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Vissing NH, Dungu KHS, Andersen FM, Mønster MB, Hjalgrim LL, Schmiegelow K, Nygaard U. Central Venous Oxygen Saturation in Children With Cancer. Pediatr Emerg Care 2024:00006565-990000000-00501. [PMID: 39141883 DOI: 10.1097/pec.0000000000003254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
OBJECTIVE Central venous saturation (ScvO2) can guide resuscitation of children with septic shock. The normal range of ScvO2 is typically considered as 0.70-0.80, but has not been established in children with cancer. Children with cancer are particularly prone to develop sepsis due to their immunosuppressive therapy, and usually have a permanent central venous catheter, making ScvO2 readily available. We aimed to investigate normal values of ScvO2 in clinically stable children with cancer, and the association between ScvO2, hemoglobin, and lactate. METHODS We conducted a prospective clinical study at the outpatient clinic of a tertiary pediatric hematology/oncology unit. Blood samples were collected from stable children aged 0-17.9 years who were treated for cancer between January 1 and November 30, 2019, during their routine outpatient clinic visits. RESULTS A total of 183 blood samples were collected from 68 patients (24 girls and 44 boys). The predicted mean level of ScvO2 with a 95% confidence interval was 0.67 (0.56-0.78). The ScvO2 value was below the expected lower normal limit of 0.70 in 126 (69%) of the samples and in 48 patients (71%) at least once. ScvO2 was significantly associated with hemoglobin (β1 = 0.012 per g/L hemoglobin, P < 0.001), but not with age, sex, underlying diagnosis, or lactate. CONCLUSIONS The study revealed that a substantial portion of clinically stable childhood cancer patients exhibited ScvO2 levels below the typical reference value of 0.70, suggesting that these children may have inherently lower baseline ScvO2 levels. This should be kept in mind when evaluating children with cancer for septic shock, emphasizing the importance of tailored assessments in this population. Further understanding of baseline ScvO2 abnormalities may be helpful if ScvO2 is used to guide resuscitation.
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Affiliation(s)
- Nadja Hawwa Vissing
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet
| | - Kia Hee Schultz Dungu
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet
| | | | - Mette Bondo Mønster
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet
| | - Lisa Lyngsie Hjalgrim
- From the Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet
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Sánchez Díaz JS, Peniche Moguel KG, Reyes-Ruiz JM, Pérez Nieto OR, Escarramán Martínez D, Zamarrón López EI, Calyeca Sánchez MV. The ∆Pv-aCO2/∆Ca-vO2 ratio as a predictor of mortality in patients with severe acute respiratory distress syndrome related to COVID-19. PLoS One 2023; 18:e0290272. [PMID: 37672537 PMCID: PMC10482256 DOI: 10.1371/journal.pone.0290272] [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: 10/20/2022] [Accepted: 08/05/2023] [Indexed: 09/08/2023] Open
Abstract
OBJECTIVE To evaluate the central venous-to-arterial carbon dioxide difference combined with arterial-to-venous oxygen content difference (∆Pv-aCO2/∆Ca-vO2 ratio) as a predictor of mortality in patients with COVID-19-related severe acute respiratory distress syndrome (ARDS). METHODS Patients admitted to the intensive care unit with severe ARDS secondary to SARS-CoV-2, and invasive mechanical ventilation were included in this single-center and retrospective cohort study performed between April 18, 2020, and January 18, 2022. The tissue perfusion indexes (lactate, central venous oxygen saturation [ScvO2], and venous-to-arterial carbon dioxide pressure difference [∆Pv-aCO2]), anaerobic metabolism index (∆Pv-aCO2/∆Ca-vO2 ratio), and severity index (Simplified Acute Physiology Score II [SAPSII]) were evaluated to determine its association with the mortality through Cox regression analysis, Kaplan-Meier curve and receiver operating characteristic (ROC) curve. RESULTS One hundred fifteen patients were included in the study and classified into two groups, the survivor group (n = 54) and the non-survivor group (n = 61). The lactate, ScvO2, ∆Pv-aCO2, and ∆Pv-aCO2/∆Ca-vO2 ratio medians were 1.6 mEq/L, 75%, 5 mmHg, and 1.56 mmHg/mL, respectively. The ∆Pv-aCO2/∆Ca-vO2 ratio (Hazard Ratio (HR) = 1.17, 95% confidence interval (CI) = 1.06-1.29, p = 0.001) was identified as a mortality biomarker for patients with COVID-19-related severe ARDS. The area under the curve for ∆Pv-aCO2/∆Ca-vO2 ratio was 0.691 (95% CI 0.598-0.774, p = 0.0001). The best cut-off point for ∆Pv-aCO2/∆Ca-vO2 ratio was >2.14 mmHg/mL, with a sensitivity of 49.18%, specificity of 85.19%, a positive likelihood of 3.32, and a negative likelihood of 0.6. The Kaplan-Meier curve showed that survival rates were significantly worse in patients with values greater than this cut-off point. CONCLUSIONS The ∆Pv-aCO2/∆Ca-vO2 ratio could be used as a predictor of mortality in patients with severe ARDS secondary to SARS-CoV-2.
