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Fan G, Zhang F, Shan T, Jiang Y, Zheng M, Zang B, Zhao W. Association of point-of-care lung ultrasound findings with 30-day pulmonary complications after cardiac surgery: A prospective cohort study. Heliyon 2024; 10:e31293. [PMID: 38813155 PMCID: PMC11133817 DOI: 10.1016/j.heliyon.2024.e31293] [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: 03/02/2024] [Revised: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 05/31/2024] Open
Abstract
Background Several studies have shown that bedside lung ultrasound findings in postanaesthesia care units (PACUs) and intensive care units (ICUs) correlate with postoperative pulmonary complications(PPCs) after noncardiac major surgery. However, it remains unclear whether lung ultrasound findings can be used as early predictors of PPCs in patients undergoing cardiac surgery. The main aim of our study was to evaluate the relationship between early postoperative point-of-care lung ultrasound findings and PPCs after cardiac surgery. Methods Two board-certified physicians performed a point-of-care pulmonary ultrasound on cardiac surgery patients approximately 2 h after the patient was admitted to the ICU. Pulmonary complications occurring within 30 days postoperatively were recorded. Logistic regression modeling was used to analyze the relationship between lung ultrasound findings and PPCs. Results PPCs occurred in 61 (30.9 %) of the 197 patients. Lung ultrasound scores(LUS), number of lung consolidation(NLC), and depth of pleural effusion(DPE) were more significant in patients who developed PPCs (P < 0.001). According to the multivariate analysis, NLC≥3(aOR 2.71,95%CI 1.14-6.44; p = 0.024)and DPE >0.95(aOR 3.79,95%CI 1.60-8.99; p = 0.002) were found to be independently associated with PPCs during this study. Conclusions Our study demonstrated that DPE >0.95 and NLC ≥3 were associated with PPCs after cardiac surgery based on bedside lung ultrasound findings in the ICU. When these signs manifest perioperatively, the surgeon should be alerted and the necessary steps should be taken, especially if they present simultaneously.
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Affiliation(s)
- Guanglei Fan
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Fengran Zhang
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Tianchi Shan
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yaning Jiang
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Mingzhu Zheng
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Baohe Zang
- Department of Critical Care Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Wenjing Zhao
- Department of Critical Care Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
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2
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Azoulay D, Salloum C, Allard MA, Serrablo A, Moussa M, Romano P, Pietraz D, Golse N, Lim C. Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept. Ann Surg Oncol 2024:10.1245/s10434-024-15227-7. [PMID: 38592622 DOI: 10.1245/s10434-024-15227-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion. PATIENTS AND METHODS The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range). RESULTS Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero. CONCLUSIONS This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France.
| | - Chady Salloum
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Marc-Antoine Allard
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Zaragoza, Spain
| | - Maya Moussa
- Centre Hépato-Biliaire, Department of Anesthesiology, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Pierluigi Romano
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Daniel Pietraz
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Department of Surgery, Hôpital Paul Brousse, Assistance Publique-Hôpitaux de Paris, Villejuif, France
| | - Chetana Lim
- Department of Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Villejuif, France
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3
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Blanco P, Abdo-Cuza A, Palomares EA, Díaz CM, Gutiérrez VF. Ultrasonography and procedures in intensive care medicine. Med Intensiva 2023; 47:717-732. [PMID: 38035918 DOI: 10.1016/j.medine.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/20/2023] [Indexed: 12/02/2023]
Abstract
The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.
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Affiliation(s)
- Pablo Blanco
- High Dependency Unit, Hospital "Dr. Emilio Ferreyra", Necochea, Argentina.
| | | | | | - Cristina Martínez Díaz
- Intensive Care Unit, Hospital Universitario "Príncipe de Asturias Alcalá de Henares", Madrid, Spain
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4
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Bediwy AS, Al-Biltagi M, Saeed NK, Bediwy HA, Elbeltagi R. Pleural effusion in critically ill patients and intensive care setting. World J Clin Cases 2023; 11:989-999. [PMID: 36874438 PMCID: PMC9979285 DOI: 10.12998/wjcc.v11.i5.989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/14/2023] Open
Abstract
Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses. Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients, with a wide range of variable prevalence rates of up to 50%-60% in some studies. This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit (ICU). The original disease that caused pleural effusion can be the exact cause of ICU admission. There is an impairment in the pleural fluid turnover and cycling in critically ill and mechanically ventilated patients. There are also many difficulties in diagnosing pleural effusion in the ICU, including clinical, radiological, and even laboratory difficulties. These difficulties are due to unusual presentation, inability to undergo some diagnostic procedures, and heterogenous results of some of the performed tests. Pleural effusion can affect the patient’s outcome and prognosis due to the hemodynamics and lung mechanics changes in these patients, who usually have frequent comorbidities. Similarly, pleural effusion drainage can modify the ICU-admitted patient’s outcome. Finally, pleural effusion analysis can change the original diagnosis in some cases and redirect the management toward a different way.
