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Lichter Y, Gal Oz A, Adi N, Nini A, Angel Y, Nevo A, Aviram D, Moshkovits I, Wald R, Stavi D, Goder N. Linear Correlation Between Mean Arterial Pressure and Urine Output in Critically Ill Patients. Crit Care Explor 2024; 6:e1141. [PMID: 39120069 PMCID: PMC11319324 DOI: 10.1097/cce.0000000000001141] [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] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVE Mean arterial pressure (MAP) plays a significant role in regulating tissue perfusion and urine output (UO). The optimal MAP target in critically ill patients remains a subject of debate. We aimed to explore the relationship between MAP and UO. DESIGN A retrospective observational study. SETTING A general ICU in a tertiary medical center. PATIENTS All critically ill patients admitted to the ICU for more than 10 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS MAP values and hourly UO were collected in 5,207 patients. MAP levels were categorized into 10 groups of 5 mm Hg (from MAP < 60 mm Hg to MAP > 100 mg Hg), and 656,423 coupled hourly mean MAP and UO measurements were analyzed. Additionally, we compared the UO of individual patients in each MAP group with or without norepinephrine (NE) support or diuretics, as well as in patients with acute kidney injury (AKI).Hourly UO rose incrementally between MAP values of 65-100 mm Hg. Among 2,226 patients treated with NE infusion, mean UO was significantly lower in the MAP less than 60 mm Hg group (53.4 mL/hr; 95% CI, 49.3-57.5) compared with all other groups (p < 0.001), but no differences were found between groups of 75 less than or equal to MAP. Among 2500 patients with AKI, there was a linear increase in average UO from the MAP less than 60 mm Hg group (57.1 mL/hr; 95% CI, 54.2-60.0) to the group with MAP greater than or equal to 100 mm Hg (89.4 mL/hr; 95% CI, 85.7-93.1). When MAP was greater than or equal to 65 mm Hg, we observed a statistically significant trend of increased UO in periods without NE infusion. CONCLUSIONS Our analysis revealed a linear correlation between MAP and UO within the range of 65-100 mm Hg, also observed in the subgroup of patients treated with NE or diuretics and in those with AKI. These findings highlight the importance of tissue perfusion to the maintenance of diuresis and achieving adequate fluid balance in critically ill patients.
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Affiliation(s)
- Yael Lichter
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Critical Care Department, University College London Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Amir Gal Oz
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Nimrod Adi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Asaph Nini
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Angel
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Andrey Nevo
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Aviram
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Critical Care Department, University College London Hospital NHS Foundation Trust, London, United Kingdom
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Itay Moshkovits
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada
| | - Dekel Stavi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Noam Goder
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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2
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Schreiber N, Orlob S, Eichlseder M, Pichler A, Kirsch AH, Kolland M. The Association of Noninvasively Derived Tissue Perfusion Pressure With Acute Kidney Injury in Patients With Circulatory Compromise. Anesth Analg 2024:00000539-990000000-00884. [PMID: 39088365 DOI: 10.1213/ane.0000000000007134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Affiliation(s)
- Nikolaus Schreiber
- From the Department of Anaesthesiology and Intensive Care Medicine 2, Medical University of Graz, Graz, Austria
| | - Simon Orlob
- From the Department of Anaesthesiology and Intensive Care Medicine 2, Medical University of Graz, Graz, Austria
| | - Michael Eichlseder
- Department of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Alexander Pichler
- Department of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
| | - Alexander H Kirsch
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Kolland
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Jian B, Liu H, Zhang Y, Li G, Yang S, Fu G, Huang S, Huang Y, Zhou Z, Wu Z, Liang M. Postoperative Dipping Patterns of Mean Arterial Pressure and Mortality After Coronary Artery Bypass Grafting. J Cardiovasc Transl Res 2024; 17:287-297. [PMID: 38196010 DOI: 10.1007/s12265-023-10475-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/18/2023] [Indexed: 01/11/2024]
Abstract
Blood pressure dipping patterns have long been considered to be associated with adverse events. We aimed to investigate whether dipping patterns of postoperative MAP were related to 90-day and hospital mortality in patients undergoing CABG. Four thousand three hundred ninety-one patients were classified into extreme dippers (night-to-day ratio of MAP ≤ 0.8), dippers (0.8 < night-to-day ratio of MAP ≤ 0.9), non-dippers (0.9 < night-to-day ratio of MAP ≤ 1), and reverse dippers (> 1). Compared with non-dippers, reverse dippers were at a higher risk of 90-day mortality (aHR = 1.58; 95% CI, 1.10-2.27) and hospital mortality (aOR = 1.97; 95% CI, 1.12-3.47). A significant interaction was observed between hypertension and dipping patterns (P for interaction = 0.02), with a significant increased risk of 90-day mortality in non-hypertensive reverse dippers (aHR = 1.90; 95% CI, 1.17-3.07) but not in hypertensive reverse dippers (aHR = 1.26; 95% CI, 0.73-2.19).
