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Egan S, Collins-Smyth C, Chitnis S, Head J, Chiu A, Bhatti G, McLean SR. Prevention of postoperative atrial fibrillation in cardiac surgery: a quality improvement project. Can J Anaesth 2023; 70:1880-1891. [PMID: 37919634 PMCID: PMC10709480 DOI: 10.1007/s12630-023-02619-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/23/2023] [Accepted: 07/02/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE Postoperative atrial fibrillation (POAF) has an incidence of 20-60% in cardiac surgery. The Society of Cardiovascular Anesthesiologists and the European Association of Cardiothoracic Anaesthesiology Practice Advisory have recommended postoperative beta blockers and amiodarone for the prevention of POAF. By employing quality improvement (QI) strategies, we sought to increase the use of these agents and to reduce the incidence of POAF among our patients undergoing cardiac surgery. METHODS This single-centre QI initiative followed the traditional Plan, Do, Study, Act (PDSA) cycle scientific methodology. A POAF risk score was developed to categorize all patients undergoing cardiac surgery as either normal or elevated risk. Risk stratification was incorporated into a preprinted prescribing guide, which recommended postoperative beta blockade for all patients and a postoperative amiodarone protocol for patients with elevated risk starting on postoperative day one (POD1). A longitudinal audit of all patients undergoing cardiac surgery was conducted over 11 months to track the use of prophylactic medications and the incidence of POAF. RESULTS Five hundred and sixty patients undergoing surgery were included in the QI initiative from 1 December 2020 to 1 November 2021. The baseline rate of POAF across all surgical subtypes was 39% (198/560). The use of prophylactic amiodarone in high-risk patients increased from 13% (1/8) at the start of the project to 41% (48/116) at the end of the audit period. The percentage of patients receiving a beta blocker on POD1 did fluctuate, but remained essentially unchanged throughout the audit (34.8% in December 2020 vs 46.7% in October 2021). After 11 months, the overall incidence of POAF was 29% (24.9% relative reduction). Notable reductions in the incidence of POAF were observed in more complex surgical subtypes by the end of the audit, including multiple valve replacement (89% vs 56%), aortic repair (50% vs 33%), and mitral valve surgery (45% vs 33%). CONCLUSIONS This single-centre QI intervention increased the use of prophylactic amiodarone by 28% for patients at elevated risk of POAF, with no change in the early postoperative initiation of beta blockers (46.7% of patients by POD1). There was a notable reduction in the incidence of POAF in patients at elevated risk undergoing surgery.
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Affiliation(s)
- Sinead Egan
- Vancouver Acute Department of Anesthesia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Coilin Collins-Smyth
- Vancouver Acute Department of Anesthesia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Shruti Chitnis
- Vancouver Acute Department of Anesthesia, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jamie Head
- Department of A;nesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
| | - Allison Chiu
- Vancouver Coastal Health, Vancouver General Hospital, Vancouver, BC, Canada
| | - Gurdip Bhatti
- Cardiac Sciences, Vancouver General Hospital, Vancouver, BC, Canada
| | - Sean R McLean
- Vancouver Acute Department of Anesthesia, Vancouver General Hospital, Vancouver, BC, Canada.
- Vancouver Acute Department of Anesthesia and Perioperative Medicine, Vancouver General Hospital, JPP3 Room 3400, 899 West 12th Ave, Vancouver, BC, V5Z 1M9, Canada.
