULTS Distribution of patients according to SCAI stages was B=4%, C=53%, D=27%, E=16%. Thirty-day mortality increased progressively according to these stages (B=0%, C=11.88%, D=55.56%, E=87.50%; P<0.001). The exclusive use of Killip IV stage overestimated death risk compared to SCAI C (35% vs. 11.88%, P=0.002) and underestimated it compared to SCAI D and E stages (35% vs. 55.56% and 87.50%, P=0.03 and P<0.001, respectively). Age >69 years, creatinine >1.15 mg/dl and advanced SCAI stages (SCAI D and E) were independent predictors of 30-day mortality. Mechanical circulatory support use showed an almost significant benefit in advanced SCAI stages (D and E hazard ratio, 0.45; 95% confidence interval, 0.19-1.06; P=0.058). CONCLUSIONS SCAI classification showed superior death risk estimation compared to Killip IV. Age, creatinine levels and advanced SCAI stages were independent predictors of 30-day mortality. Mechanical circulatory support could play a beneficial role in advanced SCAI stages.
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Affiliation(s)
- Javier Pérez Cervera
- Cardiac Intensive Care Unit, Division of Cardiology, Complejo Hospitalario Universitario, Badajoz, Spain
| | | | | | | | | | - José Ramón López Mínguez
- Interventional Cardiology Unit, Division of Cardiology, Complejo Hospitalario Universitario, Badajoz, Spain
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14
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Rossiter A, Hilton JA, Fizza Haider S, Nasser SMT, Boyer N, Cooper C, Davis C, Marshall D, Skelding E, Pike J, Jarratt L, Wood L, Knight L, Holmes S, Cowman T, Shepley E, Dubravac N, Gray W, Munday C, Creagh-Brown B, Forni L. A service evaluation of measuring fluid responsiveness in acutely unwell hypotensive patients outside of critical care. Intensive Crit Care Nurs 2024:103694. [PMID: 38653631 DOI: 10.1016/j.iccn.2024.103694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Early recognition and prompt, appropriate management may reduce mortality in patients with sepsis. The Surviving Sepsis Campaign's guidelines suggest the use of dynamic measurements to guide fluid resuscitation in sepsis; although these methods are rarely employed to monitor cardiac output in response to fluid administration outside intensive care units. This service evaluation investigated the introduction of a nurse led protocolised goal-directed fluid management using a non-invasive cardiac output monitor to the standard assessment of hypotensive ward patients. METHODS We introduced the use of a goal-directed fluid management protocol into our critical care outreach teams' standard clinical assessment. Forty-nine sequential patients before and thirty-nine after its introduction were included in the assessment. RESULTS Patients in the post-intervention cohort received less fluid in the 6 h following outreach assessment (750mls vs 1200mls). There were no differences in clinical background or rates of renal replacement therapy, but rates of invasive and non-invasive ventilation were reduced (0% vs 31%). Although the groups were similar, the post-intervention patients had lower recorded blood pressures. CONCLUSION IV fluid therapy in the patient with hypotension complicating sepsis can be challenging. Excessive IV fluid administration is commonplace and associated with harm, and the use of advanced non-invasive haemodynamic monitoring by trained nurses can provide objective evaluation of individualised response to treatment. Avoiding excessive IV fluid and earlier institution of appropriate vasopressor therapy may improve patient outcomes. IMPLICATIONS FOR CLINICAL PRACTICE Adoption of dynamic measures of cardiac output outside of critical care by trained critical care nurses is feasible and may translate into improved patient outcomes. In hospitals with a nurse-led critical care outreach service, consideration should be given to such an approach.
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Affiliation(s)
- Adam Rossiter
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK.
| | - James Anthony Hilton
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - S Fizza Haider
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Syed M T Nasser
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Naomi Boyer
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Cath Cooper
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Charlene Davis
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | | | - Emma Skelding
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Jennifer Pike
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Laura Jarratt
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Laura Wood
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Lucy Knight
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Sophie Holmes
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Tamsin Cowman
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Elaine Shepley
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | | | - Wendy Gray
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Caz Munday
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK
| | - Ben Creagh-Brown
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Lui Forni
- Royal Surrey Hospital NHS Foundation Trust, Guildford, UK; Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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15
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Toyoshima K, Aoki H, Noguchi T, Saito N, Shimizu T, Kemmotsu T, Shimokaze T, Saito T, Shibasaki J, Kawataki M, Asou T, Tachibana T, Masutani S. Biventricular function in preterm infants with patent ductus arteriosus ligation: A three-dimensional echocardiographic study. Pediatr Res 2024:10.1038/s41390-024-03180-w. [PMID: 38615076 DOI: 10.1038/s41390-024-03180-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/05/2024] [Accepted: 03/23/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND The detailed hemodynamics after patent ductus arteriosus (PDA) ligation in preterm infants remain unknown. We aimed to clarify the effect of surgical ligation on left ventricular (LV) and right ventricular (RV) volume and function. METHODS Echocardiography was performed in 41 preterm infants (median gestational age: 25 weeks) before and after PDA ligation. Global longitudinal strain was determined using three-dimensional speckle-tracking echocardiography. These values were compared with those in 36 preterm infants without PDA (non-PDA). RESULTS Preoperatively, the PDA group had greater end-diastolic volume (EDV) and cardiac output (CO) in both ventricles, a higher LV ejection fraction (LVEF) (53% vs 44%) and LV global longitudinal strain, and a lower RVEF (47% vs 52%) than the non-PDA group. At 4-8 h postoperatively, the two groups had a similar LVEDV and RVEDV. However, the PDA group had a lower EF and CO in both ventricles than the non-PDA group. At 24-48 h postoperatively, the RVEF was increased, but the LVEF remained decreased, and LVCO was increased. CONCLUSIONS PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery. Three-dimensional echocardiography may be beneficial to understand the status of both ventricles. IMPACT Preterm infants are at high risk of hemodynamic compromise following a sudden change in loading conditions after PDA ligation. Three-dimensional echocardiography enables quantitative and serial evaluation of ventricular function and volume in preterm infants with PDA. PDA induces biventricular loading and functional abnormalities in preterm infants, and they dramatically change after surgery.
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Affiliation(s)
- Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan.
| | - Hirosato Aoki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takahiro Noguchi
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Naka Saito
- Department of Clinical Laboratory, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tatsuto Shimizu
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Takahiro Kemmotsu
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoyuki Shimokaze
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tomoko Saito
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jun Shibasaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Motoyoshi Kawataki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Toshihide Asou
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tsuyoshi Tachibana
- Department of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
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Kotani Y, D'Andria Ursoleo J, Murru CP, Landoni G. Blood Pressure Management for Hypotensive Patients in Intensive Care and Perioperative Cardiovascular Settings. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00266-0. [PMID: 38918089 DOI: 10.1053/j.jvca.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 06/27/2024]
Abstract
Blood pressure is a critical physiological parameter, particularly in the context of cardiac intensive care and perioperative settings. As a primary indicator of organ perfusion, the maintenance of adequate blood pressure is imperative for the assurance of sufficient tissue oxygen delivery. Among critically ill and major surgery patients, the continuous monitoring of blood pressure is performed as a standard practice for patients. Nonetheless, uncertainties remain regarding blood pressure goals, and there is no consensus regarding blood pressure targets. This review describes the determinants of blood pressure, examine the influence of blood pressure on organ perfusion, and synthesize the current clinical evidence from various intensive care and perioperative settings to provide a concise guidance for daily clinical practice.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Pia Murru
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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O'Shea TF, Franko LR, Paneitz DC, Shelton KT, Osho AA, Auchincloss HG. Tracheostomy is associated with decreased vasoactive-inotropic score in postoperative cardiac surgery patients on prolonged mechanical ventilation. JTCVS OPEN 2024; 18:138-144. [PMID: 38690409 PMCID: PMC11056458 DOI: 10.1016/j.xjon.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/24/2024] [Accepted: 02/02/2024] [Indexed: 05/02/2024]
Abstract
Objective We sought to quantify the influence that tracheostomy placement has on the hemodynamic stability of postoperative cardiac surgery patients with persistent ventilatory requirements. Methods A retrospective, single-center, and observational analysis of postoperative cardiac surgery patients with prolonged mechanical ventilation who underwent tracheostomy placement from 2018 to 2022 was conducted. Patients were excluded if receiving mechanical circulatory support or if they had an unrelated significant complication 3 days surrounding tracheostomy placement. Vasoactive and inotropic requirements were quantified using the Vasoactive-Inotrope Score. Results Sixty-one patients were identified, of whom 58 met inclusion criteria. The median vasoactive-inotrope score over the 3 days before tracheostomy compared with 3 days after decreased from 3.35 days (interquartile range, 0-8.79) to 0 days (interquartile range, 0-7.79 days) (P = .027). Graphic representation of this trend demonstrates a clear inflection point at the time of tracheostomy. Also, after tracheostomy placement, fewer patients were on vasoactive/inotropic infusions (67.2% [n = 39] pre vs 24.1% [n = 14] post; P < .001) and sedative infusions (62.1% [n = 36] pre vs 27.6% [n = 16] post; P < .001). The percent of patients on active mechanical ventilation did not differ. Conclusions The median vasoactive-inotrope score in cardiac surgery patients with prolonged mechanical ventilation was significantly reduced after tracheostomy placement. There was also a significant reduction in the number of patients on vasoactive/inotropic and sedative infusions 3 days after tracheostomy. These data suggest that tracheostomy has a positive effect on the hemodynamic stability of patients after cardiac surgery and should be considered to facilitate postoperative recovery.
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Affiliation(s)
| | - Lynze R. Franko
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Dane C. Paneitz
- Boston University School of Medicine, Boston, Mass
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Kenneth T. Shelton
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Mass
| | - Asishana A. Osho
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass
| | - Hugh G. Auchincloss
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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18
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Dolan KJ, Arikan A, Banc-Husu AM, Mian MUM, Thadani S, Lee JQ, Stribling L, Galván NTN, Goss J, Baijal R, Desai MS. Intraoperative renal replacement therapy during liver transplantation in children: Safety, efficacy and impact on survival. Clin Transplant 2024; 38:e15306. [PMID: 38616573 DOI: 10.1111/ctr.15306] [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: 11/28/2023] [Revised: 02/20/2024] [Accepted: 03/15/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Intraoperative Continuous Renal Replacement Therapy (iCRRT) can prevent life-threatening complications, facilitate fluid management, and maintain metabolic homeostasis during liver transplantation (LT) in adults. There is a paucity of data in pediatric LT. We evaluated the safety, efficacy, and impact on survival of iCRRT in pediatric LT. METHODS We conducted a retrospective cohort study of all children requiring CRRT pre-OLT at a quaternary children's hospital from 2014 to 2022. Demographic characteristics, intraoperative events, and post-LT outcomes were compared between those who received iCRRT and those who did not. RESULTS Out of 306 patients who received LT, 30 (10%) were supported with CRRT at least 24 h prior to LT, of which 11 (36%) received iCRRT. The two cohorts were similar in demographics, diagnosis of liver disease, and severity of illness. The iCRRT patients experienced massive blood loss and increased transfusion requirements. There was no difference in intraoperative metabolic balance. One-year post-LT mortality rates were similar. CONCLUSION ICRRT is safe in critically ill children with pre-LT renal dysfunction. It optimizes fluid and blood product resuscitation while maintaining metabolic homeostasis. Candidates need to be carefully chosen for this highly resource-intensive therapy to benefit this fragile population.