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Affiliation(s)
- Bohao Jian
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haoliang Liu
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yi Zhang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Gang Li
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Song Yang
- Department of Cardiothoracic Surgical ICU, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Guangguo Fu
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Suiqing Huang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhuoming Zhou
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Mengya Liang
- Department of Cardiac Surgery, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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4
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Gattarello S, Lombardo F, Romitti F, D'Albo R, Velati M, Fratti I, Pozzi T, Nicolardi R, Fioccola A, Busana M, Collino F, Herrmann P, Camporota L, Quintel M, Moerer O, Saager L, Meissner K, Gattinoni L. Determinants of acute kidney injury during high-power mechanical ventilation: secondary analysis from experimental data. Intensive Care Med Exp 2024; 12:31. [PMID: 38512544 PMCID: PMC10957825 DOI: 10.1186/s40635-024-00610-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The individual components of mechanical ventilation may have distinct effects on kidney perfusion and on the risk of developing acute kidney injury; we aimed to explore ventilatory predictors of acute kidney failure and the hemodynamic changes consequent to experimental high-power mechanical ventilation. METHODS Secondary analysis of two animal studies focused on the outcomes of different mechanical power settings, including 78 pigs mechanically ventilated with high mechanical power for 48 h. The animals were categorized in four groups in accordance with the RIFLE criteria for acute kidney injury (AKI), using the end-experimental creatinine: (1) NO AKI: no increase in creatinine; (2) RIFLE 1-Risk: increase of creatinine of > 50%; (3) RIFLE 2-Injury: two-fold increase of creatinine; (4) RIFLE 3-Failure: three-fold increase of creatinine; RESULTS: The main ventilatory parameter associated with AKI was the positive end-expiratory pressure (PEEP) component of mechanical power. At 30 min from the initiation of high mechanical power ventilation, the heart rate and the pulmonary artery pressure progressively increased from group NO AKI to group RIFLE 3. At 48 h, the hemodynamic variables associated with AKI were the heart rate, cardiac output, mean perfusion pressure (the difference between mean arterial and central venous pressures) and central venous pressure. Linear regression and receiving operator characteristic analyses showed that PEEP-induced changes in mean perfusion pressure (mainly due to an increase in CVP) had the strongest association with AKI. CONCLUSIONS In an experimental setting of ventilation with high mechanical power, higher PEEP had the strongest association with AKI. The most likely physiological determinant of AKI was an increase of pleural pressure and CVP with reduced mean perfusion pressure. These changes resulted from PEEP per se and from increase in fluid administration to compensate for hemodynamic impairment consequent to high PEEP.
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Affiliation(s)
- Simone Gattarello
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany.
