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Launay M, Ollier E, Kably B, Le Louedec F, Thiery G, Lanoiselée J, Perinel-Ragey S. Loading Dose of Ceftazidime Needs to Be Increased in Critically Ill Patients: A Retrospective Study to Evaluate Recommended Loading Dose with Pharmacokinetic Modelling. Antibiotics (Basel) 2024; 13:756. [PMID: 39200056 PMCID: PMC11350857 DOI: 10.3390/antibiotics13080756] [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: 07/01/2024] [Revised: 07/24/2024] [Accepted: 08/02/2024] [Indexed: 09/01/2024] Open
Abstract
To rapidly achieve ceftazidime target concentrations, a 2 g loading dose (LD) is recommended before continuous infusion, but its adequacy in critically ill patients, given their unique pharmacokinetics, needs investigation. This study included patients from six ICUs in Saint-Etienne and Paris, France, who received continuous ceftazidime infusion with plasma concentration measurements. Using MONOLIX and R, a pharmacokinetic (PK) model was developed, and the literature on ICU patient PK models was reviewed. Simulations calculated the LD needed to reach a 60 mg/L target concentration and assessed ceftazidime exposure for various regimens. Among 86 patients with 223 samples, ceftazidime PK was best described by a one-compartment model with glomerular filtration rate explaining clearance variability. Typical clearance and volume of distribution were 4.45 L/h and 88 L, respectively. The literature median volume of distribution was 37.2 L. Simulations indicated that an LD higher than 2 g was needed to achieve 60 mg/L in 80% of patients, with a median LD of 4.9 g. Our model showed a 4 g LD followed by 6 g/day infusion reached effective concentrations within 1 h, while a 2 g LD caused an 18 h delay in achieving target steady state.
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Affiliation(s)
- Manon Launay
- Medical Intensive Care Unit, University Hospital of Saint-Etienne, 42000 Saint Etienne, France
- Pharmacovigilance Department, University Hospital of Saint-Etienne, 42000 Saint Etienne, France
| | - Edouard Ollier
- Mines Saint-Étienne, Université Jean Monnet, INSERM, U1059, SAINBIOSE, 42000 Saint Etienne, France
- Clinical Pharmacology Unit, University Hospital of Saint-Etienne, 42000 Saint Etienne, France
| | - Benjamin Kably
- Pharmacology Unit DMU BioPhyGen, European Hospital Georges-Pompidou, APHP, 75015 Paris, France
| | - Félicien Le Louedec
- Cancer Research Center of Toulouse (CRCT), Team 14, INSERM UMR1037, University of Toulouse, CS 53717, 31037 Toulouse, France
| | - Guillaume Thiery
- Medical Intensive Care Unit, University Hospital of Saint-Etienne, 42000 Saint Etienne, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon, 69008 Villeurbanne, France
| | - Julien Lanoiselée
- Service d’Anesthésie et de Réanimation Chirurgicale, CHU de Saint-Etienne, 42000 Saint Etienne, France
| | - Sophie Perinel-Ragey
- Medical Intensive Care Unit, University Hospital of Saint-Etienne, 42000 Saint Etienne, France
- Mines Saint-Étienne, Université Jean Monnet, INSERM, U1059, SAINBIOSE, 42000 Saint Etienne, France
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Dillies T, Perinel-Ragey S, Correia P, Morel J, Thiery G, Launay M. Dosing Regimen for Cefotaxime Should Be Adapted to the Stage of Renal Dysfunction in Critically Ill Adult Patients-A Retrospective Study. Antibiotics (Basel) 2024; 13:313. [PMID: 38666989 PMCID: PMC11047316 DOI: 10.3390/antibiotics13040313] [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: 02/26/2024] [Revised: 03/15/2024] [Accepted: 03/27/2024] [Indexed: 04/29/2024] Open
Abstract
Cefotaxime administration is recommended in doses of 3-12 g/day in adults with a Glomerular Filtration Rate (GFR) > 5 mL/min. This study aimed to assess the impact of renal function and obesity on cefotaxime concentrations in intensive care unit (ICU) patients. A retrospective cohort study was conducted on consecutive ICU patients receiving continuous cefotaxime infusion between 2020 and 2022 [IRBN992021/CHUSTE]. Doses were not constant; consequently, a concentration-to-dose ratio (C/D) was considered. Statistical analysis was performed to assess the relationship between cefotaxime concentrations, renal function, and obesity. A total of 70 patients, median age 61 years, were included, with no significant difference in cefotaxime concentrations between obese and non-obese patients. However, concentrations varied significantly by GFR, with underdosing prevalent in patients with normal to increased renal function and overdosing in those with severely impaired renal function. Adjustment of cefotaxime dosing according to GFR was associated with improved target attainment. Cefotaxime dosing in critically ill patients should consider renal function, with higher initial doses required in patients with normal to increased GFR and lower doses in those with severely impaired renal function. Therapeutic drug monitoring may aid in optimising dosing regimens. Prospective studies are warranted to validate these findings and inform clinical practice.