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Affiliation(s)
- Kristin J Dolan
- Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ayse Arikan
- Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
- Division of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Anna M Banc-Husu
- Division of Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Houston, Texas, USA
| | | | - Sameer Thadani
- Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
- Division of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - N Thao N Galván
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - John Goss
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - Rahul Baijal
- Division of Pediatric Anesthesiology, Perioperative, and Pain Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Moreshwar S Desai
- Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
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19
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Costa-Pinto R, Neto AS, Matthewman MC, Osrin D, Liskaser G, Li J, Young M, Jones D, Udy A, Warrillow S, Bellomo R. Dose equivalence for metaraminol and noradrenaline - A retrospective analysis. J Crit Care 2024; 80:154430. [PMID: 38245376 DOI: 10.1016/j.jcrc.2023.154430] [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: 05/26/2023] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Noradrenaline and metaraminol are commonly used vasopressors in critically ill patients. However, little is known of their dose equivalence. METHODS We conducted a single centre retrospective cohort study of all ICU patients who transitioned from metaraminol to noradrenaline infusions between August 26, 2016 and December 31, 2020. Patients receiving additional vasoactive drug infusion were excluded. Dose equivalence was calculated based on the last hour metaraminol dose (in μg/min) and the first hour noradrenaline dose (in μg/min) with the closest matched mean arterial pressure (MAP). Sensitivity analyses were performed on patients with acute kidney injury (AKI), sepsis and mechanical ventilation. RESULTS We studied 195 patients. The median conversion ratio of metaraminol to noradrenaline was 12.5:1 (IQR 7.5-20.0) for the overall cohort. However, the coefficient of variation was 77% and standard deviation was 11.8. Conversion ratios were unaffected by sepsis or mechanical ventilation but increased (14:1) with AKI. One in five patients had a MAP decrease of >10 mmHg during the transition period from metaraminol to noradrenaline. Post-transition noradrenaline dose (p < 0.001) and AKI (p = 0.045) were independently associated with metaraminol dose. The proportion of variation in noradrenaline dose predicted from metaraminol dose was low (R2 = 0.545). CONCLUSIONS The median dose equivalence for metaraminol and noradrenaline in this study was 12.5:1. However, there was significant variance in dose equivalence, only half the proportion of variation in noradrenaline infusion dose was predicted by metaraminol dose, and conversion-associated hypotension was common.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Dean Osrin
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Jasun Li
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Marcus Young
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Daryl Jones
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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20
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Hayashi H, Kirschner M, Vinogradsky A, Ning Y, Kurlansky P, Yuzefpolskaya M, Colombo PC, Sayer GT, Uriel N, Naka Y, Takeda K. Acute right ventricular geometric change predicts outcomes in HeartMate 3 patients. J Heart Lung Transplant 2024; 43:642-651. [PMID: 38070663 DOI: 10.1016/j.healun.2023.11.020] [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: 01/13/2023] [Revised: 10/24/2023] [Accepted: 11/27/2023] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND The physiological response of the right ventricle (RV) following left ventricular assist device (LVAD) implantation is difficult to predict. We aimed to investigate RV geometric and functional changes after LVAD insertion and their effects on clinical outcomes. METHODS We retrospectively reviewed 188 patients who underwent HeartMate 3 implantation at our center between November 2014 and September 2021. The RV end-diastolic diameter (RVEDD) and RV end-diastolic area (RVEDA) were measured on preoperative and predischarge transthoracic echocardiography. The nonadapted group included patients with increased RVEDD and RVEDA at discharge. The composite outcome was defined as death or readmission due to worsening right heart failure. RESULTS There were 82 patients (44%) who had a nonadapted and 106 patients (56%) who had an adapted RV. Preoperatively, the nonadapted group had smaller RVEDD (46 vs 49 mm, p < 0.001) and RVEDA (27 vs 31 cm2, p < 0.001). At discharge, the nonadapted group had larger RVEDD (51 vs 43 mm, p < 0.001) and RVEDA (33 vs 27 cm2, p < 0.001). Kaplan-Meier analysis demonstrated worse 3-year survival (77% vs 91%, p = 0.006) and freedom from composite outcome (58% vs 85%, p < 0.001) in the nonadapted group. A multivariable Cox proportional hazards model showed that nonadaption (hazard ratio [HR] 3.09, 95% confidence interval [CI] 1.29-7.40, p = 0.01) and age (HR 3.73, 95% CI 1.42-9.77, p = 0.007) were independent predictors of composite outcome. CONCLUSIONS Acute RV dimensional changes after LVAD insertion may represent intrinsic RV function and may be a useful prognostic marker.
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Affiliation(s)
- Hideyuki Hayashi
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York.
| | - Michael Kirschner
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Alice Vinogradsky
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Yuming Ning
- Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, New York
| | - Paul Kurlansky
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Gabriel T Sayer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York; Department of Surgery, Division of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, New York
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
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21
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Erdoğan SB, Bastopcu M, Usca MK, Çakmak AY, Sargın M, Aka S. The Utility of Risk Scores in Postcardiotomy Extracorporeal Membrane Oxygenation. Perfusion 2024; 39:578-584. [PMID: 36705013 DOI: 10.1177/02676591231154741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The use of a venoarterial extracorporeal membrane oxygenation (ECMO) in the postcardiotomy shock setting (PC-ECMO) can be life-saving. Risk stratification for patients under PC-ECMO is currently challenging. The aim of this study was to assess the discriminatory ability of the different available risk scores for mortality in PC-ECMO patients. METHODS Patients aged >18 years undergoing coronary artery bypass, valve surgery, or a combination of these procedures and implanted an ECMO for postcardiotomy shock between January 2017 and June 2022 in a single ELSO registered center were retrospectively included. The STS, Euroscore II, SAVE, modified SAVE, APACHE II, and VIS scores were compared for their discriminatory ability concerning weaning and 30-day survival. RESULTS During the study period, 7342 patients underwent coronary bypass or valve surgery, of whom 109 patients with PC-ECMO were included in the analysis. The Euroscore II and STS scores were not associated significantly with 30-day mortality, whereas the SAVE, the modified SAVE, APACHE II, and VIS scores significantly predicted 30-day mortality. The SAVE and the modified SAVE scores showed moderate discrimination ability with AUCs of 0.672 and 0.695, while the APACHE and VIS scores had a satisfactory discriminatory ability with AUCs of 0.727 and 0.844, respectively. CONCLUSION Currently used risk scores for PC-ECMO patients do not provide satisfactory predictions for weaning and survival. VIS at the 24th hour can be a valuable parameter for risk analysis and prospective studies can investigate novel PC-ECMO risk scoring systems.
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Affiliation(s)
- Sevinç B Erdoğan
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Mehmet Kağan Usca
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Arif Yasin Çakmak
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Murat Sargın
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
| | - Serap Aka
- Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Research and Training Center, Istanbul, Turkey
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22
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Santonocito C, Cassisi C, Chiarenza F, Caruso A, Murabito P, Maybauer MO, George S, Sanfilippo F. Morning or Afternoon Scheduling for Elective Coronary Artery Bypass Surgery: Influence of Longer Fasting Periods from Metabolic and Hemodynamic Perspectives. Ann Card Anaesth 2024; 27:136-143. [PMID: 38607877 PMCID: PMC11095776 DOI: 10.4103/aca.aca_204_23] [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: 12/12/2023] [Revised: 01/17/2024] [Accepted: 01/29/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Prolonged preoperative fasting may worsen postoperative outcomes. Cardiac surgery has higher perioperative risk, and longer fasting periods may be not well-tolerated. We analysed the postoperative metabolic and hemodynamic variables in patients undergoing elective coronary artery bypass grafting (CABG) according to their morning or afternoon schedule. METHODS Single-centre retrospective study at University teaching hospital (1-year data collection from electronic medical records). Using a mixed-effects linear regression model adjusted for several covariates, we compared metabolic (lactatemia, pH, and base deficit [BD]) and haemodynamic values (patients on vasoactive support, and vasoactive inotropic score [VIS]) at 7 prespecified time-points (admission to intensive care, and 1st, 3rd, 6th, 12th, 18th, and 24th postoperative hours). RESULTS 339 patients (n = 176 morning, n = 163 afternoon) were included. Arterial lactatemia and BD were similar (overall P = 0.11 and P = 0.84, respectively), while pH was significantly lower in the morning group (overall P < 0.05; mean difference -0.01). Postoperative urine output, fluid balance, mean arterial pressure, and central venous pressure were similar (P = 0.59, P = 0.96, P = 0.58 and P = 0.53, respectively). A subgroup analysis of patients with diabetes (n = 54 morning, n = 45 afternoon) confirmed the same findings. The VIS values and the proportion of patients on vasoactive support was higher in the morning cases at the 18th (P = 0.002 and p=0.04, respectively) and 24th postoperative hours (P = 0.003 and P = 0.04, respectively). Mean intensive care length of stay was 1.94 ± 1.36 days versus 2.48 ± 2.72 days for the afternoon and morning cases, respectively (P = 0.02). CONCLUSIONS Patients undergoing elective CABG showed similar or better metabolic and hemodynamic profiles when scheduled for afternoon surgery.