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Affiliation(s)
- Jesús Salvador Sánchez Díaz
- Critical Care Department, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - Karla Gabriela Peniche Moguel
- Critical Care Department, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | - José Manuel Reyes-Ruiz
- Department of Health Research, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
| | | | - Diego Escarramán Martínez
- Department of Anesthesiology, Centro Médico Nacional "La Raza", Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Eder Iván Zamarrón López
- Critical Care Department, Hospital General Regional No. 6, Instituto Mexicano del Seguro Social (IMSS), Ciudad Madero, Tamaulipas, Mexico
| | - María Verónica Calyeca Sánchez
- Critical Care Department, Unidad Médica de Alta Especialidad, Hospital de Especialidades No. 14, Centro Médico Nacional “Adolfo Ruiz Cortines”, Instituto Mexicano del Seguro Social (IMSS), Veracruz, Mexico
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Wu C, Hu L, Shen Q, Xu H, Huang H. Predictive value of extubation failure by decrease in central venous oxygen saturation: A systematic review and meta-analysis. Heliyon 2023; 9:e18227. [PMID: 37519770 PMCID: PMC10375794 DOI: 10.1016/j.heliyon.2023.e18227] [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: 09/21/2022] [Revised: 06/16/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023] Open
Abstract
Background The predictive power of extubation failure diagnosed by decrease in central venous oxygen saturation (ΔScvO2) varies by studies. Here we summarized the diagnostic value of extubation failure tested by ΔScvO2. Methods A comprehensive online search was performed to select potentially eligible studies that evaluated the predictive power of extubation failure tested by ΔScvO2. A manual search was also performed to identify additional studies. Data were extracted to calculate the pooled sensitivity, specificity, positive likelihood ratio (LR), negative LR, diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC) to evaluate the predictive power of extubation failure. Results Overall, five studies including 353 patients were included in this review, of whom 105 (30%) were extubation failure. The cutoff values of ΔScvO2 varied across studies, ranging from 3.8% to 5.4%. Heterogeneity between studies was assessed with an overall Q = 0.007, I2 = 0%, and P = 0.498. The pooled sensitivity and specificity for the overall population were 0.83 (95% CI: 0.74-0.90) and 0.88 (95% CI: 0.83-0.92), respectively. The pooled positive LR and negative LR were 7.2 (95%CI: 4.6-11.2) and 0.19 (95%CI: 0.12-0.31), respectively. The DOR was 38 (95% CI: 17-86). Overall, the pooled AUROC was 0.92 (95% CI: 0.90-0.94). Conclusions The ΔScvO2 performed well in predicting extubation failure in adult mechanical ventilation patients. Further studies with a larger data set and well-designed models are required to confirm the diagnostic accuracy and utility of ScvO2 in predicting extubation outcomes in mechanical ventilation patients.
