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Bannard-Smith J, Elrakhawy M, Norman G, Owen R, Felton T, Dark P. The efficacy, safety and effectiveness of hyperoncotic albumin solutions in patients with sepsis: A systematic review and meta-analysis. J Intensive Care Soc 2024; 25:308-318. [PMID: 39224427 PMCID: PMC11366183 DOI: 10.1177/17511437241259437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Background Intravenous fluid therapy is a ubiquitous intervention for the management of patients with sepsis, however excessive cumulative fluid balance has been shown to result in worse outcomes. Hyperoncotic albumin is presented in low volumes, is an effective resuscitation fluid and may have effects beyond plasma volume expansion alone. This systematic review aimed to assess the efficacy, safety and effectiveness of hyperoncotic albumin solutions in the management of sepsis. Methods We searched four databases and two trial registries for controlled clinical trials of hyperoncotic albumin for management of sepsis. Review outcomes were mortality, need for renal replacement therapy, cumulative-fluid balance, and need for organ support. We used methods guided by the Cochrane Handbook for reviews of clinical interventions. Studies were assessed using Cochrane's Risk of Bias 2 tool. We performed pairwise meta-analysis where possible. Certainty of evidence was assessed using GRADE. Results We included six trials; four (2772 patients) were meta-analysed. Most studies had moderate or high risk of bias. There was no significant difference in 28-day mortality for septic patients receiving hyperoncotic albumin compared to other intravenous fluids (OR 0.95, [95% CI: 0.8-1.12]); in patients with septic shock (2013 patients) there was a significant reduction (OR 0.82 [95% CI: 0.68-0.98]). There was no significant difference in safety outcomes. Hyperoncotic albumin was associated with variable reduction in early cumulative fluid balance and faster resolution of shock. Conclusions There is no good-quality evidence to support the use of hyperoncotic albumin in patients with sepsis, but it may reduce short-term mortality in the sub-groups with septic shock. It appears safe in terms of need for renal replacement therapy and is associated with reduced early cumulative fluid balance and faster resolution of shock. Larger, better quality randomised controlled trials in patients with septic shock may enhance the certainty of these findings. Review registration PROSPERO ref: CRD42021150674.
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Affiliation(s)
- Jonathan Bannard-Smith
- Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Mohamed Elrakhawy
- North West School of Intensive Care Medicine, NHS Health Education England Northwest, Manchester, UK
| | - Gill Norman
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
- Evidence Synthesis Group, Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rhiannon Owen
- Swansea University Medical School, Faculty of Medicine, Health and Life Science, Swansea University, UK
| | - Tim Felton
- Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Paul Dark
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Northern Care Alliance NHS Foundation Trust, Salford Care Organisation, Greater Manchester, UK
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Martos-Benítez FD, Burgos-Aragüez D, García-Mesa L, Orama-Requejo V, Cárdenas-González RC, Michelena-Piedra JC, Izquierdo-Castañeda J, Sánchez-de-la-Rosa E, Corrales-González O. Fluid balance, biomarkers of renal function and mortality in critically ill patients with AKI diagnosed before, or within 24 h of intensive care unit admission: a prospective study. J Nephrol 2024; 37:439-449. [PMID: 38189864 DOI: 10.1007/s40620-023-01829-z] [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: 07/17/2023] [Accepted: 11/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND To evaluate fluid balance, biomarkers of renal function and its relation to mortality in patients with acute kidney injury (AKI) diagnosed before, or within 24 h of intensive care unit admission. METHODS A prospective cohort study considered 773 critically ill patients observed over six years. Pre-intensive care unit-onset AKI was defined as AKI diagnosed before, or within 24 h of intensive care unit admission. Body weight-adjusted fluid balance and fluid balance-adjusted biomarkers of renal function were measured daily for the first three days of intensive care unit admission. Primary outcome was mortality in the intensive care unit. RESULTS Prevalence of pre-intensive care unit-onset AKI was 55.1%, of which 55.6% of cases were hospital-acquired and 44.4% were community-acquired. Fluid balance was higher in AKI patients than in non-AKI patients (p < 0.001) and had a negative correlation with urine output (p < 0.01). Positive fluid balance and biomarkers of renal function were independently related to mortality. Multivariate analysis identified the following AKI-related variables associated with increased mortality: (1) In AKI patients: type 1 cardiorenal syndrome (OR 2.00), intra-abdominal hypertension (OR 1.71), AKI stage 3 (OR 2.15) and increase in AKI stage (OR 4.99); 2) In patients with community-acquired AKI: type 1 cardiorenal syndrome (OR 5.16), AKI stage 2 (OR 2.72), AKI stage 3 (OR 4.95) and renal replacement therapy (OR 3.05); and 3) In patients with hospital-acquired AKI: intra-abdominal hypertension (OR 2.31) and increase in AKI stage (OR 4.51). CONCLUSIONS In patients with pre-intensive care unit-onset AKI, positive fluid balance is associated with worse renal outcomes. Positive fluid balance and decline in biomarkers of renal function are related to increased mortality, thus in this subpopulation of critically ill patients, positive fluid balance is not recommended and renal function must be closely monitored.