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Affiliation(s)
- Adel Salah Bediwy
- Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Chest Diseases, University Medical Center, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Mohammed Al-Biltagi
- Department of Pediatric, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Pediatric, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Chairperson of the Pathology Department, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 26671, Bahrain
- Microbiology Section, Pathology Department, Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
| | | | - Reem Elbeltagi
- Department of Medicine, Royal College of Surgeons in Ireland - Bahrain, Busaiteen 15503, Muharraq, Bahrain
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5
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Evaluation and management of pleural sepsis. Respir Med 2021; 187:106553. [PMID: 34340174 DOI: 10.1016/j.rmed.2021.106553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/21/2022]
Abstract
Pleural sepsis stems from an infection within the pleural space typically from an underlying bacterial pneumonia leading to development of a parapneumonic effusion. This effusion is traditionally divided into uncomplicated, complicated, and empyema. Poor clinical outcomes and increased mortality can be associated with the development of parapneumonic effusions, reinforcing the importance of early recognition and diagnosis. Management necessitates a multimodal therapeutic strategy consisting of antimicrobials, catheter/tube thoracostomy, and at times, video-assisted thoracoscopic surgery.
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6
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Small Drainage Volumes of Pleural Effusions Are Associated with Complications in Critically Ill Patients: A Retrospective Analysis. J Clin Med 2021; 10:jcm10112453. [PMID: 34205925 PMCID: PMC8197788 DOI: 10.3390/jcm10112453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 11/29/2022] Open
Abstract
Pleural effusions are a common finding in critically ill patients and small bore chest drains (SBCD) are proven to be efficient for pleural drainage. The data on the potential benefits and risks of drainage remains controversial. We aimed to determine the cut-off volume for complications, to investigate the impact of pleural drainage and drained volume on clinically relevant outcomes. Medical records of all critically ill patients undergoing insertion of SBCD were retrospectively examined. We screened 13,003 chest radiographs and included 396 SBCD cases in the final analysis. SBCD drained on average 900 mL, with less amount in patients with complications (p = 0.003). A drainage volume of 975 mL in 24 h represented the optimal threshold for complications. Pneumothorax was the most frequent complication (4.5%), followed by bleeding (0.8%). Female and lighter-weighted patients experienced a higher risk for any complication. We observed an improvement in the arterial partial pressure of oxygen and respiratory quotient (p < 0.001). We conclude that the small drainage volumes are associated with complications in critically ill patients—the more you drain, the safer the procedure gets. The use of SBCD is a safe and efficient procedure, further investigations regarding the higher rate of complications in female and lighter-weighted patients are desirable.
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7
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Xie M, Chou YH, Zhang L, Zhang D, Tiu CM. Application of Point-of-care Cardiac Ultrasonography in COVID-19 Infection: Lessons Learned from the Early Experience. J Med Ultrasound 2021; 29:3-8. [PMID: 34084709 PMCID: PMC8081104 DOI: 10.4103/jmu.jmu_140_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/02/2020] [Accepted: 12/28/2020] [Indexed: 12/15/2022] Open
Abstract
The outbreak of the SARS-CoV-2 infection, also known as coronavirus disease 2019 (COVID-19), was formally defined a pandemic by the World Health Organization (WHO) in March 2020, and is still a global health issue. Since there is a high prevalence of acute cardiac injury in patients with COVID-19 infection, point-of-care cardiac ultrasound (PoCCUS) may be used for longitudinal monitoring of patients infected with COVID-19. However, there is still limited experience on the application of PoCCUS in the COVID-19 pandemic. Within the point of care setting in our system, focused cardiac US exams were performed with specific imaging protocols on the basis of suspicion of a specific disease, such as ruling out tamponade or thrombotic complications. Our preliminary experience shows that PoCCUS helps distinguish the causes of dyspnea in febrile patients. The COVID-19 infection may play a role in unmasking or exacerbating underlying chronic cardiovascular conditions, especially in patients with inadequate past history. In hospitalized patients with COVID-19, CURB-65 score for pneumonia severity and raised D-dimer were significantly associated with deep vein thrombosis (DVT). COVID-19 patients with DVT had worse prognosis, and patients with lower leg edema deserve further evaluation by using point-of-care ultrasound for the lower legs and heart. In COVID-19 patients with arrhythmia, PoCCUS used by experienced hands may reveal abnormal right ventricle (RV) functional parameters and lead to a more comprehensive cardiac US study. When there is suspicion of cardiac disease, PoCCUS can be done first, and if information is inadequate, limited transthoracic echocardiography (TTE), and critical care echocardiography (CCE) can be followed. Ultrasound practitioners should follow the standard precautions for COVID-19 as outlined by the Centers for Disease Control and Prevention to prevent transmission of infection, regardless of suspected or confirmed COVID-19.