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Affiliation(s)
- Cristina Santonocito
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco,”, Catania, Italy
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Cesare Cassisi
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco,”, Catania, Italy
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Federica Chiarenza
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco,”, Catania, Italy
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Alessandro Caruso
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco,”, Catania, Italy
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Paolo Murabito
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco,”, Catania, Italy
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Marc O. Maybauer
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, FL, United States
- Department of Anesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Shane George
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
| | - Filippo Sanfilippo
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
- Department of Anaesthesia and Intensive Care, A.O.U. “Policlinico-San Marco,”, Catania, Italy
- School of Anesthesia and Intensive Care, University of Catania, Catania, Italy
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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23
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Nersesian G, Lewin D, Ott S, Schoenrath F, Hrytsyna Y, Starck C, Spillmann F, O'Brien B, Falk V, Potapov E, Lanmueller P. Temporary extracorporeal life support: single-centre experience with a new concept. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae043. [PMID: 38490254 PMCID: PMC10980585 DOI: 10.1093/icvts/ivae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/22/2024] [Accepted: 03/13/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVES The combination of veno-arterial extracorporeal membrane oxygenation with a micro-axial flow pump (ECMELLA) is increasingly used for cardiogenic shock (CS) therapy. We report our experience with a novel single-artery access ECMELLA setup with either femoral (2.0) or jugular venous cannulation (2.1), respectively. METHODS Data from 67 consecutive CS patients treated with ECMELLA 2.0 (n = 56) and 2.1 (n = 11) from December 2020 and December 2022 in a tertiary cardiac center were retrospectively analyzed. RESULTS The mean age was 60.7 ± 11 years, 56 patients (84%) were male. CS aetiology was acute on chronic heart failure (n = 35, 52%), myocardial infarction (n = 13, 19.5%), postcardiotomy syndrome (n = 16, 24%) and myocarditis (n = 3, 4.5%). Preoperatively 31 patients (46%) were resuscitated, 53 (79%) were on a ventilator and 60 (90%) were on inotropic support. The median vasoactive inotropic score was 32, and the mean arterial lactate was 8.1 mmol/l. In 39 patients (58%), veno-arterial extracorporeal membrane oxygenation was explanted after a median ECMELLA support of 4 days. Myocardial recovery was achieved in 18 patients (27%), transition to a durable left ventricular assist device in 16 (24%). Thirty-three patients (n = 33; 49%) died on support (25 on ECMELLA and 8 on Impella after de-escalation), 9 (13%) of whom were palliated. Axillary access site bleeding occurred in 9 patients (13.5%), upper limb ischaemia requiring surgical revision in 3 (4.5%). Axillary site infection occurred in 6 cases (9%), and perioperative stroke in 10 (15%; 6 hemorrhagic, 4 thromboembolic). CONCLUSIONS ECMELLA 2.0/2.1 is a feasible and effective therapy for severe CS. The single-artery cannulation technique is associated with a relatively low rate of access-related complications.
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Affiliation(s)
- Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Daniel Lewin
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Sascha Ott
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Yuriy Hrytsyna
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Frank Spillmann
- Department of Internal Medicine and Cardiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Benjamin O'Brien
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- William Harvey Research Institute, London, UK
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Health Sciences and Technology, Institute of Translational Medicine, Translational Cardiovascular Technologies, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Pia Lanmueller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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24
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Kazawa M, Kabata D, Yoshida H, Minami K, Maeda T, Yoshitani K, Matsuda H, Shintani A. Amino acids to prevent cardiac surgery-associated acute kidney injury: a randomized controlled trial. JA Clin Rep 2024; 10:19. [PMID: 38528235 DOI: 10.1186/s40981-024-00703-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND This study aimed to examine the preventive effect of amino acids on postoperative acute kidney injury (AKI). METHODS This was single-center, patient- and assessor-blinded, randomized controlled trial. Patients who underwent aortic surgery with cardiopulmonary bypass were included. The intervention group received 60 g/day of amino acids for up to 3 days. The control group received standard care. The primary outcome was the incidence of AKI. We assessed the effect of amino acids on AKI using a Cox proportional hazards regression model. RESULTS Sixty-six patients were randomly assigned to the control or intervention group. One patient in the control group withdrew consent after randomization. The incidence of AKI was 10 patients (30.3%) in the intervention group versus 18 patients (56.2%) in the control group (adjusted hazard ratio, 0.44; 95% confidence interval, 0.20-0.95; P = 0.04). CONCLUSIONS This trial demonstrated a significant reduction in AKI incidence with amino acid supplementation. TRIAL REGISTRATION jRCT, jRCTs051210154. Registered 31 December 2021, https://jrct.niph.go.jp/re/reports/detail/69916.
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Affiliation(s)
- Masahiro Kazawa
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shinmachi, Suita, Osaka, Japan.
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan.
| | - Daijiro Kabata
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kimito Minami
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, 6-1, Kishibe-Shinmachi, Suita, Osaka, Japan
| | - Takuma Maeda
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenji Yoshitani
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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25
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Faltys M, Neto AS, Cioccari L. Physiological changes after fluid bolus therapy in cardiac surgery patients: A propensity score matched case-control study. CRIT CARE RESUSC 2024; 26:32-40. [PMID: 38690188 PMCID: PMC11056405 DOI: 10.1016/j.ccrj.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 05/02/2024]
Abstract
Objective Fluid bolus therapy (FBT) is ubiquitous in intensive care units (ICUs) after cardiac surgery. However, its physiological effects remain unclear. Design : We performed an electronic health record-based quasi-experimental ICU study after cardiac surgery. We applied propensity score matching and compared the physiological changes after FBT episodes to matched control episodes where despite equivalent physiology no fluid bolus was given. Setting The study was conducted in a multidisciplinary ICU of a tertiary-level academic hospital. Participants The study included 2,736 patients who underwent Coronary Artery Bypass Grafting and/or heart valve surgery. Main Outcome Measures Changes in cardiac output (CO) and mean arterial pressure (MAP) during the 60 minutes following FBT. Results We analysed 3572 matched fluid bolus (FB) episodes. After FBT, but not in control episodes, CO increased within 10 min, with a maximum increase of 0.2 l/min (95%CI 0.1 to 0.2) or 4% above baseline at 40 min (p < 0.0001 vs. controls). CO increased by > 10% from baseline in 60.6% of FBT and 49.1% of control episodes (p < 0.0001). MAP increased by > 10% in 51.7% of FB episodes compared to 53.4% of controls. Finally, FBT was not associated with changes in acid-base status or oxygen delivery. Conclusion In this quasi-experimental comparative ICU study in cardiac surgery patients, FBT was associated with statistically significant but numerically small increases in CO. Nearly half of FBT failed to induce a positive CO or MAP response.
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Affiliation(s)
- Martin Faltys
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC 3004, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | - Luca Cioccari
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
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Caruso V, Berthoud V, Bouchot O, Nguyen M, Bouhemad B, Guinot PG. Should the Vasoactive Inotropic Score be a Determinant for Early Initiation of VA ECMO in Postcardiotomy Cardiogenic Shock? J Cardiothorac Vasc Anesth 2024; 38:724-730. [PMID: 38182434 DOI: 10.1053/j.jvca.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVES The authors investigated the role of early venoarterial extracorporeal membrane oxygenation (VA ECMO) implantation in patients with postcardiotomy cardiogenic shock (PCS) on mortality and morbidity when integrating vasoactive-inotropic score (VIS) and type of catecholamine support. DESIGN A retrospective, multicenter, observational study with propensity-weight matching. SETTING Four university-affiliated intensive care units. PARTICIPANTS Patients with PCS in the operating room. INTERVENTIONS Early VA ECMO support. MEASUREMENTS AND MAIN RESULTS Of 2,742 patients screened during the study period, 424 (16%) patients were treated with inotropic drugs, and 75 (3%) patients were supported by VA ECMO in the operating room. Patients supported by VA ECMO had a higher use of vasopressor and inotropic drugs, with a higher VIS score. After propensity matching (integrating VIS and catecholamines type), mortality (56% v 20%, p < 0.001) and morbidity (cardiac, renal, transfusion) were higher in patients supported by VA ECMO than in a matched control group. CONCLUSIONS When matching integrated the pre-ECMO VIS and the type of catecholamines, VA ECMO remained associated with high mortality and morbidity, suggesting that VIS alone should not be used as a main determinant of VA ECMO implantation.
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Affiliation(s)
- Vincenza Caruso
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Olivier Bouchot
- Department of Cardiac Surgery, Dijon University Medical Centre, Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, Dijon, France.
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Suárez MDP, Fernández-Sarmiento J, González LE, Rico MP, Barajas JS, Amaya RG. Evaluation of the Renal Angina Index to Predict the Development of Acute Kidney Injury in Children With Sepsis Who Live in Middle-Income Countries. Pediatr Emerg Care 2024; 40:208-213. [PMID: 37079697 DOI: 10.1097/pec.0000000000002951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
OBJECTIVE The renal angina index (RAI) provides a clinically feasible and applicable tool to identify critically ill children at risk of severe acute kidney injury (AKI) in high-income countries. Our objective was to evaluate the performance of the RAI as a predictor of the development of AKI in children with sepsis in a middle-income country and its association with unfavorable outcomes. METHODS This is a retrospective cohort study in children with sepsis hospitalized in the pediatric intensive care unit (PICU) between January 2016 and January 2020. The RAI was calculated 12 hours after admission to predict the development of AKI and at 72 hours to explore its association with mortality, the need for renal support therapy, and PICU stay. RESULTS We included 209 PICU patients with sepsis with a median age of 23 months (interquartile range, 7-60). We found that 41.1% of the cases (86/209) developed de novo AKI on the third day of admission (KDIGO 1, 24.9%; KDIGO 2, 12.9%; and KDIGO 3, 3.3%).Overall mortality was 8.1% (17/209), higher in patients with AKI (7.7% vs 0.5%, P < 0.01). The RAI on admission was able to predict the presence of AKI on day 3 (area under the curve (AUC), 0.87; sensitivity, 94.2%; specificity, 100%; P < 0.01), with a negative predictive value greater than 95%. An RAI greater than 8 at 72 hours was associated with a greater risk of mortality (adjusted odds ratio [aOR], 2.6; 95% confidence interval [CI], 2.0-3.2; P < 0.01), a need for renal support therapy (aOR, 2.9; 95% CI, 2.3-3.6; P < 0.01), and a PICU stay of more than 10 days (aOR, 1.54; 95% CI, 1.1-2.1; P < 0.01). CONCLUSIONS The RAI on the day of admission is a reliable and accurate tool for predicting the risk of developing AKI on day 3, in critically ill children with sepsis in a limited resource context. A score greater than eight 72 hours after admission is associated with a higher risk of death, the need for renal support therapy, and PICU stay.