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Affiliation(s)
- Frank Daniel Martos-Benítez
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba.
| | - Dailé Burgos-Aragüez
- Intensive Care Unit-8, Hermanos Ameijeiras Hospital, San Lázaro St., Centro Havana, 10200, Havana, Cuba
| | - Liselotte García-Mesa
- Intensive Care Unit-8, Hermanos Ameijeiras Hospital, San Lázaro St., Centro Havana, 10200, Havana, Cuba
| | | | | | - Juan Carlos Michelena-Piedra
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Judet Izquierdo-Castañeda
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Ernesto Sánchez-de-la-Rosa
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Olivia Corrales-González
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
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3
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Gurnani PK, Barlow B, Boling B, Busse LW, Diaz-Gomez JL, Ford J, Gibson GA, Khanna AK, Lee JS, Rivosecchi RM, Spezzano KM, Thornton N, Vallabhajosyula S, Witenko CJ, Wieruszewski PM. Major Publications in the Critical Care Pharmacotherapy Literature: 2022. Crit Care Explor 2023; 5:e0981. [PMID: 37753239 PMCID: PMC10519466 DOI: 10.1097/cce.0000000000000981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
OBJECTIVES A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022. DATA SOURCES PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. STUDY SELECTION Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article. DATA EXTRACTION Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature. DATA SYNTHESIS The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia. CONCLUSIONS This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice.
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Affiliation(s)
- Payal K Gurnani
- Department of Pharmacy, Memorial Hermann The Woodlands Medical Center, The Woodlands, TX
| | - Brooke Barlow
- Department of Pharmacy, Memorial Hermann The Woodlands Medical Center, The Woodlands, TX
| | - Bryan Boling
- Department of Anesthesiology, Division of Critical Care Medicine, University of Kentucky, Lexington, KY
| | | | - Jose L Diaz-Gomez
- Department of Anesthesiology and Critical Care Medicine, Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Jenna Ford
- Department of Neurology, University of Florida, Gainesville, FL
| | | | - Ashish K Khanna
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | | | | | - Nathan Thornton
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Saraschandra Vallabhajosyula
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Corey J Witenko
- Department of Pharmacy, New York-Presbyterian Hospital, New York, NY
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4
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Carlos Sanchez E, Pinsky MR, Sinha S, Mishra RC, Lopa AJ, Chatterjee R. Fluids and Early Vasopressors in the Management of Septic Shock: Do We Have the Right Answers Yet? J Crit Care Med (Targu Mures) 2023; 9:138-147. [PMID: 37588181 PMCID: PMC10425929 DOI: 10.2478/jccm-2023-0022] [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: 06/12/2023] [Accepted: 07/22/2023] [Indexed: 08/18/2023] Open
Abstract
Septic shock is a common condition associated with hypotension and organ dysfunction. It is associated with high mortality rates of up to 60% despite the best recommended resuscitation strategies in international guidelines. Patients with septic shock generally have a Mean Arterial Pressure below 65 mmHg and hypotension is the most important determinant of mortality among this group of patients. The extent and duration of hypotension are important. The two initial options that we have are 1) administration of intravenous (IV) fluids and 2) vasopressors, The current recommendation of the Surviving Sepsis Campaign guidelines to administer 30 ml/kg fluid cannot be applied to all patients. Complications of fluid over-resuscitation further delay organ recovery, prolong ICU and hospital length of stay, and increase mortality. The only reason for administering intravenous fluids in a patient with circulatory shock is to increase the mean systemic filling pressure in a patient who is volume-responsive, such that cardiac output also increases. The use of vasopressors seems to be a more appropriate strategy, the very early administration of vasopressors, preferably during the first hour after diagnosis of septic shock, may have a multimodal action and potential advantages, leading to lower morbidity and mortality in the management of septic patients. Vasopressor therapy should be initiated as soon as possible in patients with septic shock.