| | - Fabio Lombardo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosanna D'Albo
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mara Velati
- Department of Anesthesia and Intensive Care Medicine Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Isabella Fratti
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosmery Nicolardi
- Department of Anesthesia and Intensive Care Medicine Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Fioccola
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "Città Della Salute E Della Scienza" Hospital, Turin, Italy
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Michael Quintel
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine Donau-Isar-Klinikum Deggendorf, Deggendorf, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Leif Saager
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Centre Göttingen, Göttingen, Germany
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5
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Lavillegrand JR, Blum L, Morin A, Urbina T, Gabarre P, Bonny V, Baudel JL, Guidet B, Maury E, Ait-Oufella H. Permissive Hypotension Has No Deleterious Impact on Fluid Balance or Kidney Function. Crit Care Explor 2023; 5:e0991. [PMID: 37868030 PMCID: PMC10586843 DOI: 10.1097/cce.0000000000000991] [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] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVES Mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely in the absence of tissue hypoperfusion, but the consequences on fluid balance and kidney function remain unknown. DESIGN During a 1-year period, we retrospectively collected data of consecutive septic patients admitted for sepsis with a mean arterial pressure (MAP) less than 65 mm Hg despite fluid resuscitation. SETTING Medical 18-bed ICU in a tertiary teaching hospital. PATIENTS Septic patients with a MAP less than 65 mm Hg despite initial resuscitation. INTERVENTIONS In our ICU, MAP between 55 and 65 mm Hg was tolerated in the absence of peripheral hypoperfusion (permissive hypotension) or corrected using norepinephrine (septic shock group) when peripheral tissue hypoperfusion was present. MEASUREMENTS AND MAIN RESULTS Ninety-four consecutive septic patients were included, 15 in the permissive hypotension group and 79 in the septic shock group. Median age was 66 years (57-77 yr) and 42% were women. The main sources of infection were respiratory (45%) and abdominal (18%). Severity was more important in septic shock group with higher Sequential Organ Failure Assessment score (7 [5-10] vs. 4 [1-6]; p < 0.0001), more frequent organ support therapy and ultimately higher mortality (38 vs. 0%; p < 0.01). The total volume of crystalloids infused before ICU admission was not different between groups (1930 ± 250 vs. 1850 ± 150 mL; p = 0.40). Within the 6 first hours of ICU stay, patients in the permissive hypotension group received less fluids (530 ± 170 vs. 1100 ± 110 mL; p = 0.03) and had higher urinary output (1.4 mL [0.88-2.34 mL] vs. 0.47 mL/kg/hr [0.08-1.25 mL/kg/hr]; p < 0.001). In addition, kidney injury evaluated using KDIGO score was lower in the permissive hypotension group at 48 hours (0 hr [0-1 hr] vs. 1 hr [0-2 hr]; p < 0.05). CONCLUSIONS In septic patients without clinical peripheral hypoperfusion, mean arterial hypotension between 55 and 65 mm Hg could be tolerated safely without vasopressor infusion and was not associated with excessive fluid administration or kidney damage.
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Affiliation(s)
- Jean-Rémi Lavillegrand
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
| | - Laurene Blum
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandra Morin
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Tomas Urbina
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Paul Gabarre
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
| | - Vincent Bonny
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean-Luc Baudel
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Bertrand Guidet
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
- Inserm UMR 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Sorbonne Université, Paris, France
- Inserm UMR 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
- Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
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6
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Alfieri F, Ancona A, Tripepi G, Rubeis A, Arjoldi N, Finazzi S, Cauda V, Fagugli RM. Continuous and early prediction of future moderate and severe Acute Kidney Injury in critically ill patients: Development and multi-centric, multi-national external validation of a machine-learning model. PLoS One 2023; 18:e0287398. [PMID: 37490482 PMCID: PMC10368244 DOI: 10.1371/journal.pone.0287398] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/05/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Acute Kidney Injury (AKI) is a major complication in patients admitted to Intensive Care Units (ICU), causing both clinical and economic burden on the healthcare system. This study develops a novel machine-learning (ML) model to predict, with several hours in advance, the AKI episodes of stage 2 and 3 (according to KDIGO definition) acquired in ICU. METHODS A total of 16'760 ICU adult patients from 145 different ICU centers and 3 different countries (US, Netherland, Italy) are retrospectively enrolled for the study. Every hour the model continuously analyzes the routinely-collected clinical data to generate a new probability of developing AKI stage 2 and 3, according to KDIGO definition, during the ICU stay. RESULTS The predictive model obtains an auROC of 0.884 for AKI (stage 2/3 KDIGO) prediction, when evaluated on the internal test set composed by 1'749 ICU stays from US and EU centers. When externally tested on a multi-centric US dataset of 6'985 ICU stays and multi-centric Italian dataset of 1'025 ICU stays, the model achieves an auROC of 0.877 and of 0.911, respectively. In all datasets, the time between model prediction and AKI (stage 2/3 KDIGO) onset is at least of 14 hours after the first day of ICU hospitalization. CONCLUSIONS In this study, a novel ML model for continuous and early AKI (stage 2/3 KDIGO) prediction is successfully developed, leveraging only routinely-available data. It continuously predicts AKI episodes during ICU stay, at least 14 hours in advance when the AKI episode happens after the first 24 hours of ICU admission. Its performances are validated in an extensive, multi-national and multi-centric cohort of ICU adult patients. This ML model overcomes the main limitations of currently available predictive models. The benefits of its real-world implementation enable an early proactive clinical management and the prevention of AKI episodes in ICU patients. Furthermore, the software could be directly integrated with IT system of the ICU.