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Schulz J, Bauer I, Herminghaus A, Picker O, Truse R, Vollmer C. Sub-therapeutic vasopressin but not therapeutic vasopressin improves gastrointestinal microcirculation in septic rats: A randomized, placebo-controlled, blinded trial. PLoS One 2021; 16:e0257034. [PMID: 34555053 PMCID: PMC8460032 DOI: 10.1371/journal.pone.0257034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/20/2021] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Sepsis impairs gastrointestinal microcirculation and it is hypothesized that this might increase patient's mortality. Sub-therapeutic vasopressin improves gastric microcirculation under physiologic conditions whereas a therapeutic dosing regimen seems to be rather detrimental. However, the effects of sub-therapeutic vasopressin on gastrointestinal microcirculation in sepsis are largely unknown. Therefore, we conducted this trial to investigate the effect of sub-therapeutic as well as therapeutic vasopressin on gastrointestinal microcirculation in sepsis. METHODS 40 male Wistar rats were randomized into 4 groups. Colon ascendens stent peritonitis (CASP)-surgery was performed to establish mild or moderate sepsis. 24 hours after surgery, animals received either vasopressin with increasing dosages every 30 min (6.75, 13.5 (sub-therapeutic), 27 mU · kg-1 · h-1 (therapeutic)) or vehicle. Microcirculatory oxygenation (μHBO2) of the colon was recorded for 90 min using tissue reflectance spectrophotometry. Intestinal microcirculatory perfusion (total vessel density (TVD; mm/mm2) and perfused vessel density (PVD; mm/mm2)) were measured using incident dark field-Imaging at baseline and after 60 min. RESULTS In mild as well as in moderate septic animals with vehicle-infusion intestinal μHbO2, TVD and PVD remained constant. In contrast, in moderate sepsis, sub-therapeutic vasopressin with 13.5 mU · kg-1 · h-1 elevated intestinal μHBO2 (+ 6.1 ± 5.3%; p < 0.05 vs. baseline) and TVD (+ 5.2 ± 3.0 mm/mm2; p < 0.05 vs. baseline). μHBO2, TVD and PVD were significantly increased compared to moderate sepsis alone. However, therapeutic vasopressin did not change intestinal microcirculation. In mild septic animals sub-therapeutic as well as therapeutic vasopressin had no relevant effect on gastrointestinal microcirculation. Systemic blood pressure remained constant in all groups. CONCLUSION Sub-therapeutic vasopressin improves gastrointestinal microcirculatory oxygenation in moderate sepsis without altering systemic blood pressure. This protective effect seems to be mediated by an enhanced microcirculatory perfusion and thereby increased oxygen supply. In contrast, therapeutic vasopressin did not show this beneficial effect.
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Affiliation(s)
- Jan Schulz
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany
| | - Inge Bauer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany
| | - Olaf Picker
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany
| | - Richard Truse
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, North Rhine-Westphalia, Germany
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Schulz J, Kramer S, Kanatli Y, Kuebart A, Bauer I, Picker O, Vollmer C, Truse R, Herminghaus A. Sodium Thiosulfate Improves Intestinal and Hepatic Microcirculation Without Affecting Mitochondrial Function in Experimental Sepsis. Front Immunol 2021; 12:671935. [PMID: 34163476 PMCID: PMC8215355 DOI: 10.3389/fimmu.2021.671935] [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: 02/24/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction In the immunology of sepsis microcirculatory and mitochondrial dysfunction in the gastrointestinal system are important contributors to mortality. Hydrogen sulfide (H2S) optimizes gastrointestinal oxygen supply and mitochondrial respiration predominantly via K(ATP)-channels. Therefore, we tested the hypothesis that sodium thiosulfate (STS), an inducer of endogenous H2S, improves intestinal and hepatic microcirculation and mitochondrial function via K(ATP)-channels in sepsis. Methods In 40 male Wistar rats colon ascendens stent peritonitis (CASP) surgery was performed to establish sepsis. Animals were randomized into 4 groups (1: STS 1 g • kg-1 i.p., 2: glibenclamide (GL) 5 mg • kg-1 i.p., 3: STS + GL, 4: vehicle (VE) i.p.). Treatment was given directly after CASP-surgery and 24 hours later. Microcirculatory oxygenation (µHBO2) and flow (µflow) of the colon and the liver were continuously recorded over 90 min using tissue reflectance spectrophotometry. Mitochondrial oxygen consumption in tissue homogenates was determined with respirometry. Statistic: two-way ANOVA + Dunnett´s and Tukey post - hoc test (microcirculation) and Kruskal-Wallis test + Dunn’s multiple comparison test (mitochondria). p < 0.05 was considered significant. Results STS increased µHbO2 (colon: 90 min: + 10.4 ± 18.3%; liver: 90 min: + 5.8 ± 9.1%; p < 0.05 vs. baseline). Furthermore, STS ameliorated µflow (colon: 60 min: + 51.9 ± 71.1 aU; liver: 90 min: + 22.5 ± 20.0 aU; p < 0.05 vs. baseline). In both organs, µHbO2 and µflow were significantly higher after STS compared to VE. The combination of STS and GL increased colonic µHbO2 and µflow (µHbO2 90 min: + 8.7 ± 11.5%; µflow: 90 min: + 41.8 ± 63.3 aU; p < 0.05 vs. baseline), with significantly higher values compared to VE. Liver µHbO2 and µflow did not change after STS and GL. GL alone did not change colonic or hepatic µHbO2 or µflow. Mitochondrial oxygen consumption and macrohemodynamic remained unaltered. Conclusion The beneficial effect of STS on intestinal and hepatic microcirculatory oxygenation in sepsis seems to be mediated by an increased microcirculatory perfusion and not by mitochondrial respiratory or macrohemodynamic changes. Furthermore, the effect of STS on hepatic but not on intestinal microcirculation seems to be K(ATP)-channel-dependent.