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Affiliation(s)
- Théo Dillies
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
| | - Sophie Perinel-Ragey
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
- SAINBIOSE U1059, Université Jean Monnet, INSERM, F-42023 Saint Etienne, France
| | - Patricia Correia
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
| | - Jérôme Morel
- Service de Réanimation Polyvalente B, CHU de Saint-Etienne, F-42055 Saint Etienne, France
| | - Guillaume Thiery
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon, F-69008 Lyon, France
| | - Manon Launay
- Service de Médecine Intensive et Réanimation G, Centre Hospitalier Universitaire (CHU) deSaint-Etienne, F-42055 Saint Etienne, France
- Centre Régional de Pharmacovigilance, CHU de Saint-Etienne, F-42055 Saint Etienne, France
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Martínez-Camacho MÁ, Jones-Baro RA, Gómez-González A, Morales-Hernández D, Lugo-García DS, Melo-Villalobos A, Navarrete-Rodríguez CA, Delgado-Camacho J. Physical and respiratory therapy in the critically ill patient with obesity: a narrative review. Front Med (Lausanne) 2024; 11:1321692. [PMID: 38455478 PMCID: PMC10918845 DOI: 10.3389/fmed.2024.1321692] [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: 10/24/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024] Open
Abstract
Obesity has become increasingly prevalent in the intensive care unit, presenting a significant challenge for healthcare systems and professionals, including rehabilitation teams. Caring for critically ill patients with obesity involves addressing complex issues. Despite the well-established and safe practice of early mobilization during critical illness, in rehabilitation matters, the diverse clinical disturbances and scenarios within the obese patient population necessitate a comprehensive understanding. This includes recognizing the importance of metabolic support, both non-invasive and invasive ventilatory support, and their weaning processes as essential prerequisites. Physiotherapists, working collaboratively with a multidisciplinary team, play a crucial role in ensuring proper assessment and functional rehabilitation in the critical care setting. This review aims to provide critical insights into the key management and rehabilitation principles for obese patients in the intensive care unit.
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Affiliation(s)
- Miguel Ángel Martínez-Camacho
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
- Doctorate Programme in Health Sciences, Universidad Anahuac Norte, State of Mexico, Mexico
| | - Robert Alexander Jones-Baro
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
- Master’s Programme in Health Sciences, Instituto Politecnico Nacional, Mexico City, Mexico
| | - Alberto Gómez-González
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
| | - Diego Morales-Hernández
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
| | - Dalia Sahian Lugo-García
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
| | - Andrea Melo-Villalobos
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
| | - Carlos Alberto Navarrete-Rodríguez
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
| | - Josué Delgado-Camacho
- Critical Care Physical Therapy Department and Post-operative Recovery and Multi-Organ Support Unit, Hospital General de México “Dr. Eduardo Liceaga,” Mexico City, Mexico
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Li S, Fu Z, Zhang W, Liu H. Impact of obesity on intensive care unit outcomes in older patients with critical illness: A cohort study. PLoS One 2024; 19:e0297635. [PMID: 38354125 PMCID: PMC10866459 DOI: 10.1371/journal.pone.0297635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Although the paradoxical association between obesity and improved survival has been reported in a variety of clinical settings, its applicability to intensive care unit (ICU) outcomes in older critically ill patients remains unclear. We sought to examine the association between obesity and 30-day mortality and other adverse outcomes in this population. METHODS We analyzed data of older patients (≥ 60 years) in the eICU Collaborative Research Database. Body mass index (BMI) was stratified according to the World Health Organization obesity classification. Logistic regression model was used to estimate adjusted odds ratios (ORs), and cubic spline curve was used to explore the nonlinear association between BMI and 30-day ICU outcomes. Stratified analysis and sensitivity analysis were also performed. RESULTS Compared with class I obesity, under- and normal-weight were associated with higher all-cause, cardiovascular and noncardiovascular mortality, and class III obesity was associated with greater all-cause and cardiovascular mortality (OR, 1.18 [95% CI, 1.06-1.32], 1.28 [1.08-1.51]). Obesity classes II and III were associated with higher composite all-cause mortality, mechanical ventilation, or vasoactive drug usage risks (OR, 1.12 [95% CI, 1.04-1.20], 1.33 [1.24-1.43]). Mechanical ventilation was strongly positively associated with BMI. A significant BMI-by-sex interaction was observed for cardiovascular mortality, such that the association between severe obesity and mortality was more pronounced among older men than older women. CONCLUSIONS The obesity paradox does not appear to apply to short-term ICU outcomes in older patients with critical illness, mainly due to increased all-cause and cardiovascular mortality in severely obese patients, particularly in men.
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Affiliation(s)
- Shan Li
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Zhiqing Fu
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Wei Zhang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hongbin Liu
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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Ahn YH, Yoon SM, Lee J, Lee SM, Oh DK, Lee SY, Park MH, Lim CM, Lee HY. Early Sepsis-Associated Acute Kidney Injury and Obesity. JAMA Netw Open 2024; 7:e2354923. [PMID: 38319660 PMCID: PMC10848068 DOI: 10.1001/jamanetworkopen.2023.54923] [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] [Received: 08/03/2023] [Accepted: 12/14/2023] [Indexed: 02/07/2024] Open
Abstract
Importance The prevalence of obesity is increasing in the intensive care unit (ICU). Although obesity is a known risk factor for chronic kidney disease, its association with early sepsis-associated acute kidney injury (SA-AKI) and their combined association with patient outcomes warrant further investigation. Objective To explore the association between obesity, early SA-AKI incidence, and clinical outcomes in patients with sepsis. Design, Setting, and Participants This nationwide, prospective cohort study analyzed patients aged 19 years or older who had sepsis and were admitted to 20 tertiary hospital ICUs in Korea between September 1, 2019, and December 31, 2021. Patients with preexisting stage 3A to 5 chronic kidney disease and those with missing body mass index (BMI) values were excluded. Exposures Sepsis and hospitalization in the ICU. Main Outcomes and Measures The primary outcome was SA-AKI incidence within 48 hours of ICU admission, and secondary outcomes were mortality and clinical recovery (survival to discharge within 30 days). Patients were categorized by BMI (calculated as weight in kilograms divided by height in meters squared), and data were analyzed by logistic regression adjusted for key characteristics and clinical factors. Multivariable fractional polynomial regression models and restricted cubic spline models were used to analyze the clinical outcomes with BMI as a continuous variable. Results Of the 4041 patients (median age, 73 years [IQR, 63-81 years]; 2349 [58.1%] male) included in the study, 1367 (33.8%) developed early SA-AKI. Obesity was associated with a higher incidence of SA-AKI compared with normal weight (adjusted odds ratio [AOR], 1.40; 95% CI, 1.15-1.70), as was every increase in BMI of 10 (OR, 1.75; 95% CI, 1.47-2.08). While obesity was associated with lower in-hospital mortality in patients without SA-AKI compared with their counterparts without obesity (ie, underweight, normal weight, overweight) (AOR, 0.72; 95% CI, 0.54-0.94), no difference in mortality was observed in those with SA-AKI (AOR, 0.85; 95% CI, 0.65-1.12). Although patients with obesity without SA-AKI had a greater likelihood of clinical recovery than their counterparts without obesity, clinical recovery was less likely among those with both obesity and SA-AKI. Conclusions and Relevance In this cohort study of patients with sepsis, obesity was associated with a higher risk of early SA-AKI and the presence of SA-AKI modified the association of obesity with clinical outcomes.