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Xiao H, Li L, Zhang F, Cheng L, Li Y, Han W, Li H, Fan M. Preoperative systemic immune-inflammation index may predict prolonged mechanical ventilation in patients with spontaneous basal ganglia intracerebral hemorrhage undergoing surgical operation. Front Neurol 2023; 14:1190544. [PMID: 37396763 PMCID: PMC10310536 DOI: 10.3389/fneur.2023.1190544] [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: 03/21/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Background Prolonged mechanical ventilation (PMV) has been proven as a risk factor for poor prognosis in patients with neurocritical illness. Spontaneous basal ganglia intracerebral hemorrhage (ICH) is one common subtype of hemorrhagic stroke and is associated with high morbidity and mortality. The systemic immune-inflammation index (SII) is used as a novel and valuable prognostic marker for various neoplastic diseases and other critical illnesses. Objective This study aimed to analyze the predictive value of preoperative SII for PMV in patients with spontaneous basal ganglia ICH who underwent surgical operations. Methods This retrospective study was conducted in patients with spontaneous basal ganglia ICH who underwent surgical operations between October 2014 and June 2021. SII was calculated using the following formula: SII = platelet count × neutrophil count/lymphocyte count. Multivariate logistic regression analysis and receiver operating characteristics curve (ROC) were used to evaluate the potential risk factors of PMV after spontaneous basal ganglia ICH. Results A total of 271 patients were enrolled. Of these, 112 patients (47.6%) presented with PMV. Multivariate logistic regression analysis showed that preoperative GCS (OR, 0.780; 95% CI, 0.688-0.883; P < 0.001), hematoma size (OR, 1.031; 95% CI, 1.016-1.047; P < 0.001), lactic acid (OR, 1.431; 95% CI, 1.015-2.017; P = 0.041) and SII (OR, 1.283; 95% CI, 1.049-1.568; P = 0.015) were significant risk factors for PMV. The area under the ROC curve (AUC) of SII was 0.662 (95% CI, 0.595-0.729, P < 0.001), with a cutoff value was 2,454.51. Conclusion Preoperative SII may predict PMV in patients with spontaneous basal ganglia ICH undergoing a surgical operation.
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Affiliation(s)
- Huaming Xiao
- Department of Neurosurgery, Weihai Central Hospital, The Affiliated Hospital of Qingdao University, Weihai, Shandong, China
| | - Lei Li
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Feng Zhang
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Lei Cheng
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yang Li
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Wenlan Han
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Huanting Li
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Mingchao Fan
- Department of Neurosurgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
- Department of Neurosurgical Intensive Care Unit, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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Jamal S, Ijaz SH, Minhas AMK, Kichloo A, Khan MZ, Albosta M, Aljadah M, Banga S, Baloch ZQ, Aboud H, Haji AQ, Sheikh A, Kanjwal K. Outcomes of Hospitalizations with Acute Respiratory Distress Syndrome with and without Atrial Fibrillation - Analyses from the National Inpatient Sample (2004-2014). Am J Med Sci 2022; 364:289-295. [DOI: 10.1016/j.amjms.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 10/17/2021] [Accepted: 01/31/2022] [Indexed: 11/01/2022]
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4
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Li C, Pajoumand M, Lambert K, Najia L, Bathula AL, Mazzeffi MA, Galvagno SM, Tabatabai A, Grazioli A, Dahi S, Hochberg ES, Plazak ME. New-Onset Atrial Arrhythmias Are Independently Associated With In-Hospital Mortality in Veno-Venous Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 36:1648-1655. [DOI: 10.1053/j.jvca.2021.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 12/16/2022]
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5
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Brunetti R, Zitelny E, Newman N, Bundy R, Singleton MJ, Dowell J, Dharod A, Bhave PD. New-onset atrial fibrillation incidence and associated outcomes in the medical intensive care unit. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1380-1386. [PMID: 34173671 DOI: 10.1111/pace.14301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/08/2021] [Accepted: 06/21/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND In patients with critical medical illness, data regarding new-onset atrial fibrillation (NOAF) is relatively sparse. This study examines the incidence, associated risk factors, and associated outcomes of NOAF in patients in the medical intensive care unit (MICU). METHODS This single-center retrospective observational cohort study included 2234 patients with MICU stays in 2018. An automated extraction process using ICD-10 codes, validated by a 196-patient manual chart review, was used for data collection. Demographics, medications, and risk factors were collected. Multiple risk scores were calculated for each patient, and AF recurrence was also manually extracted. Length of stay, mortality, and new stroke were primary recorded outcomes. RESULTS Two hundred and forty one patients of the 2234 patient cohort (11.4%) developed NOAF during their MICU stay. NOAF was associated with greater length of stay in the MICU (5.84 vs. 3.52 days, p < .001) and in the hospital (15.7 vs. 10.9 days, p < .001). Patients with NOAF had greater odds of hospital mortality (odds ratio (OR) = 1.92, 95% confidence interval (CI) 1.34-2.71, p < .001) and 1-year mortality (OR = 1.37, 95% CI 1.02-1.82, p = .03). CHARGE-AF scores performed best in predicting NOAF (area under the curve (AUC) 0.691, p < .001). CONCLUSIONS The incidence of NOAF in this MICU cohort was 11.4%, and NOAF was associated with a significant increase in hospital LOS and mortality. Furthermore, the CHARGE-AF score performed best in predicting NOAF.