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Affiliation(s)
- Jan Schulz
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Sandra Kramer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Yasin Kanatli
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anne Kuebart
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Richard Truse
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
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Effect of Pravastatin Pretreatment and Hypercapnia on Intestinal Microvascular Oxygenation and Blood Flow During Sepsis. Shock 2021; 53:88-94. [PMID: 30724816 DOI: 10.1097/shk.0000000000001323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION In septic patients, adequate microvascular oxygenation (μHBO2) of the intestine is vital for their outcome. Recent studies suggest that statins can ameliorate septic microcirculation in a variety of tissues. However, the effect on intestinal microvascular oxygenation and blood flow is largely unknown. Furthermore, there are indications that statin therapy might not be beneficial in the presence of hypercapnia, as observed in septic acute respiratory distress syndrome (ARDS) patients. Therefore, the present study explores the effect of pravastatin with and without additional moderate acute hypercapnia on intestinal microvascular oxygenation and blood flow in experimental sepsis. METHODS Forty male Wistar rats were randomized into four groups. Half of the animals received 0.2 mg • kg pravastatin s.c., the other half received the same volume as vehicle (NaCl 0.9%). After 18 h, colon ascendens stent peritonitis surgery was conducted in all animals to induce sepsis. Twenty-four hours after surgery, baseline was established and the animals were subjected to either 120 min of normocapnic (pCO2 40 ± 6 mm Hg) or moderate hypercapnic (pCO2 72 ± 10 mm Hg) ventilation. Microcirculatory oxygenation (μHBO2) and perfusion (μflow) of the colon were continuously recorded using tissue reflectance spectrophotometry and laser Doppler, respectively. RESULTS In normocapnic septic animals μHBO2 decreased over time (-8.4 ± 8.7%; P < 0.05 vs. baseline), whereas after pravastatin pretreatment μHBO2 remained constant (-1.9 ± 5.7% vs. baseline). However, in hypercapnic septic animals pretreated with pravastatin μHBO2 declined significantly over time (-8.9 ± 11.8%; P < 0.05 vs. baseline) and was significantly lower compared with normocapnic pravastatin-pretreated animals. μflow did not change over time in any group. CONCLUSION Pravastatin pretreatment ameliorates the intestinal microvascular oxygenation in sepsis and thus seems to prevent intestinal hypoxia. Furthermore, we demonstrated that additional hypercapnia abolishes this effect, indicating why septic ARDS patients might not benefit from pravastatin therapy.