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Affiliation(s)
- Yoon Hae Ahn
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Si Mong Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Korea
| | - Su Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, Korea
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
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Correia P, Launay M, Balluet R, Gergele L, Gauthier V, Morel J, Beuret P, Mariat C, Thiery G, Perinel Ragey S. Towards optimization of ceftazidime dosing in obese ICU patients: the end of the 'one-size-fits-all' approach? J Antimicrob Chemother 2023; 78:2968-2975. [PMID: 37919244 DOI: 10.1093/jac/dkad339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Ceftazidime is commonly used as a key antibiotic against Pseudomonas aeruginosa in critically ill patients. ICU patients have severely altered and variable antibiotic pharmacokinetics, resulting in lower antimicrobial concentrations and potentially poor outcome. Several factors, including obesity and renal function, may influence pharmacokinetics. Thus, the objective of the study was to evaluate the impact of obesity and renal function on ceftazidime plasma concentrations and dosing regimen in ICU patients. METHODS All consecutive adult patients from six ICUs, treated with continuous ceftazidime infusion and under therapeutic drug monitoring evaluation, were included. Obesity was defined as BMI ≥30 kg/m². Glomerular filtration rate (GFR) was estimated by the Chronic Kidney Disease Epidemiology Collaboration formula. The ceftazidime recommended target for plasma concentrations was between 35 and 80 mg/L. RESULTS A total of 98 patients (45 obese), with an average weight of 90 (±25) kg, were included. Mean GFR was 84.1 (±40.4) mL/min/1.73 m2. Recommended ceftazidime plasma concentrations were achieved for only 48.0% of patients, with median dosing regimen of 6 g/day. Obese patients had lower ceftazidime plasma concentrations compared with non-obese patients (37.8 versus 56.3 mg/L; P = 0.0042) despite similar dosing regimens (5.83 g/day versus 5.52 g/day, P = 0.2529). Almost all augmented renal clearance patients were underdosed despite ceftazidime dosing of 6.6 (±0.8) g/day. Weight-based ceftazidime dosing seemed to attenuate such obesity-related discrepancies, regardless of GFR. CONCLUSIONS Obese ICU patients required significantly greater ceftazidime doses to achieve the target range. A tailored dosing regimen may be considered based on weight and GFR. Future prospective studies should be performed to confirm this individualized dosing approach.
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Affiliation(s)
- Patricia Correia
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
| | - Manon Launay
- Laboratoire de Biologie-Pathologie, CHU de Saint-Etienne, Saint Etienne, France
| | - Rémi Balluet
- Laboratoire de Pharmacologie-Toxicologie-Gaz du Sang, CHU de Saint-Etienne, Avenue Albert Raymond, 42270 Saint Priest en Jarez, Saint Etienne, France
| | - Laurent Gergele
- Service de Réanimation Polyvalente, Hôpital Privé de la Loire, Saint Etienne, France
| | - Vincent Gauthier
- Service de Réanimation Polyvalente, Clinique Mutualiste, Saint Etienne, France
| | - Jérome Morel
- Service de Réanimation Polyvalente B, CHU de Saint Etienne, Saint Etienne, France
| | - Pascal Beuret
- Service de Réanimation, CHR de Roanne, Roanne, France
| | - Christophe Mariat
- Service de Réanimation Néphrologique, CHU de Saint Etienne, Saint Etienne, France
| | - Guillaume Thiery
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon, Villeurbanne, France
| | - Sophie Perinel Ragey
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
- SAINBIOSE U1059 Research Unit, Université Jean Monnet, INSERM, Saint-Etienne, France
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Do Body Mass Index and Nutritional Risk Score 2002 Influence the In-Hospital Mortality of Patients Following Cardiac Arrest? Nutrients 2023; 15:nu15020436. [PMID: 36678307 PMCID: PMC9863085 DOI: 10.3390/nu15020436] [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: 12/26/2022] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Contemporarily, cardiac arrest (CA) remains one of the leading causes of death. Poor nutritional status can increase the post-CA mortality risk. The aim of this study was to determine the relationship between body mass index (BMI) and Nutritional Risk Score 2002 (NRS 2002) results and in-hospital mortality in patients admitted to the intensive care unit (ICU) after in-hospital and out-of-hospital cardiac arrest. METHODS A retrospective study and analysis of medical records of 161 patients admitted to the ICU of the University Clinical Hospital in Wrocław (Wrocław, Poland) was conducted. RESULTS No significant differences in body mass index (BMI) and nutritional risk score (NRS 2002) values were observed between non-survivors and survivors. Non-survivors had significantly lower albumin concentration (p = 0.017) and total cholesterol (TC) (p = 0.015). In multivariate analysis BMI and NRS 2002 scores were not, per se, associated with the in-hospital mortality defined as the odds of death (Model 1: p: 0.700, 0.430; Model 2: p: 0.576, 0.599). Univariate analysis revealed significant associations between the hazard ratio (HR) and TG (p ≈ 0.017, HR: 0.23) and hsCRP (p ≈ 0.018, HR: 0.34). In multivariate analysis, mortality risk over time was influenced by higher scores in parameters such as BMI (HR = 0.164; p = 0.048) and hsCRP (HR = 1.006, p = 0.002). CONCLUSIONS BMI and NRS 2002, on their own (unconditionally - in the whole study group) did not alter the odds of mortality in patients admitted to the intensive care unit (ICU) after in-hospital and out-of-hospital cardiac arrest. The risk of in-hospital mortality (expressed as hazard ratio - the risk over the time period of the study) increased with an increase in BMI but not with NRS 2002.