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Affiliation(s)
- E. Carlos Sanchez
- Department of Critical Care Medicine, King Salman Hospital, Riyadh, Saudi Arabia
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, India
| | - Rajesh Chandra Mishra
- Department of Critical Care Medicine, Ahmedabad Khyati Multi-speciality Hospitals, Ahmedabad, India Department of Critical Care Medicine, Ahmedabad Shaibya Comprehensive Care Clinic, Ahmedabad, India
| | - Ahsina Jahan Lopa
- ICU and Emergency Department, Shahabuddin Medical College Hospital, Dhaka, Bangladesh
| | - Ranajit Chatterjee
- Department of Critical Care Medicine, accident and emergency, Swami Dayanand Hospital Delhi, India
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5
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Wrzosek A, Drygalski T, Garlicki J, Woroń J, Szpunar W, Polak M, Droś J, Wordliczek J, Zajączkowska R. The volume of infusion fluids correlates with treatment outcomes in critically ill trauma patients. Front Med (Lausanne) 2023; 9:1040098. [PMID: 36714115 PMCID: PMC9877421 DOI: 10.3389/fmed.2022.1040098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023] Open
Abstract
Background Appropriate fluid management is essential in the treatment of critically ill trauma patients. Both insufficient and excessive fluid volume can be associated with worse outcomes. Intensive fluid resuscitation is a crucial element of early resuscitation in trauma; however, excessive fluid infusion may lead to fluid accumulation and consequent complications such as pulmonary edema, cardiac failure, impaired bowel function, and delayed wound healing. The aim of this study was to examine the volumes of fluids infused in critically ill trauma patients during the first hours and days of treatment and their relationship to survival and outcomes. Methods We retrospectively screened records of all consecutive patients admitted to the intensive care unit (ICU) from the beginning of 2019 to the end of 2020. All adults who were admitted to ICU after trauma and were hospitalized for a minimum of 2 days were included in the study. We used multivariate regression analysis models to assess a relationship between volume of infused fluid or fluid balance, age, ISS or APACHE II score, and mortality. We also compared volumes of fluids in survivors and non-survivors including additional analyses in subgroups depending on disease severity (ISS score, APACHE II score), blood loss, and age. Results A total of 52 patients met the inclusion criteria for the study. The volume of infused fluids and fluid balance were positively correlated with mortality, complication rate, time on mechanical ventilation, length of stay in the ICU, INR, and APTT. Fluid volumes were significantly higher in non-survivors than in survivors at the end of the second day of ICU stay (2.77 vs. 2.14 ml/kg/h) and non-survivors had a highly positive fluid balance (6.21 compared with 2.48 L in survivors). Conclusion In critically ill trauma patients, worse outcomes were associated with higher volumes of infusion fluids and a more positive fluid balance. Although fluid resuscitation is lifesaving, especially in the first hours after trauma, fluid infusion should be limited to a necessary minimum to avoid fluid overload and its negative consequences.