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Affiliation(s)
| | - Jaime Fernández-Sarmiento
- Pediatrics and Intensive Care Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | | | - Mayerly Prada Rico
- From the Departments of Pediatrics and Pediatric Nephrology, Universidad del Bosque
| | - Juan Sebastián Barajas
- Pediatrics and Intensive Care Universidad de La Sabana, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
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Wintermark P, Lapointe A, Steinhorn R, Rampakakis E, Burhenne J, Meid AD, Bajraktari-Sylejmani G, Khairy M, Altit G, Adamo MT, Poccia A, Gilbert G, Saint-Martin C, Toffoli D, Vachon J, Hailu E, Colin P, Haefeli WE. Feasibility and Safety of Sildenafil to Repair Brain Injury Secondary to Birth Asphyxia (SANE-01): A Randomized, Double-blind, Placebo-controlled Phase Ib Clinical Trial. J Pediatr 2024; 266:113879. [PMID: 38142044 DOI: 10.1016/j.jpeds.2023.113879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/21/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE To test feasibility and safety of administering sildenafil in neonates with neonatal encephalopathy (NE), developing brain injury despite therapeutic hypothermia (TH). STUDY DESIGN We performed a randomized, double-blind, placebo-controlled phase Ib clinical trial between 2016 and 2019 in neonates with moderate or severe NE, displaying brain injury on day-2 magnetic resonance imaging (MRI) despite TH. Neonates were randomized (2:1) to 7-day sildenafil or placebo (2 mg/kg/dose enterally every 12 hours, 14 doses). Outcomes included feasibility and safety (primary outcomes), pharmacokinetics (secondary), and day-30 neuroimaging and 18-month neurodevelopment assessments (exploratory). RESULTS Of the 24 enrolled neonates, 8 were randomized to sildenafil and 3 to placebo. A mild decrease in blood pressure was reported in 2 of the 8 neonates after initial dose, but not with subsequent doses. Sildenafil plasma steady-state concentration was rapidly reached, but decreased after TH discontinuation. Twelve percent of neonates (1/8) neonates died in the sildenafil group and 0% (0/3) in the placebo group. Among surviving neonates, partial recovery of injury, fewer cystic lesions, and less brain volume loss on day-30 magnetic resonance imaging were noted in 71% (5/7) of the sildenafil group and in 0% (0/3) of the placebo group. The rate of death or survival to 18 months with severe neurodevelopmental impairment was 57% (4/7) in the sildenafil group and 100% (3/3) in the placebo group. CONCLUSIONS Sildenafil was safe and well-absorbed in neonates with NE treated with TH. Optimal dosing needs to be established. Evaluation of a larger number of neonates through subsequent phases II and III trials is required to establish efficacy. CLINICAL TRIAL REGISTRATION ClinicalTrials.govNCT02812433.
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Affiliation(s)
- Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada.
| | - Anie Lapointe
- Department of Neonatology, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Robin Steinhorn
- Department of Pediatrics, University of California San Diego, and Rady Children's Hospital, San Diego, CA
| | | | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gzona Bajraktari-Sylejmani
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - May Khairy
- Department of Pediatrics, McGill University, Montreal, Québec, Canada
| | - Gabriel Altit
- Division of Newborn Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Marie-Therese Adamo
- Pharmacy Department, McGill University Health Center, Montreal, Québec, Canada
| | - Alishia Poccia
- Research Institute of the McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Guillaume Gilbert
- MR Clinical Science, Philips Healthcare, Mississauga, Ontario, Canada
| | | | - Daniela Toffoli
- Department of Ophthalmology, McGill University, Montreal, Québec, Canada
| | - Julie Vachon
- Member of the Ordre des Psychologues du Quebec, Montreal, Québec, Canada
| | - Elizabeth Hailu
- Division of Newborn Medicine, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Patrick Colin
- Patrick Colin Consultant Inc, Montreal, Québec, Canada
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
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Bocchino PP, Cingolani M, Frea S, Angelini F, Gallone G, Garatti L, Sacco A, Raineri C, Pidello S, Morici N, De Ferrari GM. Organ perfusion pressure at admission and clinical outcomes in patients hospitalized for acute heart failure. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:215-224. [PMID: 37883706 DOI: 10.1093/ehjacc/zuad133] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 10/11/2023] [Accepted: 10/23/2023] [Indexed: 10/28/2023]
Abstract
AIMS Hypoperfusion portends adverse outcomes in acute heart failure (AHF). The gradient between end-organ inflow and outflow pressures may more closely reflect hypoperfusion than mean arterial pressure (MAP) alone. The aim of this study was to investigate organ perfusion pressure (OPP), calculated as MAP minus central venous pressure (CVP), as a prognostic marker in AHF. METHODS AND RESULTS The Sodium NItroPrusside Treatment in Acute Heart Failure (SNIP)-AHF study was a multicentre retrospective cohort study of 200 consecutive patients hospitalized for AHF treated with sodium nitroprusside. Only patients with both MAP and invasive CVP data available from the SNIP-AHF cohort were included in this analysis. The primary endpoint was to assess OPP as a predictor of worsening heart failure (WHF), defined as the worsening of signs and symptoms of heart failure leading to intensification of therapy at 48 h. One hundred and forty-six patients fulfilling the inclusion criteria were included [mean age: 61.1 ± 13.5 years, 32 (21.9%) females; mean body mass index: 26.2 ± 11.7 kg/m2; mean left ventricular ejection fraction: 23.8%±11.4%, mean MAP: 80.2 ± 13.2 mmHg, and mean CVP: 14.0 ± 6.1 mmHg]. WHF occurred in 14 (9.6%) patients. At multivariable models including hemodynamic variables (OPP, shock index, and CVP), OPP at admission was the best predictor of WHF at 48 h [OR 0.91 (95% confidence interval 0.86-0.96), P-value = 0.001] with an optimal cut-off value of 67.5 mmHg (specificity 47.3%, sensitivity 100%, and AUC 0.784 ± 0.054). In multivariable models, including univariable significant parameters available at first bedside assessment, namely New York Heart Association functional class, OPP, shock index, CVP, and left ventricular end-diastolic diameter, OPP consistently and significantly predicted WHF at 48 h. CONCLUSION In this retrospective analysis on patients hospitalized for AHF treated with sodium nitroprusside, on-admission OPP significantly predicted WHF at 48 h with high sensitivity.
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Affiliation(s)
- Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Marco Cingolani
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Laura Garatti
- Department of Cardiology De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alice Sacco
- Department of Cardiology De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Raineri
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Stefano Pidello
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
| | - Nuccia Morici
- IRCCS Fondazione Don Gnocchi, ONLUS, Santa Maria Nascente, Milan, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Citta della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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Falk L, Lidegran M, Diaz Ruiz S, Hultman J, Broman LM. Severe Lung Dysfunction and Pulmonary Blood Flow during Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:1113. [PMID: 38398425 PMCID: PMC10889439 DOI: 10.3390/jcm13041113] [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: 01/10/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is indicated for patients with severe respiratory and/or circulatory failure. The standard technique to visualize the extent of pulmonary damage during ECMO is computed tomography (CT). PURPOSE This single-center, retrospective study investigated whether pulmonary blood flow (PBF) measured with echocardiography can assist in assessing the extent of pulmonary damage and whether echocardiography and CT findings are associated with patient outcomes. METHODS All patients (>15 years) commenced on ECMO between 2011 and 2017 with septic shock of pulmonary origin and a treatment time >28 days were screened. Of 277 eligible patients, 9 were identified where both CT and echocardiography had been consecutively performed. RESULTS CT failed to indicate any differences in viable lung parenchyma within or between survivors and non-survivors at any time during ECMO treatment. Upon initiation of ECMO, the survivors (n = 5) and non-survivors (n = 4) had similar PBF. During a full course of ECMO support, survivors showed no change in PBF (3.8 ± 2.1 at ECMO start vs. 7.9 ± 4.3 L/min, p = 0.12), whereas non-survivors significantly deteriorated in PBF from 3.5 ± 1.0 to 1.0 ± 1.1 L/min (p = 0.029). Tidal volumes were significantly lower over time among the non-survivors, p = 0.047. CONCLUSIONS In prolonged ECMO for pulmonary septic shock, CT was not found to be effective for the evaluation of pulmonary viability or recovery. This hypothesis-generating investigation supports echocardiography as a tool to predict pulmonary recovery via the assessment of PBF at the early to later stages of ECMO support.
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Affiliation(s)
- Lars Falk
- ECMO Centre Karolinska, ME Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Straket 14, 171 76 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Marika Lidegran
- Department of Pediatric Radiology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.L.); (S.D.R.)
| | - Sandra Diaz Ruiz
- Department of Pediatric Radiology, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 76 Stockholm, Sweden; (M.L.); (S.D.R.)
- Department of Women’s and Children’s Health, Karolinska Institutet, 171 76 Stockholm, Sweden
- Department of Radiology, Lund University, 221 00 Lund, Sweden
| | - Jan Hultman
- ECMO Centre Karolinska, ME Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Straket 14, 171 76 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, ME Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Akademiska Straket 14, 171 76 Stockholm, Sweden; (J.H.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 171 76 Stockholm, Sweden
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Seefeldt JM, Libai Y, Berg K, Jespersen NR, Lassen TR, Dalsgaard FF, Ryhammer P, Pedersen M, Ilkjaer LB, Hu MA, Erasmus ME, Nielsen RR, Bøtker HE, Caspi O, Eiskjær H, Moeslund N. Effects of ketone body 3-hydroxybutyrate on cardiac and mitochondrial function during donation after circulatory death heart transplantation. Sci Rep 2024; 14:757. [PMID: 38191915 PMCID: PMC10774377 DOI: 10.1038/s41598-024-51387-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024] Open
Abstract
Normothermic regional perfusion (NRP) allows assessment of therapeutic interventions prior to donation after circulatory death transplantation. Sodium-3-hydroxybutyrate (3-OHB) increases cardiac output in heart failure patients and diminishes ischemia-reperfusion injury, presumably by improving mitochondrial metabolism. We investigated effects of 3-OHB on cardiac and mitochondrial function in transplanted hearts and in cardiac organoids. Donor pigs (n = 14) underwent circulatory death followed by NRP. Following static cold storage, hearts were transplanted into recipient pigs. 3-OHB or Ringer's acetate infusions were initiated during NRP and after transplantation. We evaluated hemodynamics and mitochondrial function. 3-OHB mediated effects on contractility, relaxation, calcium, and conduction were tested in cardiac organoids from human pluripotent stem cells. Following NRP, 3-OHB increased cardiac output (P < 0.0001) by increasing stroke volume (P = 0.006), dP/dt (P = 0.02) and reducing arterial elastance (P = 0.02). Following transplantation, infusion of 3-OHB maintained mitochondrial respiration (P = 0.009) but caused inotropy-resistant vasoplegia that prevented weaning. In cardiac organoids, 3-OHB increased contraction amplitude (P = 0.002) and shortened contraction duration (P = 0.013) without affecting calcium handling or conduction velocity. 3-OHB had beneficial cardiac effects and may have a potential to secure cardiac function during heart transplantation. Further studies are needed to optimize administration practice in donors and recipients and to validate the effect on mitochondrial function.