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Yang Q, Chen W, Wen Y, Zheng J, Chen J, Yu S, Chen X, Chen W, Xiong X, Wen D, Zhang Z. Association Between Wait Time of Central Venous Pressure Measurement and Outcomes in Critical Patients With Acute Kidney Injury: A Retrospective Cohort Study. Front Public Health 2022; 10:893683. [PMID: 36016902 PMCID: PMC9395608 DOI: 10.3389/fpubh.2022.893683] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/08/2022] [Indexed: 01/22/2023] Open
Abstract
Background Hemodynamic management is of paramount importance in patients with acute kidney injury (AKI). Central venous pressure (CVP) has been used to assess volume status. We intended to identify the optimal time window in which to obtain CVP to avoid the incidence of adverse outcomes in patients with AKI. Methods The study was based on the Medical Information Mart for Intensive Care (MIMIC) IV database. The primary outcome was in-hospital mortality. Secondary outcomes included the number of ICU-free days and norepinephrine-free days at 28 days after ICU admission, and total fluid input and fluid balance during the first and second day. A time-dose-response relationship between wait time of CVP measurement and in-hospital mortality was implemented to find an inflection point for grouping, followed by propensity-score matching (PSM), which was used to compare the outcomes between the two groups. Results Twenty Nine Thousand and Three Hundred Thirty Six patients with AKI were enrolled, and the risk of in-hospital mortality increased when the CVP acquisition time was >9 h in the Cox proportional hazards regression model. Compared with 8,071 patients (27.5%) who underwent CVP measurement within 9 h and were assigned to the early group, 21,265 patients (72.5%) who delayed or did not monitor CVP had a significantly higher in-hospital mortality in univariate and multivariate Cox regression analyses. After adjusting for potential confounders by PSM and adjusting for propensity score, pairwise algorithmic, overlap weight, and doubly robust analysis, the results were still stable. The HRs were 0.58-0.72, all p < 0.001. E-value analysis suggested robustness to unmeasured confounding. Conclusions Among adults with AKI in ICU, increased CVP wait time was associated with a greater risk of in-hospital mortality. In addition, early CVP monitoring perhaps contributed to shortening the length of ICU stays and days of norepinephrine use, as well as better fluid management.
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Affiliation(s)
- Qilin Yang
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weixiao Chen
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yichao Wen
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiezhao Zheng
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jieru Chen
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shuilian Yu
- Department of Rheumatology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaohua Chen
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Weiyan Chen
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xuming Xiong
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Deliang Wen
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,*Correspondence: Deliang Wen
| | - Zhenhui Zhang
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,Zhenhui Zhang
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Tang R, Peng J, Wang D. Central Venous Pressure Measurement Is Associated With Improved Outcomes in Patients With or at Risk for Acute Respiratory Distress Syndrome: An Analysis of the Medical Information Mart for Intensive Care IV Database. Front Med (Lausanne) 2022; 9:858838. [PMID: 35419383 PMCID: PMC8995425 DOI: 10.3389/fmed.2022.858838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/23/2022] [Indexed: 11/21/2022] Open
Abstract
Background Central venous pressure (CVP) monitoring is widely used in the intensive care unit (ICU). However, the formal utility of CVP measurement to altering patient outcomes among ICU patients with or at risk for acute respiratory distress syndrome (ARDS) has never been investigated. Our study aimed to explore the association of CVP measurement with 28-day mortality specifically in that population. Methods This study was based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients were divided into CVP and no CVP groups according to whether they had CVP measurement within 24 h of admission to the ICU. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the association between CVP measurement and 28-day mortality, and propensity score matching (PSM) and propensity score-based overlap weighting (OW) were employed to verify the stability of our results. Results A total of 10,198 patients with or at risk for ARDS were included in our study, of which 4,647 patients (45.6%) belonged to the CVP group. Multivariate logistic regression showed that the early measurement of CVP was independently associated with lower 28-day mortality (OR: 0.49; 95% CI: 0.42–0.57; p < 0.001). This association remained robust after PSM and OW (both p < 0.001). Patients in the CVP group had shorter ICU stay, lower in-hospital mortality, more fluid on day 1 and higher clearance of blood lactate than those in the no CVP group. Conclusion Early CVP measurement is associated with an improvement in 28-day mortality among a general population of critically ill patients with or at risk for ARDS.