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Affiliation(s)
| | | | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Andrea Rubeis
- Department of Applied Science and Technology, Politecnico di Torino, Turin, Italy
| | - Niccolò Arjoldi
- Department of Applied Science and Technology, Politecnico di Torino, Turin, Italy
| | - Stefano Finazzi
- Dipartimento di Salute Pubblica, Laboratorio di Clinical Data Science, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Valentina Cauda
- U-Care Medical srl, Torino, Italy
- Department of Applied Science and Technology, Politecnico di Torino, Turin, Italy
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7
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Schuurmans J, van Nieuw Amerongen AR, Terwindt LE, Schenk J, Veelo DP, Vlaar APJ, van der Ster BJP. Feasibility of continuous non-invasive finger blood pressure monitoring in adult patients admitted to an intensive care unit: A retrospective cohort study. Heart Lung 2023; 61:51-58. [PMID: 37148815 DOI: 10.1016/j.hrtlng.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Arterial catheters are often used for blood pressure monitoring in the intensive care unit (ICU), but they can cause complications. Non-invasive continuous finger blood pressure monitors could serve as an alternative. However, failure to obtain finger blood pressure signals is reported in up to 12% of ICU patients. OBJECTIVES Our primary objective was to identify the success rate of finger blood pressure monitoring in ICU patients. Secondary objectives were to assess whether patient admission characteristics could be used to identify patients unsuitable for non-invasive blood pressure monitoring and to determine the quality of non-invasive blood pressure waveforms. METHODS Retrospective observational study conducted in a cohort of 499 ICU patients. When available, the signal quality of the first hour of finger measurement was determined using an open-source waveform algorithm. RESULTS Finger blood pressure signals were obtained in 94% of patients. These patients had a high quality blood pressure waveform for 84% of the measurement time. Patients without a finger blood pressure signal significantly more frequently had a history of kidney and vascular disease, were more often treated with inotropic agents, had lower hemoglobin levels, and had higher arterial lactate levels. CONCLUSIONS Finger blood pressure signals were obtained in nearly all ICU patients. Significant differences in baseline characteristics between patients with and without finger blood pressure signals were found, but they were not clinically relevant. The characteristics studied could therefore not be used to identify patients unsuitable for finger blood pressure monitoring.
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Affiliation(s)
- Jaap Schuurmans
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Lotte Elisabeth Terwindt
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands
| | - Jimmy Schenk
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands; Department of Epidemiology and Data Science, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Denise Petra Veelo
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands.
| | - Alexander Petrus Johannes Vlaar
- Department of Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Björn Jacob Petrus van der Ster
- Department of Anesthesiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands
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8
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Recent Developments in the Evaluation and Management of Cardiorenal Syndrome: A Comprehensive Review. Curr Probl Cardiol 2023; 48:101509. [PMID: 36402213 DOI: 10.1016/j.cpcardiol.2022.101509] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.
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9
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Carayannopoulos KL, Pidutti A, Upadhyaya Y, Alshamsi F, Basmaji J, Granholm A, Alhazzani W, Lewis K. Mean Arterial Pressure Targets and Patient-Important Outcomes in Critically Ill Adults: A Systematic Review and Meta-Analysis of Randomized Trials. Crit Care Med 2023; 51:241-253. [PMID: 36661452 DOI: 10.1097/ccm.0000000000005726] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis to determine whether targeting a higher mean arterial pressure (MAP) compared with a lower MAP in adults with shock results in differences in patient important outcomes. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov through May 2021. STUDY SELECTION Titles and abstracts were screened independently and in duplicate to identify potentially eligible studies, then full text for final eligibility. We included parallel-group randomized controlled trials in adult patients with a diagnosis of shock requiring vasoactive medications. The higher MAP group was required to receive vasoactive medications to target a higher MAP as established by study authors, whereas the lower MAP group received vasoactive medications to target lower MAP. DATA EXTRACTION In triplicate, reviewers independently extracted data using a prepiloted abstraction form. Statistical analyses were conducted using the RevMan software Version 5.3. DATA SYNTHESIS Six randomized controlled trials (n = 3,690) met eligibility criteria. Targeting a higher MAP (75-85 mm Hg) compared with lower MAP of 65 mm Hg resulted in no difference in mortality (relative risk [RR], 1.06; 95% CI, 0.98-1.15; I2 = 0%; p = 0.12; moderate certainty. Targeting a higher MAP resulted in no difference in the risk of undergoing renal replacement therapy (RR, 0.96; 95% CI, 0.83-1.11; I2 = 24%; p = 0.57; moderate certainty); however, a subgroup analysis comparing patients with and without chronic hypertension demonstrated that a higher MAP may reduce the risk of undergoing renal replacement therapy (RR, 0.83; 95% CI, 0.71-0.98; I2 = 0%; p = 0.02). CONCLUSIONS In conclusion, our systematic review and meta-analysis demonstrated with moderate certainty that there is no difference in mortality when a higher MAP is targeted in critically ill adult patients with shock. Further studies are needed to determine the impact of mean arterial pressure on need for renal replacement therapy in this population.