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Affiliation(s)
- Mingxing Xie
- Department of Ultrasound, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yi-Hong Chou
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan.,Department of Radiology, School of Medicine, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan.,Department of Radiology, Yee Zen General Hospital, Taoyuan, Taiwan
| | - Li Zhang
- Department of Ultrasound, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Danqing Zhang
- Department of Ultrasound, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chui-Mei Tiu
- Department of Medical Imaging and Radiological Technology, Yuanpei University of Medical Technology, Hsinchu, Taiwan.,Department of Radiology, School of Medicine, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan.,Department of Radiology, Yee Zen General Hospital, Taoyuan, Taiwan
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8
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Levy O, Fux D, Bartsikhovsky T, Vosko S, Tishler M, Copel L. Clinical relevance of bilateral pleural effusion in patients with acute pulmonary embolism. Intern Med J 2020; 50:938-944. [PMID: 31661186 DOI: 10.1111/imj.14671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The clinical relevance of bilateral pleural effusion (BPE) in patients with acute pulmonary embolism (PE) is unclear. AIMS To describe characteristics of patients with acute PE that present with BPE. METHODS Patients with acute PE were retrospectively analysed and divided into three groups: without pleural effusion, unilateral pleural effusion and bilateral effusion. Clinical, laboratory and radiological characteristics were compared between the three groups. RESULTS The study population (n = 343) consisted of unilateral effusion group (n = 83), BPE group (n = 94) and without effusion group (n = 166). Several variables were noted in higher proportion (%), in the BPE group in comparison to both the unilateral effusion and without effusion groups: heart failure (17.0 vs 7.2 vs 6.7, P = 0.017), hypoalbuminaemia (59.3 vs 39.5 vs 25.6, P ˂ 0.001), PE occurrence in-hospital setting (51 vs 25.6 vs 15.1, P ˂ 0.001), major operation (31 vs 19.2 vs 15.2, P = 0.01) and mechanical ventilation (13.0 vs 4.9 vs 4.2, P = 0.019). Norton scale scores were found to be lower among patients with BPE in comparison to both patients with unilateral and without pleural effusion (15.55 vs 16.92 vs 17.36, P = 0.006). After adjusting confounding variables, patients with BPE have lower probability for in-hospital survival in comparison to both patients with unilateral pleural effusion (odds ratio = 0.30, 95% confidence interval 0.12-0.79), and patients without pleural effusion (odds ratio = 0.26, 95% confidence interval 0.11-0.61). CONCLUSIONS BPE in patients with acute PE may have significant clinical implications. It may signify serious underlying comorbidities which contribute to higher in-hospital mortality in comparison to both patients with unilateral pleural effusion and patients without pleural effusion.