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Affiliation(s)
- Rui Tang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junnan Peng
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daoxin Wang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Bansal V, Smischney NJ, Kashyap R, Li Z, Marquez A, Diedrich DA, Siegel JL, Sen A, Tomlinson AD, Venegas-Borsellino CP, Freeman WD. Reintubation Summation Calculation: A Predictive Score for Extubation Failure in Critically Ill Patients. Front Med (Lausanne) 2022; 8:789440. [PMID: 35252224 PMCID: PMC8891541 DOI: 10.3389/fmed.2021.789440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
Objective To derive and validate a multivariate risk score for the prediction of respiratory failure after extubation. Patients and methods We performed a retrospective cohort study of adult patients admitted to the intensive care unit from January 1, 2006, to December 31, 2015, who received mechanical ventilation for ≥48 h. Extubation failure was defined as the need for reintubation within 72 h after extubation. Multivariate logistic regression model coefficient estimates generated the Re-Intubation Summation Calculation (RISC) score. Results The 6,161 included patients were randomly divided into 2 sets: derivation (n = 3,080) and validation (n = 3,081). Predictors of extubation failure in the derivation set included body mass index <18.5 kg/m2 [odds ratio (OR), 1.91; 95% CI, 1.12–3.26; P = 0.02], threshold of Glasgow Coma Scale of at least 10 (OR, 1.68; 95% CI, 1.31–2.16; P < 0.001), mean airway pressure at 1 min of spontaneous breathing trial <10 cmH2O (OR, 2.11; 95% CI, 1.68–2.66; P < 0.001), fluid balance ≥1,500 mL 24 h preceding extubation (OR, 2.36; 95% CI, 1.87–2.96; P < 0.001), and total mechanical ventilation days ≥5 (OR, 3.94; 95% CI 3.04–5.11; P < 0.001). The C-index for the derivation and validation sets were 0.72 (95% CI, 0.70–0.75) and 0.72 (95% CI, 0.69–0.75). Multivariate logistic regression demonstrated that an increase of 1 in RISC score increased odds of extubation failure 1.6-fold (OR, 1.58; 95% CI, 1.47–1.69; P < 0.001). Conclusion RISC predicts extubation failure in mechanically ventilated patients in the intensive care unit using several clinically relevant variables available in the electronic medical record but requires a larger validation cohort before widespread clinical implementation.
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Affiliation(s)
- Vikas Bansal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
| | - Nathan J. Smischney
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Rahul Kashyap
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Zhuo Li
- Biostatistics Unit, Mayo Clinic, Jacksonville, FL, United States
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Daniel A. Diedrich
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN, United States
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jason L. Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, AZ, United States
- Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix, AZ, United States
| | - Amanda D. Tomlinson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
| | | | - William David Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
- *Correspondence: William David Freeman
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12
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De Jong A, Huguet H, Molinari N, Jaber S. Non-invasive ventilation versus oxygen therapy after extubation in patients with obesity in intensive care units: the multicentre randomised EXTUB-OBESE study protocol. BMJ Open 2022; 12:e052712. [PMID: 35045999 PMCID: PMC8772410 DOI: 10.1136/bmjopen-2021-052712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Patients with obesity are considered to be at high risk of acute respiratory failure (ARF) after extubation in intensive care unit (ICU). Compared with oxygen therapy, non-invasive ventilation (NIV) may prevent ARF in high-risk patients. However, these strategies have never been compared following extubation of critically ill patients with obesity. Our hypothesis is that NIV is associated with less treatment failure compared with oxygen therapy in patients with obesity after extubation in ICU. METHODS AND ANALYSIS The NIV versus oxygen therapy after extubation in patients with obesity in ICUs protocol (EXTUB-obese) trial is an investigator-initiated, multicentre, stratified, parallel-group unblinded trial with an electronic system-based randomisation. Patients with obesity defined as a body mass index ≥30 kg/m² will be randomly assigned in the 'NIV-group' to receive prophylactic NIV applied immediately after extubation combined with high-flow nasal oxygen (HFNO) or standard oxygen between NIV sessions versus in the 'oxygen therapy group' to receive oxygen therapy alone (HFNO or standard oxygen,). The primary outcome is treatment failure within the 72 hours, defined as reintubation for mechanical ventilation, switch to the other study treatment, or premature study-treatment discontinuation (at the request of the patient or for medical reasons such as gastric distention). The single, prespecified, secondary outcome is the incidence of ARF until day 7. Other outcomes analysed will include tracheal intubation rate at day 7 and day 28, length of ICU and hospital stay, ICU mortality, day 28 and day 90 mortality. ETHICS AND DISSEMINATION The study project has been approved by the appropriate ethics committee 'Comité-de-Protection-des-Personnes Ile de FranceV-19.04.05.70025 Cat2 2019-A00956-51'. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If use of NIV shows positive effects, teams (medical and surgical) will use NIV following extubation of critically ill patients with obesity. TRIAL REGISTRATION NUMBER NCT04014920.
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Affiliation(s)
- Audrey De Jong
- Département d'Anesthésie Réanimation B PhyMedExp, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Helena Huguet
- Clinical research department of Montpellier university hospital, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Samir Jaber
- Département d'Anesthésie Réanimation B PhyMedExp, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
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13
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Predictors of Mortality and Outcomes of Ventilated Patients Managed in a Resource-Limited Acute Surgical Ward. World J Surg 2022; 46:497-503. [PMID: 35013777 PMCID: PMC8747849 DOI: 10.1007/s00268-021-06408-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acute care surgery is an important component of health care in the developed nations. However, in Malaysia, acute care surgery is yet to be recognized as a specific subspecialty service. Due to high demands of limited ICU beds, some patients have to be ventilated in the wards. This study aims to describe the outcomes of acute surgical patients that required mechanical ventilation. METHODS This is a retrospective review of all mechanically ventilated surgical patients in the wards, in a tertiary hospital, in 2020. Sixty-two patients out of 116 patients ventilated in surgical wards fulfilled the inclusion criteria. Demography, surgical diagnosis and procedures and physiologic, biochemical and survival data were analyzed to explore the outcomes and predictors of mortality. RESULTS Twenty-two out of 62 patients eventually gained ICU admission. Mean time from intubation to ICU entry and mean length of ICU stay were 48 h (0 to 312) and 10 days (1 to 33), respectively. Survival for patients admitted to ICU compared to ventilation in the acute surgery wards was 54.5% (12/22) vs 17.5% (7/40). Thirty-four patients underwent surgery, and the majority were bowel-related emergency operations. SAPS2 score validation revealed AUC of 0.701. More than half of patients with mortality risk < 50% eventually were not admitted to ICU. CONCLUSIONS ICU care for critically ill surgical patients provides better survival. There is a need to improve triaging for intensive care, especially for low-mortality-risk patients using risk scores which are locally validated.