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Affiliation(s)
- Ryan Brunetti
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine. One Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Edan Zitelny
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine. One Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Noah Newman
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine. One Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Richa Bundy
- Wake Forest Center for Biomedical Informatics, Winston Salem, North Carolina, USA
| | - Matthew J Singleton
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine. One Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Jonathan Dowell
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine. One Medical Center Boulevard, Winston-Salem, North Carolina, USA
| | - Ajay Dharod
- Wake Forest Center for Biomedical Informatics, Winston Salem, North Carolina, USA.,Department of Implementation Science, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Wake Forest Center for Healthcare Innovation, Winston Salem, North Carolina, USA.,Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Prashant D Bhave
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine. One Medical Center Boulevard, Winston-Salem, North Carolina, USA
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Gundlund A, Olesen JB, Butt JH, Christensen MA, Gislason GH, Torp-Pedersen C, Køber L, Kümler T, Fosbøl EL. One-year outcomes in atrial fibrillation presenting during infections: a nationwide registry-based study. Eur Heart J 2021; 41:1112-1119. [PMID: 31848584 DOI: 10.1093/eurheartj/ehz873] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/02/2019] [Accepted: 11/27/2019] [Indexed: 12/20/2022] Open
Abstract
AIMS Thromboprophylaxis guidelines for patients with concurrent atrial fibrillation (AF) during infections are unclear and not supported by data. We compared 1-year outcomes in patients with infection-related AF and infection without AF. METHODS AND RESULTS By crosslinking Danish nationwide registry data, AF naïve patients admitted with infection (1996-2016) were identified. Those with AF during the infection (infection-related AF) were matched 1:3 according to age, sex, type of infection, and year with patients with infection without AF. Outcomes (AF, thromboembolic events) were assessed by multivariable Cox regression. The study population comprised 30 307 patients with infection-related AF and 90 912 patients with infection without AF [median age 79 years (interquartile range 71-86), 47.6% males in both groups]. The 1-year absolute risk of AF and thromboembolic events were 36.4% and 7.6%, respectively (infection-related AF) and 1.9% and 4.4%, respectively (infection without AF). In the multivariable analyses, infection-related AF was associated with an increased long-term risk of AF and thromboembolic events compared with infection without AF: hazard ratio (HR) 25.98, 95% confidence interval (CI) 24.64-27.39 for AF and HR 2.10, 95% CI 1.98-2.22 for thromboembolic events. Further, differences in risks existed across different subtypes of infections. CONCLUSION During the first year after discharge, 36% of patients with infection-related AF had a new hospital contact with AF. Infection-related AF was associated with increased risk of thromboembolic events compared with infection without AF and our results suggest that AF related to infection may merit treatment and follow-up similar to that of AF not related to infection.
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Affiliation(s)
- Anna Gundlund
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Jawad H Butt
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Mathias Aagaard Christensen
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Research Unit 1, Copenhagen University Hospital Herlev-Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen K, Denmark.,The National Institute of Public Health, University of Southern Denmark, Øster farimagsgade 5A, 1353 Copenhagen K, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjaellands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Lars Køber
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Thomas Kümler
- Department of Cardiology, Copenhagen University Hospital Herlev-Gentofte, Borgmester Ib Juuls Vej 1, 2730 Herlev, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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7
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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8
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Ler A, Sazzad F, Ong GS, Kofidis T. Comparison of outcomes of the use of Del Nido and St. Thomas cardioplegia in adult and paediatric cardiac surgery: a systematic review and meta-analysis. Perfusion 2020; 35:724-735. [DOI: 10.1177/0267659120919350] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: In recent years, the use of del Nido cardioplegia, initially intended for paediatric cardiac surgery, has been extended to adult cardiac surgery in many institutions. Our aim was thus to compare the outcomes of the use of del Nido cardioplegia with that of conventional cardioplegia and discuss its role in both adult and paediatric cardiac surgery. Method: A systematic literature search was conducted in August 2019 on Medline (via PubMed), Embase and Cochrane electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Any retrospective studies and randomised controlled trials that reported findings comparing the outcomes of the use of del Nido cardioplegia with that of St. Thomas cardioplegia were included. Results: We observed shorter aortic cross-clamp time (mean difference: −15.18, confidence interval: −27.21 to −3.15, p = 0.01) and cardiopulmonary bypass time (mean difference: −13.52, confidence interval: −20.64 to −6.39, p = 0.0002) associated with the use of del Nido cardioplegia in adult cardiac surgery as compared to St. Thomas cardioplegia. Defibrillation rates were significantly lower in patients who had been given del Nido cardioplegia, in both adult (relative risk: 0.28, confidence interval: 0.12 to 0.64, p = 0.003) and paediatric patients (relative risk: 0.25, confidence interval: 0.08 to 0.79, p = 0.02). Conclusion: Del Nido cardioplegia may be a viable alternative to the use of St. Thomas cardioplegia in both adult and paediatric patients, providing similar postoperative outcomes while also affording the additional advantage of shorter aortic cross-clamp time and cardiopulmonary bypass time (in adult cardiac surgery) and decreased rates of defibrillation (in both adult and paediatric cardiac surgery).