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Affiliation(s)
| | - Andrew Pidutti
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - John Basmaji
- Department of Medicine & Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
| | - Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Impact and Evidence, McMaster University, Hamilton, ON, Canada
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10
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Deng J, Li L, Feng Y, Yang J. Comprehensive Management of Blood Pressure in Patients with Septic AKI. J Clin Med 2023; 12:jcm12031018. [PMID: 36769666 PMCID: PMC9917880 DOI: 10.3390/jcm12031018] [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: 11/27/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
Acute kidney injury (AKI) is one of the serious complications of sepsis in clinical practice, and is an important cause of prolonged hospitalization, death, increased medical costs, and a huge medical burden to society. The pathogenesis of AKI associated with sepsis is relatively complex and includes hemodynamic abnormalities due to inflammatory response, oxidative stress, and shock, which subsequently cause a decrease in renal perfusion pressure and eventually lead to ischemia and hypoxia in renal tissue. Active clinical correction of hypotension can effectively improve renal microcirculatory disorders and promote the recovery of renal function. Furthermore, it has been found that in patients with a previous history of hypertension, small changes in blood pressure may be even more deleterious for kidney function. Therefore, the management of blood pressure in patients with sepsis-related AKI will directly affect the short-term and long-term renal function prognosis. This review summarizes the pathophysiological mechanisms of microcirculatory disorders affecting renal function, fluid management, vasopressor, the clinical blood pressure target, and kidney replacement therapy to provide a reference for the clinical management of sepsis-related AKI, thereby promoting the recovery of renal function for the purpose of improving patient prognosis.
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Affiliation(s)
- Junhui Deng
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Lina Li
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
| | - Yuanjun Feng
- Department of Renal Rheumatology, Space Hospital Affiliated to Zunyi Medical University, Zunyi 563002, China
| | - Jurong Yang
- Department of Nephrology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 400120, China
- Correspondence: or
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11
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Vinit S, Michel-Flutot P, Mansart A, Fayssoil A. Effects of C2 hemisection on respiratory and cardiovascular functions in rats. Neural Regen Res 2023; 18:428-433. [PMID: 35900441 PMCID: PMC9396504 DOI: 10.4103/1673-5374.346469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
High cervical spinal cord injuries induce permanent neuromotor and autonomic deficits. These injuries impact both central respiratory and cardiovascular functions through modulation of the sympathetic nervous system. So far, cardiovascular studies have focused on models of complete contusion or transection at the lower cervical and thoracic levels and diaphragm activity evaluations using invasive methods. The present study aimed to evaluate the impact of C2 hemisection on different parameters representing vital functions (i.e., respiratory function, cardiovascular, and renal filtration parameters) at the moment of injury and 7 days post-injury in rats. No ventilatory parameters evaluated by plethysmography were impacted during quiet breathing after 7 days post-injury, whereas permanent diaphragm hemiplegia was observed by ultrasound and confirmed by diaphragmatic electromyography in anesthetized rats. Interestingly, the mean arterial pressure was reduced immediately after C2 hemisection, with complete compensation at 7 days post-injury. Renal filtration was unaffected at 7 days post-injury; however, remnant systolic dysfunction characterized by a reduced left ventricular ejection fraction persisted at 7 days post-injury. Taken together, these results demonstrated that following C2 hemisection, diaphragm activity and systolic function are impacted up to 7 days post-injury, whereas the respiratory and cardiovascular systems display vast adaptation to maintain ventilatory parameters and blood pressure homeostasis, with the latter likely sustained by the remaining descending sympathetic inputs spared by the initial injury. A better broad characterization of the physiopathology of high cervical spinal cord injuries covering a longer time period post-injury could be beneficial for understanding evaluations of putative therapeutics to further increase cardiorespiratory recovery.