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14
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Factors associated with all-cause mortality at 90 days in hospitalized adult patients who received parenteral nutrition. NUTR HOSP 2022; 39:728-737. [DOI: 10.20960/nh.04106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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15
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Rouget A, Vardon-Bounes F, Lorber P, Vavasseur A, Marion O, Marcheix B, Lairez O, Balardy L, Fourcade O, Conil JM, Minville V. Prevalence of malnutrition in coronavirus disease 19: the NUTRICOV study. Br J Nutr 2021; 126:1296-1303. [PMID: 33342449 PMCID: PMC7853739 DOI: 10.1017/s0007114520005127] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/16/2020] [Accepted: 12/09/2020] [Indexed: 01/08/2023]
Abstract
Recent European Society of Parenteral and Enteral Nutrition guidelines highlighted the interest of prevention, diagnosis and treatment of malnutrition in the management of coronavirus disease 19 (COVID-19) patients. The aim of our study was to evaluate the prevalence of malnutrition in patients hospitalised for COVID-19. In a prospective observational cohort study malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) two-step approach. Patients were divided into two groups according to the diagnosis of malnutrition. Covariate selection for the multivariate analysis was based on P <0·2 in univariate analysis, with a logistic regression model and a backward elimination procedure. A partitioning of the population was realised. Eighty patients were prospectively enrolled. Thirty patients (37·5 %) had criteria for malnutrition. The need for intensive care unit admission (n 46, 57·5 %) was similar in the two groups. Three patients who died (3·75 %) were malnourished. Multivariate analysis exhibited that low BMI (OR 0·83, 95 % CI 0·73, 0·96, P = 0·0083), dyslipidaemia (OR 29·45, 95 % CI 3·12, 277·73, P = 0·0031), oral intake reduction <50 % (OR 3·169, 95 % CI 1·04, 9·64, P = 0·0422) and glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration; CKD-EPI) at admission (OR 0·979, 95 % CI 0·96, 0·998, P = 0·0297) were associated with the occurrence of malnutrition. We demonstrate the existence of a high prevalence of malnutrition in a general cohort of COVID-19 inpatients according to GLIM criteria. Nutritional support in COVID-19 care seems an essential element.
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Affiliation(s)
- Antoine Rouget
- Department of Anesthesiology and Critical Care Unit, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Fanny Vardon-Bounes
- Department of Anesthesiology and Critical Care Unit, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
- INSERM UMR 1048, Institut des maladies métaboliques et cardiovasculaires, CHU Toulouse, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Pierre Lorber
- Department of Anesthesiology and Critical Care Unit, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Adrien Vavasseur
- Department of Radiology, CHU Toulouse Rangueil, 1 av du Pr J Poulhès, 31400Toulouse, France
| | - Olivier Marion
- Department of Nephrology and Organ Transplant, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Bertrand Marcheix
- Department of Cardiac Surgery, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Olivier Lairez
- INSERM UMR 1048, Institut des maladies métaboliques et cardiovasculaires, CHU Toulouse, 1 av du Pr Jean Poulhès, 31400Toulouse, France
- Department of Cardiology, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Laurent Balardy
- Department of Geriatric Medicine, CHU Toulouse Purpan, Place du Dr Baylac, 31000Toulouse, France
| | - Olivier Fourcade
- Department of Anesthesiology and Critical Care Unit, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Jean-Marie Conil
- Department of Anesthesiology and Critical Care Unit, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
| | - Vincent Minville
- Department of Anesthesiology and Critical Care Unit, CHU Toulouse Rangueil, 1 av du Pr Jean Poulhès, 31400Toulouse, France
- INSERM UMR 1048, Institut des maladies métaboliques et cardiovasculaires, CHU Toulouse, 1 av du Pr Jean Poulhès, 31400Toulouse, France
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16
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Sanaie S, Hosseini MS, Karrubi F, Iranpour A, Mahmoodpoor A. Impact of Body Mass Index on the Mortality of Critically Ill Patients Admitted to the Intensive Care Unit: An Observational Study. Anesth Pain Med 2020; 11:e108561. [PMID: 34249664 PMCID: PMC8256440 DOI: 10.5812/aapm.108561] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/20/2020] [Accepted: 09/26/2020] [Indexed: 01/22/2023] Open
Abstract
Background Obesity is a severe multifactorial disorder that carries high morbidity and mortality. Objectives This study aimed to evaluate the possible association between body mass index (BMI) and mortality in patients admitted to intensive care units (ICU). Methods In this cross-sectional study, all patients admitted to the ICU were studied. The demographic characteristics, ICU, and hospital length of stay, organ failure, mortality, duration of mechanical ventilation, the occurrence of nosocomial infection, and type of admission were recorded for all patients. Patients were categorized based on their BMI. Results In total, 502 patients were studied who 53.2% of them were male. Most of the death (28.6%) were recorded in the obesity class II patients, while the lowest rate (3.9%) was for the normal-weight patients (P value < 0.001). The APACHE II and waist circumference had a statistically significant association with the mortality rate (P value < 0.001). After adjusting for age and gender, a significant association was found between waist circumference and mortality rate (OR = 1.15, 95% CI = 1.03 - 1.29; P value = 0.014), APACHE II score, and mortality rate (OR = 2.79, 95% CI = 1.91 - 4.07, P value < 0.001); but there was no significant association between BMI and mortality rate. Conclusions This study demonstrated that BMI is associated with an increased risk of mortality, regardless of age and gender. However, after adjusting for age and gender as confounding factors, BMI didn’t have a significant effect on mortality, while the APACHE II score and waist circumference affected the mortality rate.