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Omar IH, Okasha AS, Ahmed AM, Saleh RS. Goal Directed Fluid Therapy based on Stroke Volume Variation and Oxygen Delivery Index using Electrical Cardiometry in patients undergoing Scoliosis Surgery. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1927418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Islam Hassan Omar
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Saied Okasha
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Mansour Ahmed
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rabab Saber Saleh
- Anesthesia and Surgical Intensive Care, Alexandria Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Intraoperative Hemodynamic Parameters and Acute Kidney Injury After Living Donor Liver Transplantation. Transplantation 2020; 103:1877-1886. [PMID: 30720690 DOI: 10.1097/tp.0000000000002584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after living donor liver transplantation (LDLT) is associated with increased mortality. We sought to identify associations between intraoperative hemodynamic variables and postoperative AKI. METHODS We retrospectively reviewed 734 cases of LDLT. Intraoperative hemodynamic variables of systemic and pulmonary arterial pressure, central venous pressure (CVP), and pulmonary artery catheter-derived parameters including mixed venous oxygen saturation (SvO2), right ventricular end-diastolic volume (RVEDV), stroke volume, systemic vascular resistance, right ventricular ejection fraction, and stroke work index were collected. Propensity score matching analysis was performed between patients with (n = 265) and without (n = 265) postoperative AKI. Hemodynamic variables were compared between patients with AKI, defined by Kidney Disease Improving Global Outcomes criteria, and those without AKI in the matched sample. RESULTS The incidence of AKI was 36.1% (265/734). Baseline CVP, baseline RVEDV, and SvO2 at 5 minutes before reperfusion were significantly different between patients with and without AKI in the matched sample of 265 pairs. Multivariable logistic regression analysis revealed that baseline CVP, baseline RVEDV, and SvO2 at 5 minutes before reperfusion were independent predictors of AKI (CVP per 5 cm H2O increase: odds ratio [OR], 1.20; 95% confidence interval [CI], 1.09-1.32; SvO2: OR, 1.45; 95% CI, 1.27-1.71; RVEDV: OR, 1.48; 95% CI, 1.24-1.78). CONCLUSIONS The elevated baseline CVP, elevated baseline RVEDV after anesthesia induction, and decreased SvO2 during anhepatic phase were associated with postoperative AKI. Prospective trials are required to evaluate whether the optimization of these variables may decrease the risk of AKI after LDLT.
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Abstract
This article reviews treatment and management of common cardiovascular emergencies in critically ill patients, focusing on acute decompensated heart failure, cardiogenic shock, pulmonary embolism, and hypertensive crisis management with inotropes, vasopressors, diuretics, and antiarrhythmic drugs. Clinicians frequently come across challenging clinical scenarios, and there is a gap between evidence-based medicine and clinical practice. Inotropic and vasopressor agents are useful in the acute setting but must be weaned off or used as a bridge for mechanical circulation support devices. Clinicians should aim to lower complications by choosing medications with respect to comorbidities and close the gap between evidence-based medicine and clinical practice.
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Affiliation(s)
- Yogamaya Mantha
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Rakushumimarika Harada
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Michinari Hieda
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Dallas, TX 75231, USA.
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Kim WH, Lee HJ, Yoon HC, Lee KH, Suh KS. Intraoperative Oxygen Delivery and Acute Kidney Injury after Liver Transplantation. J Clin Med 2020; 9:E564. [PMID: 32092886 PMCID: PMC7073538 DOI: 10.3390/jcm9020564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/02/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
Although intraoperative hemodynamic variables were reported to be associated with acute kidney injury (AKI) after liver transplantation, the time-dependent association between intraoperative oxygen delivery and AKI has not yet been evaluated. We reviewed 676 cases of liver transplantation. Oxygen delivery index (DO2I) was calculated at least ten times during surgery. AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. The area under the curve (AUC) was calculated as below a DO2I of 300 (AUC < 300), 400 and 500 mL/min/m2 threshold. Also, the cumulative time below a DO2I of 300 (Time < 300), 400, and 500 mL/min/m2 were calculated. Multivariable logistic regression analysis was performed to evaluate whether AUC < 300 or time < 300 was independently associated with the risk of AKI. As a sensitivity analysis, propensity score matching analysis was performed between the two intraoperative mean DO2I groups using a cutoff of 500 ml/min/m2, and the incidence of AKI was compared between the groups. Multivariable analysis showed that AUC < 300 or time < 300 was an independent predictor of AKI (AUC < 300: odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.06-1.13, time < 300: OR = 1.10, 95% CI 1.08-1.14). Propensity score matching yielded 192 pairs of low and high mean DO2I groups. The incidence of overall and stage 2 or 3 AKI was significantly higher in the lower DO2I group compared to the higher group (overall AKI: lower group, n = 64 (33.3%) vs. higher group, n = 106 (55.2%), P < 0.001). In conclusion, there was a significant time-dependent association between the intraoperative poor oxygen delivery <300 mL/min/m2 and the risk of AKI after liver transplantation. The intraoperative optimization of oxygen delivery may mitigate the risk of AKI.