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Affiliation(s)
- Ofer Levy
- Internal Medicine B, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Fux
- Internal Medicine B, Assaf Harofeh Medical Center, Zerifin, Israel
| | | | - Sergei Vosko
- Internal Medicine B, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Moshe Tishler
- Internal Medicine B, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Laurian Copel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Assaf Harofeh Medical Center, Zerifin, Israel
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9
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Reducing Iatrogenic Pneumothoraces: Using Real-Time Ultrasound Guidance for Pleural Procedures. Crit Care Med 2020; 47:903-909. [PMID: 30985389 DOI: 10.1097/ccm.0000000000003761] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Awareness of the impact of bedside ultrasound to reduce iatrogenic pneumothoraces while performing bedside pleural procedures has increased but with little understanding in how ultrasound is used for these procedures. DESIGN AND SETTING We conducted a retrospective chart review at a tertiary referral center in the United States from January 1, 2014, to March 31, 2017. Our study assessed adverse effect rates between real-time ultrasound-guided and ultrasound-marked thoracenteses and thoracostomy tube placements. PATIENTS Three-hundred ninety-four ICU patients were included in this study. MEASUREMENTS AND MAIN RESULTS There was a significant difference in the rate of adverse effects between real-time ultrasound-guided (0.63% [95% CI, 0.11-3.4%]) and ultrasound-marked (6.89% [95% CI, 4.15-11.24%]; p ≤ 0.01) procedures. More specifically, the rate of pneumothoraces was different between the two procedures (0.63% [95% CI, 0.11-3.4%] vs 4.43% [95% CI, 2.35-8.21%]; p = 0.02). In patients mechanically ventilated, there was a significant difference in overall adverse effect rates between groups of ultrasound use (p = 0.01). CONCLUSIONS The use of real-time ultrasound guidance was associated with a lower rate of iatrogenic pneumothoraces.
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10
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Sakurai M, Morinaga K, Shimoyama K, Mishima S, Oda J. Effects of pleural drainage on oxygenation in critically ill patients. Acute Med Surg 2020; 7:e489. [PMID: 32742663 PMCID: PMC7384977 DOI: 10.1002/ams2.489] [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: 05/18/2019] [Revised: 01/24/2020] [Accepted: 01/26/2020] [Indexed: 12/02/2022] Open
Abstract
Aim Pleural effusion is common among critically ill patients and associated with clinical consequences; however, the benefits of draining pleural effusion remain debatable. Thus, we aimed to investigate pleural drainage effectiveness by focusing on preprocedure patient status. Methods We retrospectively analyzed 22 patients with pleural effusion. Gas exchange, ventilator settings, vital signs, inflammatory response, and nutrition status were examined preprocedure and 24 h and 1 week postprocedure. Data were analyzed using the non‐parametric test and discriminant analysis with receiver operating characteristic curves. Results The partial arterial oxygen pressure (PaO2) to fraction of inspiratory oxygen (FIO2) (P/F) ratio at 24 h was higher postdrainage than predrainage (250 ± 87 versus 196 ± 84, P < 0.05); however, no significant difference between the P/F ratio predrainage and 1 week postdrainage was noted. Patients were classified into effective and ineffective groups according to a 110% increase in the P/F ratio 1 week postdrainage compared with predrainage. The predrainage P/F ratio was lower in the effective group than in the ineffective group (165 ± 91 versus 217 ± 74, P < 0.05). Discriminant analysis showed the area under the receiver operating characteristic curve was 0.72; the cut‐off value of the predrainage P/F ratio (divided into effective and ineffective groups) was 174. Conclusions Pleural drainage could be effective in patients who have lower preprocedure P/F ratios.
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Affiliation(s)
- Masako Sakurai
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Kentaro Morinaga
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Keiichiro Shimoyama
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Shiro Mishima
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Jun Oda
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
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11
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Fysh ETH, Smallbone P, Mattock N, McCloskey C, Litton E, Wibrow B, Ho KM, Lee YCG. Clinically Significant Pleural Effusion in Intensive Care: A Prospective Multicenter Cohort Study. Crit Care Explor 2020; 2:e0070. [PMID: 32166290 PMCID: PMC7063904 DOI: 10.1097/cce.0000000000000070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The prevalence and optimal management of clinically significant pleural effusion, confirmed by thoracic ultrasound, in the critically ill is unknown. This study aimed to determine: 1) the prevalence, characteristics, and outcomes of patients treated in intensive care with clinically significant effusion and 2) the comparative efficacy and safety of pleural drainage or expectant medical management. DESIGN A prospective multicenter cohort study. SETTING ICUs in four teaching hospitals in Western Australia. PATIENTS Consecutive patients with clinically significant pleural effusions (depth ≥ 2 cm on thoracic ultrasound with clinician-determined adverse effects on patient progress). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was the change in Pao2:Fio2 (mm Hg) ratio from baseline to 24 hours. Changes in diagnosis and treatment based on pleural fluid analysis and pleural effusion related serious adverse events between those who underwent either drainage within 24 hours or expectant management were compared. Of the 7,342 patients screened, 226 patients (3.1%) with 300 pleural effusions were enrolled. Early drainage of pleural effusion occurred in 76 patients (34%) and significantly improved oxygenation (Pao2:Fio2 ratio 203 at baseline vs 263 at 24 hr, +29.6% increment; p < 0.01). This was not observed in the other 150 patients who had expectant management (Pao2:Fio2 ratio 250 at baseline vs 268 at 24 hr, +7.2% increment; p = 0.44). The improvement in oxygenation after early drainage remained unchanged after adjustment for a propensity score on the decision to initiate early drainage. Pleural effusion related serious adverse events were not different between the two groups (early drainage 10.5% vs no early drainage 16.0%; p = 0.32). Improvements in diagnosis were noted in 91 initial (nonrepetitive) drainages (76.5% out of 119); treatment strategy was optimized after 80 drainage episodes (59.7% out of 134). CONCLUSIONS Early drainage of clinically significant pleural effusion was associated with improved oxygenation and diagnostic accuracy without increased complications.