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Affiliation(s)
- Ashlynn Ler
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Faizus Sazzad
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
- Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Geok Seen Ong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
- Cardiovascular Research Institute, National University of Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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9
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Wu Z, Fang J, Wang Y, Chen F. Prevalence, Outcomes, and Risk Factors of New-Onset Atrial Fibrillation in Critically Ill Patients. Int Heart J 2020; 61:476-485. [PMID: 32350206 DOI: 10.1536/ihj.19-511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this article is to systematically evaluate the prevalence, outcomes, and risk factors of new-onset atrial fibrillation (AF) in critically ill patients.Medline, Embase, Science Citation Index, Wanfang, CNKI, and Wiley Online Library were thoroughly searched to identify relevant studies. Studies were assessed for methodological quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) were used to assess the strength of the association. Heterogeneity, subgroup, sensitivity analyses, and publication bias were conducted.A total of 25 studies were included. The prevalence of new-onset AF ranged from 4.1% to 46%.The random-effects pooled prevalence was 10.7%. The pooled result jumped up to 35.8% in patients with septic shock. Pooled analysis showed significant associations between new-onset AF with intensive care unit (ICU) mortality and in-hospital mortality over those patients without AF (OR = 3.11; 95%CI 2.45-3.96 and OR = 1.63; 95%CI 1.27-2.08). The pooled analysis also indicated that both ICU and hospital length of stay are longer in patients with new-onset AF than those without AF (WMD = 1.87; 95%CI 0.89-2.84 and WMD = 2.73; 95%CI 0.77-4.69). Independent risk factors included increasing age, shock, sepsis, use of a pulmonary artery catheter and mechanical ventilation, fluid loading, and organ failures.New-onset AF incidence rate is high in critically ill patients. New-onset AF is associated with worse outcomes. Further studies should be done to explore how to prevent and treat new-onset AF in critically ill patients.
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Affiliation(s)
- Zesheng Wu
- Department of Emergency, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine
| | - Jinyan Fang
- Department of Emergency, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine
| | - Yi Wang
- Department of Emergency, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine
| | - Fanghui Chen
- Department of Emergency, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine
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10
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Pereira T, Gadhoumi K, Ma M, Liu X, Xiao R, Colorado RA, Keenan KJ, Meisel K, Hu X. A Supervised Approach to Robust Photoplethysmography Quality Assessment. IEEE J Biomed Health Inform 2020; 24:649-657. [PMID: 30951482 PMCID: PMC9553283 DOI: 10.1109/jbhi.2019.2909065] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Early detection of Atrial Fibrillation (AFib) is crucial to prevent stroke recurrence. New tools for monitoring cardiac rhythm are important for risk stratification and stroke prevention. As many of new approaches to long-term AFib detection are now based on photoplethysmogram (PPG) recordings from wearable devices, ensuring high PPG signal-to-noise ratios is a fundamental requirement for a robust detection of AFib episodes. Traditionally, signal quality assessment is often based on the evaluation of similarity between pulses to derive signal quality indices. There are limitations to using this approach for accurate assessment of PPG quality in the presence of arrhythmia, as in the case of AFib, mainly due to substantial changes in pulse morphology. In this paper, we first tested the performance of algorithms selected from a body of studies on PPG quality assessment using a dataset of PPG recordings from patients with AFib. We then propose machine learning approaches for PPG quality assessment in 30-s segments of PPG recording from 13 stroke patients admitted to the University of California San Francisco (UCSF) neuro intensive care unit and another dataset of 3764 patients from one of the five UCSF general intensive care units. We used data acquired from two systems, fingertip PPG (fPPG) from a bedside monitor system, and radial PPG (rPPG) measured using a wearable commercial wristband. We compared various supervised machine learning techniques including k-nearest neighbors, decisions trees, and a two-class support vector machine (SVM). SVM provided the best performance. fPPG signals were used to build the model and achieved 0.9477 accuracy when tested on the data from the fPPG exclusive to the test set, and 0.9589 accuracy when tested on the rPPG data.