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Affiliation(s)
- Jacob Marthinsen Seefeldt
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Yaara Libai
- The Laboratory for Cardiovascular Precision Medicine, Rapport Faculty of Medicine, Technion and Rambam's Cardiovascular Research and Innovation Center, 2 Efron St, Haifa, Israel
| | - Katrine Berg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Nichlas Riise Jespersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Thomas Ravn Lassen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Frederik Flyvholm Dalsgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Pia Ryhammer
- Department of Anesthesiology, Regional Hospital Silkeborg, Falkevej 1A, 8600, Silkeborg, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Lars Bo Ilkjaer
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
| | - Michiel A Hu
- Department of Cardiothoracic Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Michiel E Erasmus
- Department of Cardiothoracic Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Roni R Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Hans Erik Bøtker
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Oren Caspi
- The Laboratory for Cardiovascular Precision Medicine, Rapport Faculty of Medicine, Technion and Rambam's Cardiovascular Research and Innovation Center, 2 Efron St, Haifa, Israel
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Niels Moeslund
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus N, Denmark
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Sun YT, Wu W, Yao YT. The association of vasoactive-inotropic score and surgical patients' outcomes: a systematic review and meta-analysis. Syst Rev 2024; 13:20. [PMID: 38184601 PMCID: PMC10770946 DOI: 10.1186/s13643-023-02403-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/30/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND The objective of this study is to conduct a systematic review and meta-analysis examining the relationship between the vasoactive-inotropic score (VIS) and patient outcomes in surgical settings. METHODS Two independent reviewers searched PubMed, Web of Science, EMBASE, Scopus, Cochrane Library, Google Scholar, and CNKI databases from November 2010, when the VIS was first published, to December 2022. Additional studies were identified through hand-searching the reference lists of included studies. Eligible studies were those published in English that evaluated the association between the VIS and short- or long-term patient outcomes in both pediatric and adult surgical patients. Meta-analysis was performed using RevMan Manager version 5.3, and quality assessment followed the Joanna Briggs Institute (JBI) Critical Appraisal Checklists. RESULTS A total of 58 studies comprising 29,920 patients were included in the systematic review, 34 of which were eligible for meta-analysis. Early postoperative VIS was found to be associated with prolonged mechanical ventilation (OR 5.20, 95% CI 3.78-7.16), mortality (OR 1.08, 95% CI 1.05-1.12), acute kidney injury (AKI) (OR 1.26, 95% CI 1.13-1.41), poor outcomes (OR 1.02, 95% CI 1.01-1.04), and length of stay (LOS) in the ICU (OR 3.50, 95% CI 2.25-5.44). The optimal cutoff value for the VIS as an outcome predictor varied between studies, ranging from 10 to 30. CONCLUSION Elevated early postoperative VIS is associated with various adverse outcomes, including acute kidney injury (AKI), mechanical ventilation duration, mortality, poor outcomes, and length of stay (LOS) in the ICU. Monitoring the VIS upon return to the Intensive Care Unit (ICU) could assist medical teams in risk stratification, targeted interventions, and parent counseling. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022359100.
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Affiliation(s)
- Yan-Ting Sun
- Department of Anesthesiology, Baoji High-Tech Hospital, Shaanxi, 721000, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Wei Wu
- Department of Anesthesiology, Baoji High-Tech Hospital, Shaanxi, 721000, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100037, China.
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Duan J, Ge H, Fan W, Du L, Zhang H, Jiamaliding A, Duan B, Ma Q. Cardiac Arrest-Associated Coagulopathy Could Predict 30-day Mortality: A Retrospective Study from Medical Information Mart for Intensive Care IV Database. Clin Appl Thromb Hemost 2024; 30:10760296231221986. [PMID: 38196194 PMCID: PMC10777779 DOI: 10.1177/10760296231221986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/23/2023] [Accepted: 12/06/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Cardiac arrest (CA) can activate the coagulation system. Some coagulation-related indicators are associated with clinical outcomes. Early evaluation of patients with cardiac arrest-associated coagulopathy (CAAC) not only predicts clinical outcomes, but also allows for timely clinical intervention to prevent disseminated intravascular coagulation. OBJECTIVE To assess whether CAAC predicts 30-day cumulative mortality. METHODS From the Medical Information Mart for Intensive Care IV (MIMIC-IV) database, we conducted a retrospective cohort study from 2008 to 2019. Based on international normalized ratio (INR) value and platelet count, we diagnosed CAAC cases and made the following stratification of severity: mild CAAC was defined as 1.4 > INR≧1.2 and 100,000/µL < platelet count≦150,000/µL; moderate CAAC was defined with either 1.6 > INR≧1.4 or 80,000/µL < platelet count≦100,000/µL; severe CAAC was defined as an INR≧1.6 and platelet count≦80,000/µL. RESULTS A total of 1485 patients were included. Crude survival analysis showed that patients with CAAC had higher mortality risk than those without CAAC (33.0% vs 52.0%, P < 0.001). Unadjusted survival analysis showed an incremental increase in the risk of mortality as the severity of CAAC increased. After adjusting confounders (prehospital characteristics and hospitalization characteristics), CAAC was independently associated with 30-day mortality (hazard rate [HR] 1.77, 95% confidence interval [CI] 1.41-2.25; P < 0.001); moderate CAAC (HR 1.48, 95% CI 1.09-2.10; P = 0.027) and severe CAAC (HR 2.22, 95% CI 1.64-2.97; P < 0.001) were independently associated with 30-day mortality. CONCLUSION The presence of CAAC identifies a group of CA at higher risk for mortality, and there is an incremental increase in risk of mortality as the severity of CAAC increases. However, the results of this study should be further verified by multicenter study.
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Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Hongxia Ge
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Wenyang Fan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Lanfang Du
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Hua Zhang
- Department of Epidemiology, Peking University Third Hospital, Beijing, China
| | | | - Baomin Duan
- Emergency Department, Kaifeng Central Hospital, Kaifeng, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
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Keleş BO, Yılmaz ET, Altınbaş A, Zengin S, Yılmaz S. When is the Ideal Time to Calculate the Vasoactive Inotropic Score as a Predictor of Mortality and Morbidity in Cardiac Surgery? A Retrospective Study. Ann Card Anaesth 2024; 27:37-42. [PMID: 38722119 PMCID: PMC10876136 DOI: 10.4103/aca.aca_127_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/09/2023] [Accepted: 09/29/2023] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the prediction of vasoactive inotropic score (VIS) on early mortality and morbidity after coronary artery bypass grafting (CABG) and to determine the ideal time for score calculation. MATERIALS AND METHODS The study included patients who underwent isolated on-pump CABG surgery between November 2021 and November 2022. Pre, intra, and postoperative data were obtained by retrospective chart review. The final VIS value in the operating room (VISintra) and the highest VIS value in the first 24 hours in the intensive care unit (VISmax) were calculated. The patients were divided into two groups; Group 1 who developed early postoperative morbidity and mortality and Group 2 who did not. And the data were analyzed by groups. RESULTS A total of 221 patients with a mean age of 63.49 ± 9.96 years were evaluated and 73 (33%) were in Group 1. The cut-off value for VISintra was determined to be 6.20, VISmax was 6,05. VISintra and VISmax values were significantly higher in the poor outcome group. Multivariate analysis showed that only VISmax value was an independent variable on mortality-morbidity. CONCLUSIONS Our results imply that the vasoactive inotropic score is an easy and inexpensive score to calculate and can be used as a specific scoring system to predict poor early outcomes in CABG patients. According to statistical analyses, the most predictive time among VIS measurements was VISmax, the highest value calculated in the ICU in the first 24 hours postoperatively.
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Affiliation(s)
- Bilge Olgun Keleş
- Department of Anesthesiology and Reanimation, Giresun University Faculty of Medicine, Giresun, Turkey
| | - Elvan Tekir Yılmaz
- Department of Anesthesiology and Reanimation, Giresun University Faculty of Medicine, Giresun, Turkey
| | - Ali Altınbaş
- Department of Anesthesiology and Reanimation, Giresun University Faculty of Medicine, Giresun, Turkey
| | - Sabür Zengin
- Department of Cardiovascular Surgery, Giresun University Faculty of Medicine, Giresun, Turkey
| | - Seyhan Yılmaz
- Department of Cardiovascular Surgery, Giresun University Faculty of Medicine, Giresun, Turkey
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Zhao JO, Patel BK, Krishack P, Stutz MR, Pearson SD, Lin J, Lecompte-Osorio PA, Dugan KC, Kim S, Gras N, Pohlman A, Kress JP, Hall JB, Sperling AI, Adegunsoye A, Verhoef PA, Wolfe KS. Identification of Clinically Significant Cytokine Signature Clusters in Patients With Septic Shock. Crit Care Med 2023; 51:e253-e263. [PMID: 37678209 PMCID: PMC10840934 DOI: 10.1097/ccm.0000000000006032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To identify cytokine signature clusters in patients with septic shock. DESIGN Prospective observational cohort study. SETTING Single academic center in the United States. PATIENTS Adult (≥ 18 yr old) patients admitted to the medical ICU with septic shock requiring vasoactive medication support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred fourteen patients with septic shock completed cytokine measurement at time of enrollment (t 1 ) and 24 hours later (t 2 ). Unsupervised random forest analysis of the change in cytokines over time, defined as delta (t 2 -t 1 ), identified three clusters with distinct cytokine profiles. Patients in cluster 1 had the lowest initial levels of circulating cytokines that decreased over time. Patients in cluster 2 and cluster 3 had higher initial levels that decreased over time in cluster 2 and increased in cluster 3. Patients in clusters 2 and 3 had higher mortality compared with cluster 1 (clusters 1-3: 11% vs 31%; odds ratio [OR], 3.56 [1.10-14.23] vs 54% OR, 9.23 [2.89-37.22]). Cluster 3 was independently associated with in-hospital mortality (hazard ratio, 5.24; p = 0.005) in multivariable analysis. There were no significant differences in initial clinical severity scoring or steroid use between the clusters. Analysis of either t 1 or t 2 cytokine measurements alone or in combination did not reveal clusters with clear clinical significance. CONCLUSIONS Longitudinal measurement of cytokine profiles at initiation of vasoactive medications and 24 hours later revealed three distinct cytokine signature clusters that correlated with clinical outcomes.