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Affiliation(s)
- Anna Wrzosek
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,*Correspondence: Anna Wrzosek, ; orcid.org/0000-0002-7802-1325
| | - Tomasz Drygalski
- Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław Garlicki
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland
| | - Jarosław Woroń
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,Department of Clinical Pharmacology, Medical College, Jagiellonian University, Kraków, Poland
| | - Wojciech Szpunar
- Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland
| | - Maciej Polak
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland
| | - Jakub Droś
- Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,Doctoral School in Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy Wordliczek
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland
| | - Renata Zajączkowska
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland
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6
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Mallat J, Rahman N, Hamed F, Hernandez G, Fischer MO. Pathophysiology, mechanisms, and managements of tissue hypoxia. Anaesth Crit Care Pain Med 2022; 41:101087. [PMID: 35462083 DOI: 10.1016/j.accpm.2022.101087] [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: 12/29/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/01/2022]
Abstract
Oxygen is needed to generate aerobic adenosine triphosphate and energy that is required to support vital cellular functions. Oxygen delivery (DO2) to the tissues is determined by convective and diffusive processes. The ability of the body to adjust oxygen extraction (ERO2) in response to changes in DO2 is crucial to maintain constant tissue oxygen consumption (VO2). The capability to increase ERO2 is the result of the regulation of the circulation and the effects of the simultaneous activation of both central and local factors. The endothelium plays a crucial role in matching tissue oxygen supply to demand in situations of acute drop in tissue oxygenation. Tissue oxygenation is adequate when tissue oxygen demand is met. When DO2 is severely compromised, a critical DO2 value is reached below which VO2 falls and becomes dependent on DO2, resulting in tissue hypoxia. The different mechanisms of tissue hypoxia are circulatory, anaemic, and hypoxic, characterised by a diminished DO2 but preserved capacity of increasing ERO2. Cytopathic hypoxia is another mechanism of tissue hypoxia that is due to impairment in mitochondrial respiration that can be observed in septic conditions with normal overall DO2. Sepsis induces microcirculatory alterations with decreased functional capillary density, increased number of stopped-flow capillaries, and marked heterogeneity between the areas with large intercapillary distance, resulting in impairment of the tissue to extract oxygen and to satisfy the increased tissue oxygen demand, leading to the development of tissue hypoxia. Different therapeutic approaches exist to increase DO2 and improve microcirculation, such as fluid therapy, transfusion, vasopressors, inotropes, and vasodilators. However, the effects of these agents on microcirculation are quite variable.
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Affiliation(s)
- Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA; Normandy University, UNICAEN, ED 497, Caen, France.
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontifcia Universidad Católica de Chile, Santiago, Chile
| | - Marc-Olivier Fischer
- Department of Anaesthesiology-Resuscitation and Perioperative Medicine, Normandy University, UNICAEN, Caen University Hospital, Normandy, Caen, France
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7
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Wang TJ, Pai KC, Huang CT, Wong LT, Wang MS, Lai CM, Chen CH, Wu CL, Chao WC. A Positive Fluid Balance in the First Week Was Associated With Increased Long-Term Mortality in Critically Ill Patients: A Retrospective Cohort Study. Front Med (Lausanne) 2022; 9:727103. [PMID: 35308497 PMCID: PMC8927621 DOI: 10.3389/fmed.2022.727103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Early fluid balance has been found to affect short-term mortality in critically ill patients; however, there is little knowledge regarding the association between early cumulative fluid balance (CFB) and long-term mortality. This study aims to determine the distinct association between CFB day 1-3 (CFB 1-3) and day 4-7 (CFB 4-7) and long-term mortality in critically ill patients. Patients and Methods This study was conducted at Taichung Veterans General Hospital, a tertiary care referral center in central Taiwan, by linking the hospital critical care data warehouse 2015-2019 and death registry data of the Taiwanese National Health Research Database. The patients followed up until deceased or the end of the study on 31 December 2019. We use the log-rank test to examine the association between CFB 1-3 and CFB 4-7 with long-term mortality and multivariable Cox regression to identify independent predictors during index admission for long-term mortality in critically ill patients. Results A total of 4,610 patients were evaluated. The mean age was 66.4 ± 16.4 years, where 63.8% were men. In patients without shock, a positive CFB 4-7, but not CFB 1-3, was associated with 1-year mortality, while a positive CFB 1-3 and CFB 4-7 had a consistent and excess hazard of 1-year mortality among critically ill patients with shock. The multivariate Cox proportional hazard regression model identified that CFB 1-3 and CFB 4-7 (with per 1-liter increment, HR: 1.047 and 1.094; 95% CI 1.037-1.058 and 1.080-1.108, respectively) were independently associated with high long-term mortality in critically ill patients after adjustment of relevant covariates, including disease severity and the presence of shock. Conclusions We found that the fluid balance in the first week, especially on days 4-7, appears to be an early predictor for long-term mortality in critically ill patients. More studies are needed to validate our findings and elucidate underlying mechanisms.