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11
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Pereira T, Ding C, Gadhoumi K, Tran N, Colorado RA, Meisel K, Hu X. Deep learning approaches for plethysmography signal quality assessment in the presence of atrial fibrillation. Physiol Meas 2019; 40:125002. [PMID: 31766037 PMCID: PMC7198064 DOI: 10.1088/1361-6579/ab5b84] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Photoplethysmography (PPG) monitoring has been implemented in many portable and wearable devices we use daily for health and fitness tracking. Its simplicity and cost-effectiveness has enabled a variety of biomedical applications, such as continuous long-term monitoring of heart arrhythmias, fitness, and sleep tracking, and hydration monitoring. One major issue that can hinder PPG-based applications is movement artifacts, which can lead to false interpretations. In many implementations, noisy PPG signals are discarded. Misinterpreted or discarded PPG signals pose a problem in applications where the goal is to increase the yield of detecting physiological events, such as in the case of paroxysmal atrial fibrillation (AF)-a common episodic heart arrhythmia and a leading risk factor for stroke. In this work, we compared a traditional machine learning and deep learning approaches for PPG quality assessment in the presence of AF, in order to find the most robust method for PPG quality assessment. APPROACH The training data set was composed of 78 278 30 s long PPG recordings from 3764 patients using bedside patient monitors. Two different representations of PPG signals were employed-a time-series based (1D) one and an image-based (2D) one. Trained models were tested on an independent set of 2683 30 s PPG signals from 13 stroke patients. MAIN RESULTS ResNet18 showed a higher performance (0.985 accuracy, 0.979 specificity, and 0.988 sensitivity) than SVM and other deep learning approaches. 2D-based models were generally more accurate than 1D-based models. SIGNIFICANCE 2D representation of PPG signal enhances the accuracy of PPG signal quality assessment.
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Affiliation(s)
- Tania Pereira
- Department of Physiological Nursing, University of California, San Francisco, CA, United States of America
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12
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Kanjanahattakij N, Rattanawong P, Krishnamoorthy P, Horn B, Chongsathidkiet P, Garvia V, Putthapiban P, Sirinvaravong N, Figueredo VM. New-onset atrial fibrillation is associated with increased mortality in critically ill patients: a systematic review and meta-analysis. Acta Cardiol 2019; 74:162-169. [PMID: 29975173 DOI: 10.1080/00015385.2018.1477035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) is one of the most comorbid conditions in critically ill patients requiring intensive care unit (ICU). Multiple studies have suggested that there may be an association between new-onset AF and adverse outcome in critically ill patients. However, there are no meta-analyses to assess this association. METHODS Studies were systematically searched from electronic databases. Studies that examined the relationship between new-onset AF and adverse outcomes including mortality and length of stay in ICU patients were included. Studies that included patients with prior AF were excluded. The pooled effect size was calculated with a random-effect model, weighted for the inverse of variance, to determine an association between new-onset AF and in-hospital mortality. Heterogeneity was assessed with I2. RESULTS Twelve studies were included. Pooled analysis showed statistically significant difference rate of the hospital mortality between patients with and without new-onset AF (OR 2.70; 95% CI 2.43-3.00). Subgroup analysis of only patients with sepsis or septic shock showed a significant association between new-onset AF and in-hospital mortality (OR 2.32; 95% CI 1.88-2.87). No significant heterogeneity was observed (I2 = 0%) in both analyses. Pooled analysis of four studies also showed a significant association between new-onset AF and short-term mortality (OR 2.22; 95% CI 1.28-3.83) with moderate heterogeneity (I2 = 67%). CONCLUSIONS New-onset AF is associated with worse outcome in critically ill patients. Further studies should be done to evaluate for causality and adjust for confounders.