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Affiliation(s)
- Jack O Zhao
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Bhakti K Patel
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Paulette Krishack
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Matthew R Stutz
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Steven D Pearson
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Julie Lin
- Pulmonary Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | | | | | - Seoyoen Kim
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Nicole Gras
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Anne Pohlman
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - John P Kress
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Jesse B Hall
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Anne I Sperling
- Pulmonary & Critical Care, University of Virginia, Charlottesville, VA
| | - Ayodeji Adegunsoye
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Philip A Verhoef
- Critical Care Medicine, Hawaii Permanente Medical Group, Honolulu, HI
| | - Krysta S Wolfe
- Pulmonary and Critical Care, University of Chicago Medical Center, Chicago, IL
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Dhar R, Marklin GF, Klinkenberg WD, Wang J, Goss CW, Lele AV, Kensinger CD, Lange PA, Lebovitz DJ. Intravenous Levothyroxine for Unstable Brain-Dead Heart Donors. N Engl J Med 2023; 389:2029-2038. [PMID: 38048188 PMCID: PMC10752368 DOI: 10.1056/nejmoa2305969] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Hemodynamic instability and myocardial dysfunction are major factors preventing the transplantation of hearts from organ donors after brain death. Intravenous levothyroxine is widely used in donor care, on the basis of observational data suggesting that more organs may be transplanted from donors who receive hormonal supplementation. METHODS In this trial involving 15 organ-procurement organizations in the United States, we randomly assigned hemodynamically unstable potential heart donors within 24 hours after declaration of death according to neurologic criteria to open-label infusion of intravenous levothyroxine (30 μg per hour for a minimum of 12 hours) or saline placebo. The primary outcome was transplantation of the donor heart; graft survival at 30 days after transplantation was a prespecified recipient safety outcome. Secondary outcomes included weaning from vasopressor therapy, donor ejection fraction, and number of organs transplanted per donor. RESULTS Of the 852 brain-dead donors who underwent randomization, 838 were included in the primary analysis: 419 in the levothyroxine group and 419 in the saline group. Hearts were transplanted from 230 donors (54.9%) in the levothyroxine group and 223 (53.2%) in the saline group (adjusted risk ratio, 1.01; 95% confidence interval [CI], 0.97 to 1.07; P = 0.57). Graft survival at 30 days occurred in 224 hearts (97.4%) transplanted from donors assigned to receive levothyroxine and 213 hearts (95.5%) transplanted from donors assigned to receive saline (difference, 1.9 percentage points; 95% CI, -2.3 to 6.0; P<0.001 for noninferiority at a margin of 6 percentage points). There were no substantial between-group differences in weaning from vasopressor therapy, ejection fraction on echocardiography, or organs transplanted per donor, but more cases of severe hypertension and tachycardia occurred in the levothyroxine group than in the saline group. CONCLUSIONS In hemodynamically unstable brain-dead potential heart donors, intravenous levothyroxine infusion did not result in significantly more hearts being transplanted than saline infusion. (Funded by Mid-America Transplant and others; ClinicalTrials.gov number, NCT04415658.).
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Affiliation(s)
- Rajat Dhar
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Gary F Marklin
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - W Dean Klinkenberg
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Jinli Wang
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Charles W Goss
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Abhijit V Lele
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Clark D Kensinger
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Paul A Lange
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
| | - Daniel J Lebovitz
- From the Department of Neurology, Section of Neurocritical Care (R.D.), and the Center for Biostatistics and Data Science (J.W., C.W.G.), Washington University School of Medicine, and Mid-America Transplant (G.F.M., W.D.K.) - both in St. Louis; the Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, and LifeCenter Northwest, Bellevue - both in Washington (A.V.L.); LifeLink of Georgia, Norcross, and Piedmont Transplant Institute, Atlanta - both in Georgia (C.D.K.); Donor Alliance, Denver (P.A.L.); and Akron Children's Hospital, Akron, OH (D.J.L.)
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Lomivorotov V, Merekin D, Fominskiy E, Ponomarev D, Bogachev-Prokophiev A, Zalesov A, Cherniavsky A, Shilova A, Guvakov D, Lomivorotova L, Lembo R, Landoni G. Myocardial protection with phosphocreatine in high-risk cardiac surgery patients: a randomized trial. BMC Anesthesiol 2023; 23:389. [PMID: 38030971 PMCID: PMC10685505 DOI: 10.1186/s12871-023-02341-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/06/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND This study was conducted to test the hypothesis that phosphocreatine (PCr), administered intravenously and as cardioplegia adjuvant in patients undergoing cardiac surgery with prolonged aortic cross clamping and cardiopulmonary bypass (CPB) time, would decrease troponin I concentration after surgery. METHODS In this randomized, double-blind, placebo-controlled pilot study we included 120 patients undergoing double/triple valve repair/replacement under cardiopulmonary bypass in the cardiac surgery department of a tertiary hospital. The treatment group received: intravenous administration of 2 g of PCr after anesthesia induction; 2.5 g of PCr in every 1 L of cardioplegic solution (concentration = 10 mmol/L); intravenous administration of 2 g of PCr immediately after heart recovery following aorta declamping; 4 g of PCr at intensive care unit admission. The control group received an equivolume dose of normosaline. RESULTS The primary endpoint was peak concentration of troponin I after surgery. Secondary endpoints included peak concentration of serum creatinine, need for, and dosage of inotropic support, number of defibrillations after aortic declamping, incidence of arrhythmias, duration of Intensive Care Unit (ICU) stay, length of hospitalization. There was no difference in peak troponin I concentration after surgery (PCr, 10,508 pg/ml [IQR 6,838-19,034]; placebo, 11,328 pg/ml [IQR 7.660-22.894]; p = 0.24). There were also no differences in median peak serum creatinine (PCr, 100 µmol/L [IQR 85.0-117.0]; placebo, 99.5 µmol/L [IQR 90.0-117.0]; p = 0.87), the number of patients on vasopressor/inotropic agents (PCr, 49 [88%]; placebo, 57 [91%]; p = 0.60), the inotropic score on postoperative day 1 (PCr, 4.0 (0-7); placebo, 4.0 (0-10); p = 0.47), mean SOFA score on postoperative day 1 (PCr, 5.25 ± 2.33; placebo, 5,45 ± 2,65; p = 0.83), need for defibrillation after declamping of aorta (PCr, 22 [39%]; placebo, 25 [40%]; p = 0.9),, duration of ICU stay and length of hospitalization as well as 30-day mortality (PCr, 0 (0%); placebo,1 (4.3%); p = 0.4). CONCLUSION PCr administration to patients undergoing double/triple valve surgery under cardiopulmonary bypass is safe but is not associated with a decrease in troponin I concentration. Phosphocreatine had no beneficial effect on clinical outcomes after surgery. TRIAL REGISTRATION The study is registered at ClinicalTrials.gov with the Identifier: NCT02757443. First posted (published): 02/05/2016.
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Affiliation(s)
- Vladimir Lomivorotov
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Dmitry Merekin
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Dmitry Ponomarev
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | | | - Anton Zalesov
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Alexander Cherniavsky
- Department of Aortic and Coronary Artery Surgery, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Anna Shilova
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Dmitry Guvakov
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Liudmila Lomivorotova
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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Peters BJ, Barreto EF, Mara KC, Kashani KB. Continuous Renal Replacement Therapy and Mortality in Critically Ill Obese Adults. Crit Care Explor 2023; 5:e0998. [PMID: 38304705 PMCID: PMC10833633 DOI: 10.1097/cce.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
IMPORTANCE The outcomes of critically ill adults with obesity on continuous renal replacement therapy (CRRT) are poorly characterized. The impact of CRRT dose on these outcomes is uncertain. OBJECTIVES This study aimed to determine if obesity conferred a survival advantage for critically ill adults with acute kidney injury (AKI) on CRRT. Secondarily, we evaluated whether the dose of CRRT predicted mortality in this population. DESIGN SETTING AND PARTICIPANTS A retrospective, observational cohort study performed at an academic medical center in Minnesota. The study population included critically ill adults with AKI managed with CRRT. MAIN OUTCOMES AND MEASURES The primary outcome of 30-day mortality was compared between obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese (BMI < 30 kg/m2) patients. Multivariable regression assessed was used to assess CRRT dose as a predictor of outcomes. An analysis included dose indexed according to actual body weight (ABW), adjusted body weight (AdjBW), or ideal body weight (IBW). RESULTS Among 1033 included patients, the median (interquartile range) BMI was 26 kg/m2 (23-28 kg/m2) in the nonobese group and 36 kg/m2 (32-41 kg/m2) in the obese group. Mortality was similar between groups at 30 days (54% vs. 48%; p = 0.06) but lower in the obese group at 90 days (62% vs. 55%; p = 0.02). CRRT dose predicted an increase in mortality when indexed according to ABW or AdjBW (hazard ratio [HR], 1.2-1.16) but not IBW (HR, 1.04). CONCLUSIONS AND RELEVANCE In critically ill adults with AKI requiring CRRT, short-term mortality appeared lower in obese patients compared with nonobese patients. Among weight calculations, IBW appears to be preferred to promote safe CRRT dosing in obese patients.
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Affiliation(s)
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Chaiyakulsil C, Thadahirunchot T. Implementation and effectiveness of a delirium care protocol in Thai critically ill children. Acute Crit Care 2023; 38:488-497. [PMID: 38052514 DOI: 10.4266/acc.2023.00045] [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: 01/03/2023] [Accepted: 10/07/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Delirium in critically ill children can result in long-term morbidity. Our main objectives were to evaluate the effectiveness of a new protocol on the reduction, prevalence, and duration of delirium and to identify associated risk factors. METHODS The effectiveness of the protocol was evaluated by a chart review in all critically ill children aged 1 month to 15 years during the study period. A Cornell Assessment of Pediatric Delirium score ≥9 was considered positive for delirium. Data on delirium prevalence and duration from the pre-implementation and post-implementation phases were compared. Univariate and multivariate analyses were used to identify the risk factors of delirium. RESULTS A total of 120 children was analyzed (58 children in the pre-implementation group and 62 children in the post-implementation group). Fifty children (41.7%) screened positive for delirium. Age less than 2 years, delayed development, use of mechanical ventilation, and pediatric intensive care unit (PICU) stay >7 days were significantly associated with delirium. The proportion of children screened positive was not significantly different after the implementation (before, 39.7% vs. after, 43.5%; P=0.713). Subgroup analyses revealed a significant reduction in the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. CONCLUSIONS The newly implemented protocol was able to reduce the duration of delirium in children with admission diagnosis of cardiovascular problems and after cardiothoracic surgery. More studies should be conducted to reduce delirium to prevent long-term morbidity after PICU discharge.