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Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Hee-Chul Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea;
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Molitoris BA, George AG, Murray PT, Meier D, Reilly ES, Barreto E, Sandoval RM, Rizk DV, Shaw AD, Peacock WF. A Novel Fluorescent Clinical Method to Rapidly Quantify Plasma Volume. Cardiorenal Med 2019; 9:168-179. [PMID: 30844821 PMCID: PMC7175413 DOI: 10.1159/000496480] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/28/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To determine the performance of a rapid fluorescent indicator technique for measuring plasma volume (PV). METHODS This was an open-label, observational evaluation of a two-component intravenous visible fluorescent dye technique to rapidly measure PV in 16 healthy subjects and 16 subjects with chronic kidney disease (8 stage 3 and 8 stage 4 CKD), at 2 clinical research sites. The method consisted of a single intravenous injection of 12 mg of a large 150-kDa carboxy-methyl dextran conjugated to a fluorescent rhodamine-derived dye as the PV marker (PVM), and 35 mg of a small 5-kDa carboxy-methyl dextran conjugated to fluorescein, the renal clearance marker. Dye concentrations were quantified 15 min after the injections for initial PV measurements using the indicator-dilution principle. Additional samples were taken over 8 h to evaluate the stability of the PVM as a determinant of PV. Blood volumes (BV) were calculated based on PV and the subject's hematocrit. Pharmacokinetic parameters were calculated from the plasma concentration data taken over several days using noncompartmental methods (Phoenix WinNonlin®). Linear correlation and Bland-Altman plots were used to compare visible fluorescent injectate-measured PV compared to Nadler's formula for estimating PV. Finally, 8 healthy subjects received 350 mL infusion of a 5% albumin solution in normal saline over 30 min and a repeat PV determination was then carried out. RESULTS PV and BV varied according to weight and body surface area, with PV ranging from 2,115 to 6,234 mL and 28.6 to 41.9 mL/kg when weight adjusted. Both parameters were stable for > 6 h with repeated plasma measurements of the PVM. There was no difference between healthy subjects and CKD subjects. Overall, there was general agreement with Nadler's estimation formula for the mean PV in subjects. A 24-h repeat dose measurement in 8 healthy subjects showed PV variability of 98 ± 121 mL (mean = 3.8%). Additionally, following an intravenous bolus of 350 mL of a 5% albumin solution in normal saline in 8 healthy subjects, the mean (SD) measured increase in PV was 356 (±50.0) mL post-infusion. There were no serious adverse events reported during the study. CONCLUSIONS This minimally invasive fluorescent dye approach safely allowed for rapid, accurate, and reproducible determination of PV, BV, and dynamic monitoring of changes following fluid administration.
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Affiliation(s)
- Bruce A Molitoris
- Indiana University, Indianapolis, Indiana, USA,
- FAST BioMedical, Carmel, Indiana, USA,
| | - Anthony G George
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | - Ruben M Sandoval
- Indiana University, Indianapolis, Indiana, USA
- FAST BioMedical, Carmel, Indiana, USA
| | - Dana V Rizk
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew D Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Kim WH, Lee HC, Lim L, Ryu HG, Jung CW. Intraoperative Oliguria with Decreased SvO₂ Predicts Acute Kidney Injury after Living Donor Liver Transplantation. J Clin Med 2018; 8:jcm8010029. [PMID: 30597881 PMCID: PMC6351957 DOI: 10.3390/jcm8010029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 12/17/2018] [Accepted: 12/24/2018] [Indexed: 12/14/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent complication after living donor liver transplantation (LDLT), and is associated with increased mortality. However, the association between intraoperative oliguria and the risk of AKI remains uncertain for LDLT. We sought to determine the association between intraoperative oliguria alone and oliguria coupled with hemodynamic derangement and the risk of AKI after LDLT. We evaluated the hemodynamic variables, including mean arterial pressure, cardiac index, and mixed venous oxygen saturation (SvO2). We reviewed 583 adult patients without baseline renal dysfunction and who did not receive hydroxyethyl starch during surgery. AKI was defined using the Kidney Disease Improving Global Outcomes criteria according to the serum creatinine criteria. Multivariable logistic regression analysis was performed with and without oliguria and oliguria coupled with a decrease in SvO2. The performance was compared with respect to the area under the receiver operating characteristic curve (AUC). Intraoperative oliguria <0.5 and <0.3 mL/kg/h were significantly associated with the risk of AKI; however, their performance in predicting AKI was poor. The AUC of single predictors increased significantly when oliguria was combined with decreased SvO2 (AUC 0.72; 95% confidence interval (CI) 0.68–0.75 vs. AUC of oliguria alone 0.61; 95% CI 0.56–0.61; p < 0.0001; vs. AUC of SvO2 alone 0.66; 95% CI 0.61–0.70; p < 0.0001). Addition of oliguria coupled with SvO2 reduction also increased the AUC of multivariable prediction (AUC 0.87; 95% CI 0.84–0.90 vs. AUC with oliguria 0.73; 95% CI 0.69–0.77; p < 0.0001; vs. AUC with neither oliguria nor SvO2 reduction 0.68; 95% CI 0.64–0.72; p < 0.0001). Intraoperative oliguria coupled with a decrease in SvO2 may suggest the risk of AKI after LDLT more reliably than oliguria alone or decrease in SvO2 alone. Intraoperative oliguria should be interpreted in conjunction with SvO2 to predict AKI in patients with normal preoperative renal function and who did not receive hydroxyethyl starch during surgery.