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Affiliation(s)
| | | | | | - Benjamin Horn
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | | | - Veronica Garvia
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | | | | | - Vincent M. Figueredo
- Department of Medicine, Division of Cardiology, Einstein Medical Center, Philadelphia, PA, USA
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Jung YT, Kim MJ, Lee JG, Lee SH. Predictors of early weaning failure from mechanical ventilation in critically ill patients after emergency gastrointestinal surgery: A retrospective study. Medicine (Baltimore) 2018; 97:e12741. [PMID: 30290686 PMCID: PMC6200493 DOI: 10.1097/md.0000000000012741] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Mechanical ventilation (MV) is the most common therapeutic modality used for critically ill patients. However, prolonged MV is associated with high morbidity and mortality. Therefore, it is important to avoid both premature extubation and unnecessary prolongation of MV. Although some studies have determined the predictors of early weaning success and failure, only a few have investigated these factors in critically ill surgical patients who require postoperative MV. The aim of this study was to evaluate predictors of early weaning failure from MV in critically ill patients who had undergone emergency gastrointestinal (GI) surgery.The medical records of 3327 adult patients who underwent emergency GI surgery between January 2007 and December 2016 were reviewed retrospectively. Clinical and laboratory parameters before surgery and within 2 days postsurgery were investigated.This study included 387 adult patients who required postoperative MV. A low platelet count (adjusted odds ratio [OR]: 0.995; 95% confidence interval [CI]: 0.991-1.000; P = .03), an elevated delta neutrophil index (DNI; adjusted OR: 1.025; 95% CI: 1.005-1.046; P = .016), a delayed spontaneous breathing trial (SBT; adjusted OR: 14.152; 95% CI: 6.571-30.483; P < .001), and the presence of postoperative shock (adjusted OR: 2.436; 95% CI: 1.138-5.216; P = .022) were shown to predict early weaning failure from MV in the study population.Delayed SBT, a low platelet count, an elevated DNI, and the presence of postoperative shock are independent predictors of early weaning failure from MV in critically ill patients after emergency GI surgery.
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Affiliation(s)
- Yun Tae Jung
- Department of Surgery, Ajou University School of Medicine, Suwon
| | - Myung Jun Kim
- Division of Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Gil Lee
- Division of Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hwan Lee
- Division of Trauma Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Rehberg S, Joannidis M, Whitehouse T, Morelli A. Landiolol for managing atrial fibrillation in intensive care. Eur Heart J Suppl 2018; 20:A15-A18. [PMID: 30188960 PMCID: PMC5909768 DOI: 10.1093/eurheartj/sux039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Landiolol is an injectable ultrashort acting beta-blocker with high beta1 selectivity indicated for heart rate control of atrial fibrillation in the emergency and critical care setting. Accordingly, landiolol is associated with a significantly reduced risk of arterial hypotension and negative inotropic effects. Based on this particular profile along with the clinical experience in Japan for more than a decade landiolol represents a promising agent for the management of elevated heart rate and atrial fibrillation in intensive care patients even with catecholamine requirements. This article provides a review and perspective of landiolol for heart rate control in intensive care patients based on the current literature.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anaesthesiology, University Hospital of Greifswald, Greifswald, Germany
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, University Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care Medicine, University of Rome "La Sapienza", Italy Policlinico Umberto I° Hospital, Viale del Policlinico 155, Rome, Italy
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Chean CS, McAuley D, Gordon A, Welters ID. Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey. PeerJ 2017; 5:e3716. [PMID: 28929012 PMCID: PMC5592903 DOI: 10.7717/peerj.3716] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/29/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND New-onset atrial fibrillation (AF) is the most common arrhythmia in critically ill patients. Although evidence base and expert consensus opinion for management have been summarised in several international guidelines, no specific considerations for critically ill patients have been included. We aimed to establish current practice of management of critically ill patients with new-onset AF. METHODS We designed a short user-friendly online questionnaire. All members of the Intensive Care Society were invited via email containing a link to the questionnaire, which comprised 21 questions. The online survey was conducted between November 2016 and December 2016. RESULTS The response rate was 397/3152 (12.6%). The majority of respondents (81.1%) worked in mixed Intensive Care Units and were consultants (71.8%). Most respondents (39.5%) would start intervention on patients with fast new-onset AF and stable blood pressure at a heart rate between 120 and 139 beats/min. However, 34.8% of participants would treat all patients who developed new-onset fast AF. Amiodarone and beta-blockers (80.9% and 11.6% of answers) were the most commonly used anti-arrhythmics. A total of 63.8% of respondents do not regularly anti-coagulate critically ill patients with new-onset fast AF, while 30.8% anti-coagulate within 72 hours. A total of 68.0% of survey respondents do not routinely use stroke risk scores in critically ill patients with new-onset AF. A total of 85.4% of participants would consider taking part in a clinical trial investigating treatment of new-onset fast AF in the critically ill. DISCUSSION Our results suggest a considerable disparity between contemporary practice of management of new-onset AF in critical illness and treatment recommendations for the general patient population suffering from AF, particularly with regard to anti-arrhythmics and anti-coagulation used. Amongst intensivists, there is a substantial interest in research for management of new-onset AF in critically ill patients.