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Affiliation(s)
- Chanapai Chaiyakulsil
- Division of Pediatric Critical Care, Department of Pediatrics, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Grand J, Hassager C, Schmidt H, Mølstrøm S, Nyholm B, Høigaard HF, Dahl JS, Meyer M, Beske RP, Obling L, Kjaergaard J, Møller JE. Serial assessments of cardiac output and mixed venous oxygen saturation in comatose patients after out-of-hospital cardiac arrest. Crit Care 2023; 27:410. [PMID: 37891623 PMCID: PMC10612339 DOI: 10.1186/s13054-023-04704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023] Open
Abstract
AIM To assess the association with outcomes of cardiac index (CI) and mixed venous oxygen saturation (SvO2) in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In the cohort study of 789 patients included in the "BOX"-trial, 565 (77%) patients were included in this hemodynamic substudy (age 62 ± 13 years, male sex 81%). Pulmonary artery catheters were inserted shortly after ICU admission. CI and SvO2 were measured as soon as possible in the ICU and until awakening or death. The endpoints were all-cause mortality at 1 year and renal failure defined as need for renal replacement therapy. RESULTS First measured CI was median 1.7 (1.4-2.1) l/min/m2, and first measured SvO2 was median 67 (61-73) %. CI < median with SvO2 > median was present in 222 (39%), and low SvO2 with CI < median was present in 59 (11%). Spline analysis indicated that SvO2 value < 55% was associated with poor outcome. Low CI at admission was not significantly associated with mortality in multivariable analysis (p = 0.14). SvO2 was significantly inversely associated with mortality (hazard ratioadjusted: 0.91 (0.84-0.98) per 5% increase in SvO2, p = 0.01). SvO2 was significantly inversely associated with renal failure after adjusting for confounders (ORadjusted: 0.73 [0.62-0.86] per 5% increase in SvO2, p = 0.001). The combination of lower CI and lower SvO2 was associated with higher risk of mortality (hazard ratioadjusted: 1.54 (1.06-2.23) and renal failure (ORadjusted: 5.87 [2.34-14.73]. CONCLUSION First measured SvO2 after resuscitation from OHCA was inversely associated with mortality and renal failure. If SvO2 and CI were below median, the risk of poor outcomes increased significantly. REGISTRATION The BOX-trial is registered at clinicaltrials.gov (NCT03141099, date 2017-30-04, retrospectively registered).
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Affiliation(s)
- Johannes Grand
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Cardiology, Copenhagen University Hospital Amager-Hvidovre, Copenhagen, Denmark.
| | - Christian Hassager
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, 5000, Odense, Denmark
| | - Benjamin Nyholm
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | | | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
| | - Martin Meyer
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Rasmus P Beske
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Laust Obling
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology B, Section 2142, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, 5000, Odense, Denmark
- Clinical Institute University of Southern Denmark, Odense, Denmark
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Forin E, Lorenzoni G, Ferrer R, De Cal M, Zanella M, Marchionna N, Gregori D, Forfori F, Lorenzin A, Danzi V, Ronco C, De Rosa S. Endotoxin removal therapy with Polymyxin B immobilized fiber column: a single center experience from EUPHAS2 registry. Sci Rep 2023; 13:17600. [PMID: 37845296 PMCID: PMC10579294 DOI: 10.1038/s41598-023-44850-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 10/12/2023] [Indexed: 10/18/2023] Open
Abstract
Although the precise clinical indication for initiation of PMX-HA is widely debated in the literature, a proper patient selection and timing of treatment delivery might play a critical role in the clinical course of a specific subphenotype of septic shock (endotoxic shock). In light of this view, since 2019, we have introduced in our clinical practice a diagnostic-therapeutic flowchart to select patients that can benefit the most from the treatment proposed. In addition, we reported in this study our experience of PMX-HA in a cohort of critically ill patients admitted to our intensive care unit (ICU). We analyzed a single centre, retrospective, observational web-based database (extracted from the EUPHAS2 registry) of critically ill patients admitted to the ICU between January 2016 and May 2021 who were affected by endotoxic shock. Patients were divided according to the diagnostic-therapeutic flowchart in two groups: Pre-Flowchart (Pre-F) and Post-Flowchart (Post-F). From January 2016 to May 2021, 61 patients were treated with PMX-HA out of 531 patients diagnosed with septic shock and of these, fifty patients (82%) developed AKI during their ICU stay. The most common source of infection was secondary peritonitis (36%), followed by community-acquired pneumonia (29%). Fifty-five (90%) out of 61 patients received a second PMX-HA treatment, with a statistically significant difference between the two groups (78% of the Pre-F vs. 100% of the Post-F group, p = 0.005). In both groups, between T0 and T120, the Endotoxin Activity Assay (EAA) decreased, while the SOFA score, mean arterial pressure (MAP), and Vasoactive Inotropic Score (VIS) improved with no statistically significant difference. Furthermore, when performing a propensity score matching analysis to compare mortality between the two groups, statistically significant lower ICU and 90-day mortalities were observed in the Post-F group [p = 0.016]. Although in this experienced centre data registry, PMX-HA was associated with organ function recovery, hemodynamic improvement, and current EAA level reduction in critically ill patients with endotoxic shock. Following propensity score-matched analysis, ICU mortality and 90-day mortalities were lower in the diagnostic-therapeutic flowchart group when considering two temporal groups based on strict patient selection criteria and timing to achieve PMX. Further Randomised Control Trials focused on centre selection, adequate training and a flowchart of action when assessing extracorporeal blood purification use should be performed.
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Affiliation(s)
- Edoardo Forin
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group (SODIR), Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain
- Intensive Care Department, Hospital Universitari Vall d́'Hebron, Barcelona, Spain
| | - Massimo De Cal
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Nicola Marchionna
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Francesco Forfori
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, The University of Pisa, Pisa, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
| | - Vinicio Danzi
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, Vicenza, Italy.
- Centre for Medical Sciences - CISMed, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy.
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Nersesian G, Ott S, Fardman A, Lanmueller P, Lewin D, Bernhardt A, Emrich F, Faerber G, Szabó G, Oezkur M, Panholzer B, Rojas SV, Saeed D, Schmack B, Warnecke G, Zimpfer D, Grubitzsch H, Falk V, Potapov E. Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients after Cardiac Procedures: Selection Algorithm and Weaning Strategies. Life (Basel) 2023; 13:2045. [PMID: 37895427 PMCID: PMC10608612 DOI: 10.3390/life13102045] [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: 09/07/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Mechanical circulatory support has proven effective in managing postcardiotomy cardiogenic shock by stabilizing patients' hemodynamics and ensuring adequate organ perfusion. Among the available device modalities, the combination of extracorporeal life support and a microaxial flow pump for left ventricular unloading has emerged as a valuable tool in the surgical armamentarium. In this publication, we provide recommendations for the application and weaning of temporary mechanical circulatory support in cardiogenic shock patients, derived from a consensus among leading cardiac centers in German-speaking countries.
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Affiliation(s)
- Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Sascha Ott
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), 13353 Berlin, Germany
| | - Alexander Fardman
- Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Pia Lanmueller
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Daniel Lewin
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
| | - Alexander Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20251 Hamburg, Germany
| | - Fabian Emrich
- Department of Cardiac Surgery, Goethe University Hospital, 60590 Frankfurt, Germany
| | - Gloria Faerber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, 07747 Jena, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, Middle German Heart Centre, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital Mainz, 55131 Mainz, Germany
| | - Bernd Panholzer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Sebastian V. Rojas
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr-University Bochum, 32545 Bad Oeynhausen, Germany
| | - Diyar Saeed
- Department for Cardiac Surgery, Heart Center Niederrhein, 47805 Krefeld, Germany
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, 45147 Essen, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Daniel Zimpfer
- Department of Cardiothoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Herko Grubitzsch
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10178 Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, 10178 Berlin, Germany
- Department of Health Sciences and Technology, ETH Zurich, 8092 Zurich, Switzerland
| | - Evgenij Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Augustenburger Platz 1, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
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Kunigo T, Oikawa R, Sonoda T, Nomura M. No association between pulmonary artery catheter use and postoperative complications in off-pump coronary artery bypass grafting: a single-center pilot study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:541-547. [PMID: 37458732 DOI: 10.23736/s0021-9509.23.12710-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND A pulmonary artery catheter is often used in cardiac surgery despite its uncertain effectiveness. The aim of this pilot study was to investigate the associations between the use of a pulmonary artery catheter and clinical outcomes in off-pump coronary artery bypass grafting. METHODS Patients over 20 years of age who had undergone off-pump coronary artery bypass grafting between December 2018 and November 2021 were enrolled in this single-center retrospective pilot study. The propensity score of pulmonary artery catheterization was calculated. Multivariate analysis including the propensity score as a covariate was performed to assess clinical outcomes. The primary outcome was the composite outcome of in-hospital death, unplanned intraoperative conversion to cardiopulmonary bypass, resuscitated cardiac arrest, mechanical circulatory support, myocardial infarction, stroke, new initiation of renal replacement therapy, inhaled nitric oxide, re-intubation and tracheostomy. RESULTS Among the 315 patients who were enrolled, 298 were included in the final analysis. A pulmonary artery catheter was inserted in 131 patients. There were 50 patients with the composite outcome including two in-hospital deaths. Multivariate logistic regression analysis showed that pulmonary artery catheterization was not significantly related to the composite outcome. Clinical outcomes worsened significantly as the number of anastomoses increased (odds ratio: 1.450, 95% confidence interval: 1.040-2.040, P=0.029). CONCLUSIONS Pulmonary artery catheterization did not improve the clinical outcomes in off-pump coronary artery bypass grafting in this pilot study.
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Affiliation(s)
- Tatsuya Kunigo
- School of Medicine, Department of Anesthesiology, Sapporo Medical University, Sapporo, Japan -
- School of Medicine, Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan -
| | - Risa Oikawa
- School of Medicine, Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tomoko Sonoda
- Department of Public Health, Sapporo Medical University, School of Medicine, Sapporo, Japan
| | - Minoru Nomura
- School of Medicine, Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
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Pölkki A, Pekkarinen PT, Lahtinen P, Koponen T, Reinikainen M. Vasoactive Inotropic Score compared to the sequential organ failure assessment cardiovascular score in intensive care. Acta Anaesthesiol Scand 2023; 67:1219-1228. [PMID: 37278095 DOI: 10.1111/aas.14287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND The cardiovascular component of the sequential organ failure assessment (cvSOFA) score may be outdated because of changes in intensive care. Vasoactive Inotropic Score (VIS) represents the weighted sum of vasoactive and inotropic drugs. We investigated the association of VIS with mortality in the general intensive care unit (ICU) population and studied whether replacing cvSOFA with a VIS-based score improves the accuracy of the SOFA score as a predictor of mortality. METHODS We studied the association of VIS during the first 24 h after ICU admission with 30-day mortality in a retrospective study on adult medical and non-cardiac emergency surgical patients admitted to Kuopio University Hospital ICU, Finland, in 2013-2019. We determined the area under the receiver operating characteristic curve (AUROC) for the original SOFA and for SOFAVISmax , where cvSOFA was replaced with maximum VIS (VISmax ) categories. RESULTS Of 8079 patients, 1107 (13%) died within 30 days. Mortality increased with increasing VISmax . AUROC was 0.813 (95% confidence interval [CI], 0.800-0.825) for original SOFA and 0.822 (95% CI: 0.810-0.834) for SOFAVISmax , p < .001. CONCLUSION Mortality increased consistently with increasing VISmax . Replacing cvSOFA with VISmax improved the predictive accuracy of the SOFA score.