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Affiliation(s)
- Tsai-Jung Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kai-Chih Pai
- College of Engineering, Tunghai University, Taichung, Taiwan.,Cloud Innovation School, Tunghai University, Taichung, Taiwan
| | - Chun-Te Huang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Li-Ting Wong
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Minn-Shyan Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Artificial Intelligence Workshop, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chun-Ming Lai
- College of Engineering, Tunghai University, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Artificial Intelligence Workshop, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Computer Science, Tunghai University, Taichung, Taiwan.,Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Computer Science, Tunghai University, Taichung, Taiwan.,Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan.,Big Data Center, Chung Hsing University, Taichung, Taiwan
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8
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Dong N, Gao N, Hu W, Mu Y, Pang L. Association of Fluid Management With Mortality of Sepsis Patients With Congestive Heart Failure: A Retrospective Cohort Study. Front Med (Lausanne) 2022; 9:714384. [PMID: 35308491 PMCID: PMC8924446 DOI: 10.3389/fmed.2022.714384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/25/2022] [Indexed: 12/13/2022] Open
Abstract
Sepsis management includes intravenous fluid (IVF) resuscitation, but patients with pre-existing congestive heart failure (CHF) have a higher risk of fluid overload. Further, patients with sepsis with concomitant CHF present worse clinical outcomes. Nevertheless, there is limited evidence of the association between fluid management and the outcomes of patients with concomitant sepsis and CHF. This retrospective cohort study aimed to evaluate the association between fluid management and in-hospital mortality in patients with sepsis and concomitant heart failure (HF). The patients' data were extracted from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was in-hospital mortality. A restricted cubic spline model was used to explore the relationship between variables and in-hospital mortality. Logistic models were built using the linear spline function and design variables to investigate the association of fluid balance (FB), fluid intake (FI), and fluid accumulation index (FAI, calculated as the FB/FI ratio) with mortality. Overall, 1,801 patients were included. The overall mortality rate was 27.7%. After adjusting for confounding variables, FAI was found to be associated with in-hospital mortality, whereas FB and FI were not. With FAI values of 0–0.42 set as references, FAI values <0 were not associated with in-hospital mortality [odds ratio (OR): 1.078; 95% confidence interval (CI): 0.774–1.503], whereas FAI values > 0.42 were significantly associated with higher in-hospital mortality (OR: 1.461; 95% CI: 1.099–1.954). High FAI values (>0.42) were associated with high in-hospital mortality in patients with sepsis with HF, while FB and FI were not. Proper fluid management may improve the outcomes of patients with sepsis and concomitant HF.
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Affiliation(s)
- Ning Dong
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
| | - Nan Gao
- Department of Emergency, The Third Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Wenxin Hu
- The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Yuhang Mu
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
| | - Li Pang
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
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9
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Kim KY, Ryu JH, Kang DH, Kim SJ, Choi KB, Lee S. Early fluid management affects short-term mortality in patients with end-stage kidney disease undergoing chronic hemodialysis and requiring continuous renal replacement therapy. BMC Nephrol 2022; 23:102. [PMID: 35287625 PMCID: PMC8919557 DOI: 10.1186/s12882-022-02725-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Early fluid management is considered a key element affecting mortality in critically ill patients requiring continuous renal replacement therapy (CRRT). Most studies have primarily focused on patients with intrinsic acute kidney injury requiring CRRT, although end-stage kidney disease (ESKD) patients generally exhibit greater vulnerability. We investigated the association between fluid balance and short-term mortality outcomes in ESKD patients undergoing chronic hemodialysis and requiring CRRT. Methods This retrospective study included 110 chronic hemodialysis patients who received CRRT between 2017 and 2019 at Ewha Womans University Mokdong Hospital. The amounts of daily input and output, and cumulative 3-day and 7-day input and output, were assessed from the initiation of CRRT. The participants were classified into two groups based on 7-day and 14-day mortalities. Cox regression analyses were carried out on the basis of the amounts of daily input and output, cumulative input and output, and cumulative fluid balance. Results During follow-up, 7-day and 14-day mortalities were observed in 24 (21.8%) and 34 (30.9%) patients. The patients were stratified into two groups (14-day survivors vs. non-survivors), and there were no significant differences in demographic characteristics between the two groups. However, diabetes mellitus was more common among survivors than among non-survivors. Univariate analyses showed that the amounts of daily output at 48, and 72 h, and 3-day cumulative input and output, were significantly associated with 7-day mortality risk regardless of the cumulative fluid balance (HR: 0.28, 95% CI: 0.12–0.70, p = 0.01 for daily output at 48 h; HR: 0.34, 95% CI: 0.13–0.85, p = 0.02 for daily output at 72 h.; HR: 0.72, 95% CI: 0.61–0.86, p = 0.01 for 3-day cumulative input; HR: 0.65, 95% CI: 0.41–0.90, p = 0.01 for 3-day cumulative output). Adjusted multivariate analyses showed that the lower 3-day cumulative output is an independent risk factor for 7-day and 14-day mortality. Conclusions In our study, increased cumulative output were significantly associated with reduced short-term mortality risk in chronic hemodialysis patients undergoing CRRT regardless of cumulative fluid balance. Further prospective studies to investigate the association between fluid balance and mortality in ESRD patients requiring CRRT are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02725-7.