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Affiliation(s)
- Chung Shen Chean
- Intensive Care Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Daniel McAuley
- School of Medicine, Dentistry and Biomedical Sciences, The Queen's University Belfast, Belfast, United Kingdom
| | - Anthony Gordon
- Faculty of Medicine, Department of Surgery & Cancer, Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom
| | - Ingeborg Dorothea Welters
- Intensive Care Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.,Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom
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Salem JE, Dureau P, Funck-Brentano C, Hulot JS, El-Aissaoui M, Aissaoui N, Urien S, Faisy C. Effectiveness of heart rate control on hemodynamics in critically ill patients with atrial tachyarrhythmias managed by amiodarone. Pharmacol Res 2017; 122:118-126. [PMID: 28610957 DOI: 10.1016/j.phrs.2017.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/03/2017] [Accepted: 06/09/2017] [Indexed: 11/19/2022]
Abstract
Atrial tachyarrhythmias (AT) are common in intensive care unit (ICU) patients and might contribute to hemodynamic instability if heart rate (HR) is persistently too rapid. We aimed to assess if HR control below 115 or 130bpm with amiodarone improves hemodynamics in ICU patients with AT. This observational study included 73 ICU patients with disabling AT receiving amiodarone for HR control. A total of 525 changes (mainly within 4-8h) in mean arterial pressure (MAP) and 167 changes in plasma lactate in response to HR variations above 115 or 130bpm were analyzed. Epinephrine, sedative drugs, fluid loading, use of diuretics, continuous renal replacement therapy and amiodarone dosing were among covariables assessed. Univariable analysis showed that HR variations above 115bpm were poorly correlated to change in MAP (r=0.11, p<0.01). Multivariable analysis showed that changes in MAP were still positively associated to HR variation (p<0.05) and to initiation or termination of epinephrine (p<0.05) or sedatives infusions (p<0.05). Changes in plasma lactate did not correlate to HR variations above 115bpm. When considering 130 bpm as a threshold, HR variations were not associated to changes in MAP or to changes in plasma lactate. Amiodarone dose was associated to HR decrease but not to MAP or plasma lactate increase. In ICU patients with AT, strict HR control below 115bpm or 130bpm with amiodarone does not improve hemodynamics. A prospective randomized trial assessing strict versus lenient HR control in this setting is needed.
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Affiliation(s)
- Joe-Elie Salem
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France; Cardiology - Rythmology Unit, Pitié-Salpêtrière Hospital, Assistance Publique - Hôpitaux de Paris, F-75013 Paris, France.
| | - Pauline Dureau
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France
| | - Christian Funck-Brentano
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France
| | - Jean-Sébastien Hulot
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France
| | - Maria El-Aissaoui
- Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Nadia Aissaoui
- Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Saik Urien
- CIC-1419 INSERM, EAU-08 University Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Christophe Faisy
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; Institute of Cardiometabolism and Nutrition (ICAN), France; CIC-1419 INSERM, EAU-08 University Paris Descartes Sorbonne Paris Cité, Paris, France
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