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Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
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Lee HC, Yoon SB, Yang SM, Kim WH, Ryu HG, Jung CW, Suh KS, Lee KH. Prediction of Acute Kidney Injury after Liver Transplantation: Machine Learning Approaches vs. Logistic Regression Model. J Clin Med 2018; 7:jcm7110428. [PMID: 30413107 PMCID: PMC6262324 DOI: 10.3390/jcm7110428] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 12/15/2022] Open
Abstract
Acute kidney injury (AKI) after liver transplantation has been reported to be associated with increased mortality. Recently, machine learning approaches were reported to have better predictive ability than the classic statistical analysis. We compared the performance of machine learning approaches with that of logistic regression analysis to predict AKI after liver transplantation. We reviewed 1211 patients and preoperative and intraoperative anesthesia and surgery-related variables were obtained. The primary outcome was postoperative AKI defined by acute kidney injury network criteria. The following machine learning techniques were used: decision tree, random forest, gradient boosting machine, support vector machine, naïve Bayes, multilayer perceptron, and deep belief networks. These techniques were compared with logistic regression analysis regarding the area under the receiver-operating characteristic curve (AUROC). AKI developed in 365 patients (30.1%). The performance in terms of AUROC was best in gradient boosting machine among all analyses to predict AKI of all stages (0.90, 95% confidence interval [CI] 0.86–0.93) or stage 2 or 3 AKI. The AUROC of logistic regression analysis was 0.61 (95% CI 0.56–0.66). Decision tree and random forest techniques showed moderate performance (AUROC 0.86 and 0.85, respectively). The AUROC of support the vector machine, naïve Bayes, neural network, and deep belief network was smaller than that of the other models. In our comparison of seven machine learning approaches with logistic regression analysis, the gradient boosting machine showed the best performance with the highest AUROC. An internet-based risk estimator was developed based on our model of gradient boosting. However, prospective studies are required to validate our results.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
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The cardiovascular system in critical illness. Curr Opin Crit Care 2018; 22:413-5. [PMID: 27537111 DOI: 10.1097/mcc.0000000000000348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S114-S120. [PMID: 30161065 PMCID: PMC6126368 DOI: 10.1097/pcc.0000000000001619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The respiratory subgroup included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Transfusion and Anemia Expertise Initiative experts developed seven recommendations focused on children with acute respiratory failure. All recommendations reached agreement (> 80%). Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/dL. Specific RBC transfusion strategies using physiologic-based metrics and biomarkers could not be elaborated. CONCLUSIONS The Transfusion and Anemia Expertise Initiative Consensus Conference developed specific recommendations regarding RBC transfusion management in critically ill children with respiratory failure, as well as recommendations to guide future research. Clinical recommendations emphasize relevant hemoglobin thresholds. Research recommendations emphasize the need to identify appropriate physiologic thresholds, suggest a better understanding of alternatives to RBC transfusion, and identify the need for better evidence on hemoglobin thresholds that might be used in specific subpopulations of critically ill children.