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Affiliation(s)
- Edward T H Fysh
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Intensive Care Unit, St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | - Portia Smallbone
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Nicholas Mattock
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
| | | | - Edward Litton
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Bradley Wibrow
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Kwok M Ho
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
- School of Veterinary & Life Sciences, Murdoch, Perth, WA, Australia
| | - Y C Gary Lee
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
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12
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Bateman M, Alkhatib A, John T, Parikh M, Kheir F. Pleural Effusion Outcomes in Intensive Care: Analysis of a Large Clinical Database. J Intensive Care Med 2019; 35:48-54. [PMID: 31640451 DOI: 10.1177/0885066619872449] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pleural effusions are common in critically ill patients. However, the management of pleural fluid on relevant clinical outcomes is poorly studied. We evaluated the impact of pleural effusion in the intensive care unit (ICU). METHODS A large observational ICU database Multiparameter Intelligent Monitoring in Intensive Care III was utilized. Analyses used matched patients with the same admission diagnosis, age, gender, and disease severity. RESULTS Of 50 765, 3897 (7.7%) of critically ill adult patients had pleural effusions. Compared to patients without effusion, patients with effusion had higher in-hospital (38.7% vs 31.3%, P < .0001), 1-month (43.1% vs 36.1%, P < .0001), 6-month (63.6% vs 55.7%, P < .0001), and 1-year mortality (73.8% vs 66.1%, P < .0001), as well as increased length of hospital stay (17.6 vs 12.7 days, P < .0001), ICU stay (7.3 vs 5.1 days, P < .0001), need for mechanical ventilation (63.1% vs 55.7%, P < .0001), and duration of mechanical ventilation (8.7 vs 6.3 days, P < .0001). A total of 1503 patients (38.6%) underwent pleural fluid drainage. Patients in the drainage group had higher in-hospital (43.9% vs 35.4%, P = .0002), 1-month (47.7% vs 39.7%, P = .0005), 6-month (67.1% vs 61.8%, P = .0161), and 1-year mortality (77.1% vs 72.1%, P = .0147), as well as increased lengths of hospital stay (22.1 vs 16.0 days, P < .0001), ICU stay (9.2d vs 6.4 days, P < .0001), and duration of mechanical ventilation (11.7 vs 7.1 days, P < .0001). CONCLUSIONS The presence of a pleural effusion was associated with increased mortality in critically ill patients regardless of disease severity. Drainage of pleural effusion was associated with worse outcomes in a large, heterogeneous cohort of ICU patients.
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Affiliation(s)
- Marjorie Bateman
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ala Alkhatib
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Thomas John
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Malhar Parikh
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Fayez Kheir
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA
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Brogi E, Gargani L, Bignami E, Barbariol F, Marra A, Forfori F, Vetrugno L. Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:325. [PMID: 29282107 PMCID: PMC5745967 DOI: 10.1186/s13054-017-1897-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
Abstract
Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.