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Affiliation(s)
- Sarvin Sanaie
- Neurosciences Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Fahimeh Karrubi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Ata Mahmoodpoor
- Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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17
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Central venous pressure monitoring and mortality: What was neglected? Crit Care 2020; 24:624. [PMID: 33097080 PMCID: PMC7585179 DOI: 10.1186/s13054-020-03350-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/16/2020] [Indexed: 11/10/2022] Open
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18
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Karampela I, Chrysanthopoulou E, Christodoulatos GS, Dalamaga M. Is There an Obesity Paradox in Critical Illness? Epidemiologic and Metabolic Considerations. Curr Obes Rep 2020; 9:231-244. [PMID: 32564203 DOI: 10.1007/s13679-020-00394-x] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Obesity represents a global epidemic with serious implications in public health due to its increasing prevalence and its known association with a high morbidity and mortality burden. However, a growing number of data support a survival benefit of obesity in critical illness. This review summarizes current evidence regarding the obesity paradox in critical illness, discusses methodological issues and metabolic implications, and presents potential pathophysiologic mechanisms. RECENT FINDINGS Data from meta-analyses and recent studies corroborate the obesity-related survival benefit in critically ill patients as well as in selected populations such as patients with sepsis and acute respiratory distress syndrome, but not trauma. However, this finding warrants a cautious interpretation due to certain methodological limitations of these studies, such as the retrospective design, possible selection bias, the use of BMI as an obesity index, and inadequate adjustment for confounding variables. Main pathophysiologic mechanisms related to obesity that could explain this phenomenon include higher energy reserves, inflammatory preconditioning, anti-inflammatory immune profile, endotoxin neutralization, adrenal steroid synthesis, renin-angiotensin system activation, cardioprotective metabolic effects, and prevention of muscle wasting. The survival benefit of obesity in critical illness is supported from large meta-analyses and recent studies. Due to important methodological limitations, more prospective studies are needed to further elucidate this finding, while future research should focus on the pathophysiologic role of adipose tissue in critical illness.
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Affiliation(s)
- Irene Karampela
- Second Department of Critical Care, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece.
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece.
| | - Evangelia Chrysanthopoulou
- Second Department of Critical Care, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece
| | - Gerasimos Socrates Christodoulatos
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece
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19
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How can I manage anaesthesia in obese patients? Anaesth Crit Care Pain Med 2020; 39:229-238. [DOI: 10.1016/j.accpm.2019.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 12/17/2022]
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20
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De Jong A, Verzilli D, Chanques G, Futier E, Jaber S. [Preoperative risk and perioperative management of obese patients]. Rev Mal Respir 2019; 36:985-1001. [PMID: 31521434 DOI: 10.1016/j.rmr.2019.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/07/2019] [Indexed: 12/18/2022]
Abstract
The obese patient is at an increased risk of perioperative complications. Most importantly, these include difficult access to the airways (intubation, difficult or impossible ventilation), and post-extubation respiratory distress secondary to the development of atelectasis or obstruction of the airways, sometimes associated with the use of morphine derivatives. The association of obstructive sleep apnea syndrome (OSA) with obesity is very common, and induces a high risk of peri- and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre, per and postoperative pressure. For any obese patient, the implementation of protocols for mask ventilation and/or difficult intubation and the use of protective ventilation, morphine-sparing strategies and a semi-seated positioning throughout the care, is recommended, combined with close monitoring postoperatively. The dosage of anesthetic drugs should be based on the theoretical ideal weight and then titrated, rather than dosed to the total weight. Monitoring of neuromuscular blocking should be used where appropriate, as well as monitoring of the depth of anesthesia. The occurrence of intraoperative recall is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolic disease and early mobilization are recommended, as thromboembolic disease is increased in the obese patient. The use of non-invasive ventilation to prevent the occurrence of acute post-operative respiratory failure and for its treatment is particularly effective in obese patients. In case of admission to ICU, an individualized ventilatory management based on pathophysiology and careful monitoring should be initiated.
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Affiliation(s)
- A De Jong
- PhyMedExp, University of Montpellier, Inserm, CNRS, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34080 Montpellier, France; Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - D Verzilli
- Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - G Chanques
- PhyMedExp, University of Montpellier, Inserm, CNRS, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34080 Montpellier, France; Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - E Futier
- CHU de Clermont-Ferrand, Department of Perioperative Medicine, GReD, UMR/CNRS6293, University, Clermont Auvergne, Inserm, U1103, Clermont-Ferrand, France
| | - S Jaber
- PhyMedExp, University of Montpellier, Inserm, CNRS, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34080 Montpellier, France; Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France.