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Affiliation(s)
- Anssi Pölkki
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Pirkka T Pekkarinen
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pasi Lahtinen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - Timo Koponen
- Department of Anaesthesiology and Intensive Care, North Karelia Central Hospital, Joensuu, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
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Ngai J, Keny N, James L, Katz S, Moazami N. Intraoperative Considerations and Management of Simultaneous Heart Kidney Transplantation. J Cardiothorac Vasc Anesth 2023; 37:1862-1869. [PMID: 37210325 DOI: 10.1053/j.jvca.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Jennie Ngai
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York.
| | - Nikhil Keny
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Simon Katz
- NYIT College of Osteopathic Medicine, Glen Head, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
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Bertini P, Paternoster G, Landoni G, Falcone M, Nocci M, Costanzo D, Brizzi G, Romani M, Esposito A, Guarracino F. Beneficial effects of levosimendan to wean patients from VA-ECMO: a systematic review and meta-analysis. Minerva Cardiol Angiol 2023; 71:564-574. [PMID: 35687316 DOI: 10.23736/s2724-5683.22.06054-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Patients with refractory cardiogenic shock can benefit from veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The use of levosimendan in VA-ECMO patients may facilitate weaning and enhance survival. EVIDENCE ACQUISITION MEDLINE, Scopus, Web of Science, and Cochrane were searched from inception to October 10th, 2021. Eligible clinical trials and observational studies reporting the use of levosimendan in VA-ECMO were searched. Two reviewers extracted data and independently assessed the risk of bias. To integrate the data, a random-effect model was applied. The success of weaning from VA-ECMO was the primary outcome. EVIDENCE SYNTHESIS Ten observational studies, including a total of 987 patients, were identified. Levosimendan was associated with successful weaning (362/448) compared with controls (328/539) (OR 2.37, 95% CI 1.71-3.28; P=0.01) and reduced mortality (144/433 vs. 258/507) (nine studies, OR 0.53, 95% CI 0.36-0.78; P=0.01) compared with control. CONCLUSIONS Levosimendan was associated with successful weaning and increased survival in VA-ECMO patients. Randomized trials should confirm these findings.
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Affiliation(s)
- Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy -
| | - Gianluca Paternoster
- Division of Cardiac Resuscitation, Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Falcone
- Infectious Disease Unit, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Matteo Nocci
- Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Diego Costanzo
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Giulia Brizzi
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Matteo Romani
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Andrea Esposito
- Unit of Vascular Surgery, San Carlo Hospital, Potenza, Italy
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Pieri M, Bonizzoni MA, Belletti A, Calabrò MG, Fominskiy E, Nardelli P, Ortalda A, Scandroglio AM. Extracorporeal Blood Purification with CytoSorb in 359 Critically Ill Patients. Blood Purif 2023; 52:759-767. [PMID: 37669640 DOI: 10.1159/000530872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/17/2023] [Indexed: 09/07/2023]
Abstract
INTRODUCTION Critically ill patients with inflammatory dysregulation and organ disfunction may benefit from blood purification, although the use of this technique has not been described in large case series. We evaluated clinical outcomes and survival in high-risk intensive care unit (ICU) patients who underwent extracorporeal blood purification. METHODS 359 consecutive ICU patients treated with CytoSorb were included. RESULTS Main admission diagnoses were 120 (34%) refractory cardiac arrest under mechanical chest compression; 101 (28%) profound cardiogenic shock; 81 (23%) post-cardiotomy cardiogenic shock; and 37 (10%) respiratory failure. Fifteen patients (4%) were positive for SARS-CoV-2 infection. We observed 49% 30-day mortality, 57% ICU mortality, and 62% hospital mortality, all lower than the 71% mortality predicted by SAPS II and 68% predicted by SOFA score. Parameters of shock and organ failure, above all vasoactive inotropic score, reduced during CytoSorb treatment. Multivariable analysis identified SAPS II, lactate dehydrogenase, ICU stay duration, vasoactive inotropic score, lactates, intra-aortic counterpulsation on top of VA-ECMO, and total bilirubin as predictors of mortality. No CytoSorb-related complications occurred. CONCLUSION CytoSorb treatment was effective in reducing laboratory parameters of shock and vasoactive inotropic score with possible survival implications in a large population of critically ill patients.
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Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo A Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria G Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna M Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Lau YH, Li AY, Lim SL, Woo KL, Ramanathan K, Chua HR, Akalya K, Tan AY, Phua J, Tan JJ, Puah SH, Chia YW, Loh SC, Ahmed Khan F, Chatterjee S, Kaushik M, See KC. Association of anticoagulation use during continuous kidney replacement therapy and 90-day outcomes: A multicentre study. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:390-397. [PMID: 38920170 DOI: 10.47102/annals-acadmedsg.202337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Anticoagulation is recommended during continuous kidney replacement therapy (CKRT) to prolong the filter lifespan for optimal filter performance. We aimed to evaluate the effect of anticoagulation during CKRT on dialysis dependence and mortality within 90 days of intensive care unit (ICU) admission. Method Our retrospective observational study evaluated the first CKRT session in critically ill adults with acute kidney injury (AKI) in Singapore from April to September 2017. The primary outcome was a composite of dialysis dependence or death within 90 days of ICU admission; the main exposure variable was anticoagulation use (regional citrate anticoagulation [RCA] or systemic heparin). Multivariable logistic regression was performed to adjust for possible confounders: age, female sex, Acute Physiology and Chronic Health Evaluation (APACHE II) score, liver dysfunction, coagulopathy (international normalised ratio[INR] >1.5) and platelet counts of less than 100,000/uL). Results The study cohort included 276 patients from 14 participating adult ICUs, of whom 176 (63.8%) experienced dialysis dependence or death within 90 days of ICU admission (19 dialysis dependence, 157 death). Anticoagulation significantly reduced the odds of the primary outcome (adjusted odds ratio [AOR] 0.47, 95% confidence interval [CI] 0.27-0.83, P=0.009). Logistic regression analysis using anticoagulation as a 3-level indicator variable demonstrated that RCA was associated with mortality reduction (AOR 0.46, 95% CI 0.25-0.83, P=0.011), with heparin having a consistent trend (AOR 0.51, 95% CI 0.23-1.14, P=0.102). Conclusion Among critically ill patients with AKI, anticoagulation use during CKRT was associated with reduced dialysis or death at 90 days post-ICU admission, which was statistically significant for regional citrate anticoagulation and trended in the same direction of benefit for systemic heparin anticoagulation. Anticoagulation during CKRT should be considered whenever possible.
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Affiliation(s)
- Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Andrew Y Li
- Department of Respiratory Service, Department of Medicine, Woodlands Health Campus, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kai Lee Woo
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | | | - Horng-Ruey Chua
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - K Akalya
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore
| | - Addy Yh Tan
- Department of Anaesthesia, National University Hospital Singapore
| | - Jason Phua
- Fast and Chronic programmes, Alexandra Hospital, National University Health System; Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Jonathan Je Tan
- Anaesthesia, Intensive Care, Mount Elizabeth Novena Hospital, Singapore
| | - Ser Hon Puah
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Yew Woon Chia
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Sean Ch Loh
- Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | | | | | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, National University Hospital Singapore
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Zhao D, Yang R, Liu S, Ge D, Su X. Study on the Characteristics of Early Cytokine Storm Response to Cardiac Surgery. J Interferon Cytokine Res 2023; 43:351-358. [PMID: 37566476 DOI: 10.1089/jir.2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Cardiac surgery can provoke an acute cytokine storm that may contribute to the development of postoperative multiple organ dysfunction syndrome. We prospectively observed patients undergoing cardiac surgery and divided them into two groups: the severe group and the mild group. Healthy individuals were enrolled acting as the control group for comparison. Plasma samples and clinical data were recorded at the initiation of cardiac-pulmonary bypass (CPB) and 3, 6, 12, 24, and 48 h after initiation of CPB. Cytokine levels were detected using the Luminex® technique. Thirty-nine adults were enrolled in this study (14 in the severe group, 15 in the mild group, and 10 in the control group). Cytokine concentrations were significantly higher in the severe group. Principal component analysis was used to establish a cytokine storm intensity curve, which represented the overall trend of 10 cytokines. The peak concentrations of interleukin (IL)-6, IL-10, and IL-16 were 425.1, 198.5, and 623.0 pg/mL, which were more than 1,200, 1,800, and 240 times the normal level, respectively. The maximum cytokine storm intensity predated the maximum Vasoactive-Inotropic Score (VIS) and Sequential Organ Failure Assessment (SOFA) score in the severe group. Cytokine storm response to cardiac surgery occurred early and was associated with disease severity. Interventions to cytokine storm should be initiated early as guided by cytokine storm biomarkers such as IL-6, IL-10, and IL-16 in severe patients undergoing cardiac surgery. Clinical Trial Registration: ChiCTR1900021351.
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Affiliation(s)
- Danyang Zhao
- Department of Nephrology, Qingdao West Coast New District People's Hospital, Qingdao, China
| | - Rongli Yang
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Sibo Liu
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Dong Ge
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Xiaolei Su
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
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50
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Chandrasekhar A, Padrós-Valls R, Pallarès-López R, Palanques-Tost E, Houstis N, Sundt TM, Lee HS, Sodini CG, Aguirre AD. Tissue perfusion pressure enables continuous hemodynamic evaluation and risk prediction in the intensive care unit. Nat Med 2023; 29:1998-2006. [PMID: 37550417 DOI: 10.1038/s41591-023-02474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 08/09/2023]
Abstract
Treatment of circulatory shock in critically ill patients requires management of blood pressure using invasive monitoring, but uncertainty remains as to optimal individual blood pressure targets. Critical closing pressure, which refers to the arterial pressure when blood flow stops, can provide a fundamental measure of vascular tone in response to disease and therapy, but it has not previously been possible to measure this parameter routinely in clinical care. Here we describe a method to continuously measure critical closing pressure in the systemic circulation using readily available blood pressure monitors and then show that tissue perfusion pressure (TPP), defined as the difference between mean arterial pressure and critical closing pressure, provides unique information compared to other hemodynamic parameters. Using analyses of 5,988 admissions to a modern cardiac intensive care unit, and externally validated with 864 admissions to another institution, we show that TPP can predict the risk of mortality, length of hospital stay and peak blood lactate levels. These results indicate that TPP may provide an additional target for blood pressure optimization in patients with circulatory shock.
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Affiliation(s)
- Anand Chandrasekhar
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raimon Padrós-Valls
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Roger Pallarès-López
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Palanques-Tost
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas Houstis
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Thoralf M Sundt
- Cardiac Surgery Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hae-Seung Lee
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Charles G Sodini
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Aaron D Aguirre
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA.
- Center for Systems Biology, Massachusetts General Hospital, Boston, MA, USA.
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