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Affiliation(s)
- E Brogi
- Department of Anaesthesia and Intensive Care, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - L Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - E Bignami
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Barbariol
- Department of Medicine, University of Udine, Udine, Italy
| | - A Marra
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - F Forfori
- Department of Anaesthesia and Intensive Care, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Vetrugno
- Department of Medicine, University of Udine, Udine, Italy
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Central Hepatectomy versus Extended Hepatectomy for Malignant Tumors: A Propensity Score Analysis of Postoperative Complications. World J Surg 2017; 40:2745-2757. [PMID: 27272270 DOI: 10.1007/s00268-016-3584-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The specific definition of central hepatectomy (CH) (i.e., resection of segments 4-5-8 ± 1) is not uniformly used, resulting in conflicting comparisons with the more commonly performed extended hepatectomy (EH). The study aimed to compare, using propensity score matching (PSM) analysis, the incidence of postoperative complications between CH and EH for centrally located liver tumors (CLLT). METHODS All consecutive CH and EH procedures for CLLT performed from 1980 to 2011 were retrospectively reviewed. Independent predictors of postoperative complications were identified. CH was compared to EH after PSM. RESULTS The study population consisted of 373 patients, 44 (11.8 %) of whom underwent CH and 329 (88.2 %) of whom underwent EH. Before PSM, the overall 90-day mortality was 7.2 % (27 patients) without a group difference (2 (4.5 %) for CH vs. 25 (7.6 %) for EH, p = 0.756). The CH and EH groups had similar postoperative morbidity rates (43.2 vs. 55.3 %; p = 0.108). Blood transfusion was the only independent predictor of postoperative complications (Hazard Ratio: 1.73; 95 % confidence interval: 1.11-2.68; p = 0.014). After PSM, 43 CH patients were matched with 43 EH patients. No group difference was observed for the postoperative mortality, morbidity, or duration of hospital stay. A higher number of EH patients (30.2 vs. 9.3 %, p = 0.028) presented with more than one postoperative complication. CONCLUSIONS CH and EH yield similar mortality and morbidity. For CLLT, CH may be an attractive procedure with the advantage of sparing the liver parenchyma compared with EH.
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Hundeshagen G, Kramer GC, Ribeiro NM, Salter M, Koutrouvelis AK, Li H, Solanki D, Indrikovs A, Seeton R, Henkel SN, Kinsky MP. Closed-Loop- and Decision-Assist-Guided Fluid Therapy of Human Hemorrhage. Crit Care Med 2017; 45:e1068-e1074. [PMID: 28682837 PMCID: PMC5600681 DOI: 10.1097/ccm.0000000000002593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to evaluate the efficacy, efficiency, and physiologic consequences of automated, endpoint-directed resuscitation systems and compare them to formula-based bolus resuscitation. DESIGN Experimental human hemorrhage and resuscitation. SETTING Clinical research laboratory. SUBJECTS Healthy volunteers. INTERVENTIONS Subjects (n = 7) were subjected to hemorrhage and underwent a randomized fluid resuscitation scheme on separate visits 1) formula-based bolus resuscitation; 2) semiautonomous (decision assist) fluid administration; and 3) fully autonomous (closed loop) resuscitation. Hemodynamic variables, volume shifts, fluid balance, and cardiac function were monitored during hemorrhage and resuscitation. Treatment modalities were compared based on resuscitation efficacy and efficiency. MEASUREMENTS AND MAIN RESULTS All approaches achieved target blood pressure by 60 minutes. Following hemorrhage, the total amount of infused fluid (bolus resuscitation: 30 mL/kg, decision assist: 5.6 ± 3 mL/kg, closed loop: 4.2 ± 2 mL/kg; p < 0.001), plasma volume, extravascular volume (bolus resuscitation: 17 ± 4 mL/kg, decision assist: 3 ± 1 mL/kg, closed loop: -0.3 ± 0.3 mL/kg; p < 0.001), body weight, and urinary output remained stable under decision assist and closed loop and were significantly increased under bolus resuscitation. Mean arterial pressure initially decreased further under bolus resuscitation (-10 mm Hg; p < 0.001) and was lower under bolus resuscitation than closed loop at 20 minutes (bolus resuscitation: 57 ± 2 mm Hg, closed loop: 69 ± 4 mm Hg; p = 0.036). Colloid osmotic pressure (bolus resuscitation: 19.3 ± 2 mm Hg, decision assist, closed loop: 24 ± 0.4 mm Hg; p < 0.05) and hemoglobin concentration were significantly decreased after bolus fluid administration. CONCLUSIONS We define efficacy of decision-assist and closed-loop resuscitation in human hemorrhage. In comparison with formula-based bolus resuscitation, both semiautonomous and autonomous approaches were more efficient in goal-directed resuscitation of hemorrhage. They provide favorable conditions for the avoidance of over-resuscitation and its adverse clinical sequelae. Decision-assist and closed-loop resuscitation algorithms are promising technological solutions for constrained environments and areas of limited resources.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen; University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - George C. Kramer