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Affiliation(s)
- Kyun Young Kim
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Jung-Hwa Ryu
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Duk-Hee Kang
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Seung-Jung Kim
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Kyu Bok Choi
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Shina Lee
- Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea.
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10
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Wu CL, Pai KC, Wong LT, Wang MS, Chao WC. Impact of Early Fluid Balance on Long-Term Mortality in Critically Ill Surgical Patients: A Retrospective Cohort Study in Central Taiwan. J Clin Med 2021; 10:jcm10214873. [PMID: 34768393 PMCID: PMC8584411 DOI: 10.3390/jcm10214873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022] Open
Abstract
Fluid balance is an essential issue in critical care; however, the impact of early fluid balance on the long-term mortality in critically ill surgical patients remains unknown. This study aimed to address the impact of day 1–3 and day 4–7 fluid balance on the long-term mortality in critically ill surgical patients. We enrolled patients who were admitted to surgical intensive care units (ICUs) during 2015–2019 at a tertiary hospital in central Taiwan and retrieved date-of-death from the Taiwanese nationwide death registration profile. We used a Log-rank test and a multivariable Cox proportional hazards regression model to determine the independent mortality impact of early fluid balance. A total of 6978 patients were included for analyses (mean age: 60.9 ± 15.9 years; 63.9% of them were men). In-hospital mortality, 90-day mortality, 1-year and overall mortality was 10.3%, 15.8%, 23.8% and 31.7%, respectively. In a multivariable Cox proportional hazard regression model adjusted for relevant covariates, we found that positive cumulative day 4–7 fluid balance was independently associated with long-term mortality (aHR 1.083, 95% CI 1.062–1.105), and a similar trend was found on day 1–3 fluid balance, although to a lesser extent (aHR 1.027, 95% CI 1.011–1.043). In conclusion, the fluid balance in the first week of ICU stay, particularly day 4–7 fluid balance, may affect the long-term outcome in critically ill surgical patients.
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Affiliation(s)
- Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
- School of Medicine, Chung Hsing University, Taichung 40227, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung 407224, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung 407802, Taiwan
- Artificial Intelligence Studio, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Kai-Chih Pai
- College of Engineering, Tunghai University, Taichung 407224, Taiwan;
| | - Li-Ting Wong
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Min-Shian Wang
- Artificial Intelligence Studio, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
- School of Medicine, Chung Hsing University, Taichung 40227, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung 407802, Taiwan
- Big Data Center, Chung Hsing University, Taichung 40227, Taiwan
- Correspondence:
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11
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Jarczak D, Kluge S, Nierhaus A. Sepsis-Pathophysiology and Therapeutic Concepts. Front Med (Lausanne) 2021; 8:628302. [PMID: 34055825 PMCID: PMC8160230 DOI: 10.3389/fmed.2021.628302] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition and a global disease burden. Today, the heterogeneous syndrome is defined as severe organ dysfunction caused by a dysregulated host response to infection, with renewed emphasis on immune pathophysiology. Despite all efforts of experimental and clinical research during the last three decades, the ability to positively influence course and outcome of the syndrome remains limited. Evidence-based therapy still consists of basic causal and supportive measures, while adjuvant interventions such as blood purification or targeted immunotherapy largely remain without proof of effectiveness so far. With this review, we aim to provide an overview of sepsis immune pathophysiology, to update the choice of therapeutic approaches targeting different immunological mechanisms in the course of sepsis and septic shock, and to call for a paradigm shift from the pathogen to the host response as a potentially more promising angle.
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Affiliation(s)
- Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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