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21
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Schetz M, De Jong A, Deane AM, Druml W, Hemelaar P, Pelosi P, Pickkers P, Reintam-Blaser A, Roberts J, Sakr Y, Jaber S. Obesity in the critically ill: a narrative review. Intensive Care Med 2019; 45:757-769. [PMID: 30888440 DOI: 10.1007/s00134-019-05594-1] [Citation(s) in RCA: 256] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/05/2019] [Indexed: 11/24/2022]
Abstract
The World Health Organization defines overweight and obesity as the condition where excess or abnormal fat accumulation increases risks to health. The prevalence of obesity is increasing worldwide and is around 20% in ICU patients. Adipose tissue is highly metabolically active, and especially visceral adipose tissue has a deleterious adipocyte secretory profile resulting in insulin resistance and a chronic low-grade inflammatory and procoagulant state. Obesity is strongly linked with chronic diseases such as type 2 diabetes, hypertension, cardiovascular diseases, dyslipidemia, non-alcoholic fatty liver disease, chronic kidney disease, obstructive sleep apnea and hypoventilation syndrome, mood disorders and physical disabilities. In hospitalized and ICU patients and in patients with chronic illnesses, a J-shaped relationship between BMI and mortality has been demonstrated, with overweight and moderate obesity being protective compared with a normal BMI or more severe obesity (the still debated and incompletely understood "obesity paradox"). Despite this protective effect regarding mortality, in the setting of critical illness morbidity is adversely affected with increased risk of respiratory and cardiovascular complications, requiring adapted management. Obesity is associated with increased risk of AKI and infection, may require adapted drug dosing and nutrition and is associated with diagnostic and logistic challenges. In addition, negative attitudes toward obese patients (the social stigma of obesity) affect both health care workers and patients.
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Affiliation(s)
- Miet Schetz
- Division of Cellular and Molecular Medicine, Clinical Department and Laboratory of Intensive Care Medicine, KU Leuven University, Herestraat 49, 3000, Leuven, Belgium.
| | - Audrey De Jong
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier Cedex 5, France
| | - Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.,Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
| | - Wilfried Druml
- Klinik für Innere Medizin III, Abteilung für Nephrologie, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Pleun Hemelaar
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Genoa, Italy
| | - Peter Pickkers
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - Annika Reintam-Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.,Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - Jason Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woolloongabba, Australia.,Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Departments of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier Cedex 5, France
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22
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De Jong A, Verzilli D, Jaber S. ARDS in Obese Patients: Specificities and Management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:74. [PMID: 30850002 PMCID: PMC6408839 DOI: 10.1186/s13054-019-2374-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Audrey De Jong
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France.,Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier, Universitaire Montpellier, Montpellier, France
| | - Daniel Verzilli
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Samir Jaber
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France. .,Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier, Universitaire Montpellier, Montpellier, France.
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23
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Jaber S, Quintard H, Cinotti R, Asehnoune K, Arnal JM, Guitton C, Paugam-Burtz C, Abback P, Mekontso Dessap A, Lakhal K, Lasocki S, Plantefeve G, Claud B, Pottecher J, Corne P, Ichai C, Hajjej Z, Molinari N, Chanques G, Papazian L, Azoulay E, De Jong A. Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:236. [PMID: 30243304 PMCID: PMC6151191 DOI: 10.1186/s13054-018-2150-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/07/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation. METHODS The primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure. RESULTS Between 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797-8.864), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877-6.138), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047-3.362), P = 0.03 and OR 3.240 (1.786-5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187-3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087-3.518), P = 0.025), copious secretions (OR 4.066 (2.268-7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052-4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100-3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001). CONCLUSIONS Specific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT 02450669 . Registered on 21 May 2015.
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Affiliation(s)
- Samir Jaber
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France.
| | - Hervé Quintard
- Université Cote d'Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, Nice, France
| | - Raphael Cinotti
- Intensive Care & Anesthesiology Department, University of Nantes, Hotel-Dieu Hospital, Nantes, France
| | - Karim Asehnoune
- Intensive Care & Anesthesiology Department, University of Nantes, Hotel-Dieu Hospital, Nantes, France
| | | | - Christophe Guitton
- Medical Intensive Care Unit, Hôtel-Dieu Teaching Hospital, Nantes, France
| | - Catherine Paugam-Burtz
- Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018, Paris, France
| | - Paer Abback
- Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018, Paris, France
| | - Armand Mekontso Dessap
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Faculté de Médecine de Créteil, Université Paris Est Créteil, 94010, Créteil Cedex, France
| | - Karim Lakhal
- Intensive Care & Anesthesiology Department, University of Nantes, Laennec Nord Hospital, Nantes, France
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, CHU Angers, 49933, Angers, Cedex 9, France
| | - Gaetan Plantefeve
- Medical-Surgical Intensive Care Unit, General Hospital Centre, Argenteuil, France
| | - Bernard Claud
- Medical-Surgical Intensive Care Unit, General Hospital Centre, Le Puy-en-Velay, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Pôle Anesthésie Réanimation Chirurgicale SAMU, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, stress oxydant et protection musculaire", Strasbourg, France
| | - Philippe Corne
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Carole Ichai
- Université Cote d'Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, Nice, France
| | - Zied Hajjej
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Gerald Chanques
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
| | - Laurent Papazian
- APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Univ, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, University of Paris-Diderot, Saint Louis Hospital, Paris, France
| | - Audrey De Jong
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
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24
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De Jong A, Cossic J, Verzilli D, Monet C, Carr J, Conseil M, Monnin M, Cisse M, Belafia F, Molinari N, Chanques G, Jaber S. Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases. Intensive Care Med 2018; 44:1106-1114. [PMID: 29947888 DOI: 10.1007/s00134-018-5241-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/22/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status. METHODS We conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m2) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90. RESULTS Three hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40-53) in the non-obese and 46% (95% CI, 36-56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH2O) than in non-survivors (15.2 ± 5.2 cmH2O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH2O) and non-survivors (13.2 ± 5.1 cmH2O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01-1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96-0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04-1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients. CONCLUSIONS Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.
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Affiliation(s)
- Audrey De Jong
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
| | - Jeanne Cossic
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Daniel Verzilli
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Clément Monet
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Julie Carr
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Mathieu Conseil
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Marion Monnin
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Moussa Cisse
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Fouad Belafia
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier Cedex 5, 34295, France
| | - Nicolas Molinari
- Department of Statistics, University of Montpellier Lapeyronie Hospital, UMR 729, MISTEA, Montpellier, France
| | - Gérald Chanques
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
| | - Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, CNRS, UMR 9214, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.
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