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Nicole M. Ribeiro
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Michael Salter
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Aristides K. Koutrouvelis
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Husong Li
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Daneshvari Solanki
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Alexander Indrikovs
- Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
- Hofstra Northwell School of Medicine, Department of Pathology, 500 Hofstra Blvd, Hempstead, NY 11549
| | - Roger Seeton
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Sheryl N Henkel
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
| | - Michael P Kinsky
- Department of Anesthesiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555
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Torbic H, Inaty H, Raja S, Choi H. Safe administration of intrapleural alteplase during pregnancy. J Thorac Dis 2017; 9:E801-E804. [PMID: 29221347 DOI: 10.21037/jtd.2017.07.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Instillation of intrapleural (IP) fibrinolytics has been used in patients with complicated parapneumonic pleural effusions to improve fluid drainage and decrease the need for surgical intervention. However, clinical trials have not included certain special populations such as pregnant females and there are currently no published case reports of this practice in this group. We describe the case of a 35-year-old female, G2P1 at 32 weeks of gestation, with a complicated pleural effusion due to influenza pneumonia with superimposed bacterial pneumonia. Her parapneumonic pleural effusion was successfully treated with intercostal tube drainage and IP alteplase [tissue plasminogen activator (tPA)] administration and systemic antibiotics with no harm to her or her fetus, sparing this patient from more invasive surgical procedures. This is the first reported case of successful IP tPA administration for a complicated parapneumonic pleural effusion in a pregnant patient.
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Affiliation(s)
- Heather Torbic
- 1Department of Pharmacy, 2Respiratory Institute, 3Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Hanine Inaty
- 1Department of Pharmacy, 2Respiratory Institute, 3Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Siva Raja
- 1Department of Pharmacy, 2Respiratory Institute, 3Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Humberto Choi
- 1Department of Pharmacy, 2Respiratory Institute, 3Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
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17
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Azoulay D, Bhangui P, Pascal G, Salloum C, Andreani P, Ichai P, Saliba F, Lim C. The impact of expanded indications on short-term outcomes for resection of malignant tumours of the liver over a 30 year period. HPB (Oxford) 2017; 19:638-648. [PMID: 28495439 DOI: 10.1016/j.hpb.2017.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/04/2017] [Accepted: 04/06/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are two philosophical approaches to planning liver resection for malignancy: one strives towards zero postoperative mortality by stringent selection of candidates, thus inherently limiting patients selected; the other, accepts a low yet definite postoperative mortality rate, and offers surgery to all those with potential gain in survival. The aim of this study was to retrospectively analyse an alternative and evolving strategy, and its impact on short-term outcomes. METHOD 3118 consecutive hepatectomies performed in 2627 patients over 3 decades (1980-2011) were analysed. Patient demographics, tumour characteristics, operative details, and postoperative outcomes were analysed. RESULTS 1528 patients (58%) were male. Colorectal liver metastases (1221 patients, 47%) and hepatocellular carcinoma (584 patients, 22%) were the most common diagnoses. Anatomical resections were performed in 2045 (66%), some form of vascular clamping was used in 2385 (72%), and blood transfusion was required in 1130 (36%) patients. Use of preoperative techniques to increase feasibility and safety of complex liver resections allowed expansion of indications to include sicker patients with larger tumours in the later period of the study. Overall morbidity and mortality rates were 31% and 3% respectively. During the first vs. second half of the study period the postoperative morbidity and mortality were 19% vs. 36% (p < 0.001) and 2% vs. 4% (p = 0.006) respectively. CONCLUSION With increasing experience, more patients were accepted for complex hepatectomies. However, there was a definite yet contained increase in postoperative morbidity and mortality.
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Affiliation(s)
- Daniel Azoulay
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Henri Mondor Hospital, AP-HP, Créteil, France; INSERM, Unité 955, Créteil, France.