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Monitoring and End-Points of Trauma Resuscitation. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0089-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hasanin A, Mukhtar A, Nassar H. Perfusion indices revisited. J Intensive Care 2017; 5:24. [PMID: 28331621 PMCID: PMC5351209 DOI: 10.1186/s40560-017-0220-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/07/2017] [Indexed: 12/18/2022] Open
Abstract
Monitoring of tissue perfusion is an essential step in the management of acute circulatory failure. The presence of cellular dysfunction has been a basic component of shock definition even in the absence of hypotension. Monitoring of tissue perfusion includes biomarkers of global tissue perfusion and measures for assessment of perfusion in non-vital organs. The presence of poor tissue perfusion in a shocked patient is usually associated with worse outcome. Persistently impaired perfusion despite adequate resuscitation is also associated with worse outcome. Thus, normalization of some perfusion indices has become one of the resuscitation targets in patients with septic shock. Although the collective evidence shows the clear relation between impaired peripheral perfusion and mortality, the use of different perfusion indices as a resuscitation target needs more research.
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Affiliation(s)
- Ahmed Hasanin
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt.,Critical Care Department, El-Ameen Hospital, Taif, Kingdom of Saudi Arabia
| | - Ahmed Mukhtar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
| | - Heba Nassar
- Anesthesia and Critical Care Medicine, Cairo University, Giza, Egypt
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Experimental assessment of oxygen homeostasis during acute hemodilution: the integrated role of hemoglobin concentration and blood pressure. Intensive Care Med Exp 2017; 5:12. [PMID: 28251580 PMCID: PMC5332316 DOI: 10.1186/s40635-017-0125-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 02/21/2017] [Indexed: 11/12/2022] Open
Abstract
Background Low hemoglobin concentration (Hb) and low mean arterial blood pressure (MAP) impact outcomes in critically ill patients. We utilized an experimental model of “normotensive” vs. “hypotensive” acute hemodilutional anemia to test whether optimal tissue perfusion is dependent on both Hb and MAP during acute blood loss and fluid resuscitation, and to assess the value of direct measurements of the partial pressure of oxygen in tissue (PtO2). Methods Twenty-nine anesthetized rats underwent 40% isovolemic hemodilution (1:1) (or sham-hemodilution control, n = 4) with either hydroxyethyl starch (HES) (n = 14, normotensive anemia) or saline (n = 11, hypotensive anemia) to reach a target Hb value near 70 g/L. The partial pressure of oxygen in the brain and skeletal muscle tissue (PtO2) were measured by phosphorescence quenching of oxygen using G4 Oxyphor. Mean arterial pressure (MAP), heart rate, temperature, arterial and venous co-oximetry, blood gases, and lactate were assessed at baseline and for 60 min after hemodilution. Cardiac output (CO) was measured at baseline and immediately after hemodilution. Data were analyzed by repeated measures two-way ANOVA. Results Following “normotensive” hemodilution with HES, Hb was reduced to 66 ± 6 g/L, CO increased (p < 0.05), and MAP was maintained. These conditions resulted in a reduction in brain PtO2 (22.1 ± 5.6 mmHg to 17.5 ± 4.4 mmHg, p < 0.05), unchanged muscle PO2, and an increase in venous oxygen extraction. Following “hypotensive” hemodilution with saline, Hb was reduced to 79 ± 5 g/L and both CO and MAP were decreased (P < 0.05). These conditions resulted in a more severe reduction in brain PtO2 (23.2 ± 8.2 to 10.7 ± 3.6 mmHg (p < 0.05), a reduction in muscle PtO2 (44.5 ± 11.0 to 19.9 ± 12.4 mmHg, p < 0.05), a further increase in venous oxygen extraction, and a threefold increase in systemic lactate levels (p < 0.05). Conclusions Acute normotensive anemia (HES hemodilution) was associated with a subtle decrease in brain tissue PtO2 without clear evidence of global tissue hypoperfusion. By contrast, acute hypotensive anemia (saline hemodilution) resulted in a profound decrease in both brain and muscle tissue PtO2 and evidence of inadequate global perfusion (lactic acidosis). These data emphasize the importance of maintaining CO and MAP to ensure adequacy of vital organ oxygen delivery during acute anemia. Improved methods of assessing PtO2 may provide an earlier warning signal of vital organ hypoperfusion.
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