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Delhi, NCR, India
| | - Gérard Pascal
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Chady Salloum
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Paola Andreani
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Philippe Ichai
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Paul Brousse Hospital, AP-HP, Villejuif, France; INSERM, Unité 785, Villejuif, France
| | - Faouzi Saliba
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Paul Brousse Hospital, AP-HP, Villejuif, France; INSERM, Unité 785, Villejuif, France
| | - Chetana Lim
- Department of Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Henri Mondor Hospital, AP-HP, Créteil, France
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18
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Elmahalawy II, Doha NM, Ebeid OM, Abdel-Hady MA, Saied O. Role of thoracic ultrasound in diagnosis of pulmonary and pleural diseases in critically ill patients. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2016.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Baid H. Patient Safety: Identifying and Managing Complications of Mechanical Ventilation. Crit Care Nurs Clin North Am 2016; 28:451-462. [PMID: 28236392 DOI: 10.1016/j.cnc.2016.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation is a fundamental aspect of critical care practice to help meet the respiratory needs of critically ill patients. Complications can occur though, as a direct result of being mechanically ventilated, or indirectly because of a secondary process. Preventing, identifying, and managing these complications significantly contribute to the role and responsibilities of critical care nurses in promoting patient safety. This article reviews common ventilator-associated events, including both infectious (eg, ventilator-associated pneumonia) and noninfectious causes (eg, acute respiratory distress syndrome, pulmonary edema, pleural effusion, and atelectasis).
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Affiliation(s)
- Heather Baid
- School of Health Sciences, University of Brighton, Westlain House, Village Way, Falmer Campus, Brighton BN1 9PH, UK.
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20
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Kelm DJ, Perrin JT, Cartin-Ceba R, Gajic O, Schenck L, Kennedy CC. Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015; 43:68-73. [PMID: 25247784 PMCID: PMC4269557 DOI: 10.1097/shk.0000000000000268] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Early goal-directed therapy (EGDT) consists of early, aggressive fluid resuscitation and is known to improve survival in sepsis. It is unknown how often EGDT leads to subsequent fluid overload and whether post-EGDT fluid overload affects patients' outcomes. Our hypothesis was that patients with sepsis treated with EGDT were at risk for fluid overload and that fluid overload would be associated with adverse outcomes. We conducted a retrospective cohort of 405 consecutive patients admitted with severe sepsis and septic shock to the medical intensive care unit of a tertiary care academic hospital from January 2008 to December 2009. Baseline demographics, daily weights, fluid status, clinical or radiographic evidence of fluid overload, and medical interventions (thoracentesis, paracentesis, diuretic use, and ultrafiltration) were abstracted, and associations explored using univariate and multivariate logistic and linear regression analyses. At day 1, 67% of patients developed evidence of fluid overload, and in 48%, fluid overload persisted to day 3. Interrater agreement for presence of fluid overload was substantial (κ = 0.7). An increased trend in weight was noted in those with persistent clinical and radiologic evidence of fluid overload, but not with recorded positive fluid balance. When adjusted for baseline severity of illness, fluid overload was associated with increased use of fluid-related medical interventions (thoracentesis and diuretics) and hospital mortality (odds ratio, 1.92; confidence interval, 1.16-3.22). In patients with severe sepsis and septic shock treated with EGDT, clinical evidence of persistent fluid overload is common and is associated with increased use of medical interventions and hospital mortality.
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Affiliation(s)
- Diana J Kelm
- *Department of Internal Medicine and Divisions of †Pulmonary and Critical Care and ‡Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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21
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Impact of lung ultrasound on clinical decision making in critically ill patients. Intensive Care Med 2013; 40:57-65. [DOI: 10.1007/s00134-013-3133-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 10/04/2013] [Indexed: 12/15/2022]
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22
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Blaivas M. Update on point of care ultrasound in the care of the critically ill patient. World J Crit Care Med 2012; 1:102-5. [PMID: 24701407 PMCID: PMC3953867 DOI: 10.5492/wjccm.v1.i4.102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 06/20/2012] [Accepted: 07/12/2012] [Indexed: 02/06/2023] Open
Abstract
One of the most exciting developments to come to the aid of the critically ill patient in recent years is not new at all, but rather has been repackaged and evolved to a level where point-of-care use by critical care physicians has been made possible. Critical care or point-of-care ultrasound dates back more than twenty years, but has come to prominence in the last 5 years and is spreading quickly. Multiple critical care societies have taken up ultrasound policy and training and one organization has been formed that concentrates only on point-of-care ultrasound in critical settings and interventions. The amount of literature generated on the topic is increasing rapidly and hardly a major clinical journal exists that has not published ultrasound related topics.
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Affiliation(s)
- Michael Blaivas
- Michael Blaivas, Department of Emergency Medicine, Northside Hospital Forsyth, Atlanta, GE 30041, United States
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