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12
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Tran PNT, Kusirisin P, Kaewdoungtien P, Phannajit J, Srisawat N. Higher blood pressure versus normotension targets to prevent acute kidney injury: a systematic review and meta-regression of randomized controlled trials. Crit Care 2022; 26:364. [PMID: 36434726 PMCID: PMC9700976 DOI: 10.1186/s13054-022-04236-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Renal hypoperfusion is one of the most common causes of acute kidney injury (AKI), especially in shock and perioperative patients. An optimal blood pressure (BP) target to prevent AKI remains undetermined. We conducted a systematic review and meta-analysis of available randomized clinical trial (RCT) results to address this knowledge gap. METHODS From inception to May 13, 2022, we searched Ovid Medline, EMBASE, Cochrane Library, SCOPUS, clinicaltrials.gov, and WHO ICTRP for RCTs comparing higher BP target versus normotension in hemodynamically unstable patients (shock, post-cardiac arrest, or surgery patients). The outcomes of interest were post-intervention AKI rate and renal replacement therapy (RRT) rate. Two investigators independently screened the citations and reviewed the full texts for eligible studies according to a predefined form. RESULTS Twelve trials were included, enrolling a total of 5759 participants, with shock, non-cardiac, and cardiac surgery patients accounting for 3282 (57.0%), 1687 (29.3%) and 790 (13.7%) patients, respectively. Compared to lower mean arterial blood pressure (MAP) targets that served as normotension, targeting higher MAP had no significant effect on AKI rates in shock (RR [95% CI] = 1.10 [0.93, 1.29]), in cardiac-surgery (RR [95% CI] = 0.87 [0.73, 1.03]) and non-cardiac surgery patients (RR [95% CI] = 1.25 [0.98, 1.60]) using random-effects meta-analyses. In shock patients with premorbid hypertension, however, targeting MAP above 70 mmHg resulted in significantly lower RRT risks, RR [95%CI] = 1.20 [1.03, 1.41], p < 0.05. CONCLUSIONS Targeting a higher MAP in shock or perioperative patients may not be superior to normotension, except in shock patients with premorbid hypertension. Further studies are needed to assess the effects of a high MAP target to preventing AKI in hypertensive patients across common settings of hemodynamic instability. Trial registration This systematic review has been registered on PROSPERO ( CRD42021286203 ) on November 19, 2021, prior to data extraction and analysis.
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Affiliation(s)
- Phu Nguyen Trong Tran
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.413054.70000 0004 0468 9247Department of Internal Medicine, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Cantho, Vietnam
| | - Prit Kusirisin
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7132.70000 0000 9039 7662Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Piyanut Kaewdoungtien
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.415092.b0000 0004 0576 2645Division of Nephrology, Police General Hospital, Royal Thai Police Headquarters, Bangkok, Thailand
| | - Jeerath Phannajit
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattachai Srisawat
- grid.7922.e0000 0001 0244 7875Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.411628.80000 0000 9758 8584Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand ,grid.7922.e0000 0001 0244 7875Center of Excellence in Critical Care Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand ,grid.512985.2Academy of Science, Royal Society of Thailand, Bangkok, Thailand
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13
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Lofgren LR, Hoareau GL, Kuck K, Silverton NA. Noninvasive and Invasive Renal Hypoxia Monitoring in a Porcine Model of Hemorrhagic Shock. J Vis Exp 2022:10.3791/64461. [PMID: 36373937 PMCID: PMC10044407 DOI: 10.3791/64461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Up to 50% of patients with trauma develop acute kidney injury (AKI), in part due to poor renal perfusion after severe blood loss. AKI is currently diagnosed based on a change in serum creatinine concentration from baseline or prolonged periods of decreased urine output. Unfortunately, baseline serum creatinine concentration data is unavailable in most patients with trauma, and current estimation methods are inaccurate. In addition, serum creatinine concentration may not change until 24-48 h after the injury. Lastly, oliguria must persist for a minimum of 6 h to diagnose AKI, making it impractical for early diagnosis. AKI diagnostic approaches available today are not useful for predicting risk during the resuscitation of patients with trauma. Studies suggest that urinary partial pressure of oxygen (PuO2) may be useful for assessing renal hypoxia. A monitor that connects the urinary catheter and the urine collection bag was developed to measure PuO2 noninvasively. The device incorporates an optical oxygen sensor that estimates PuO2 based on luminescence quenching principles. In addition, the device measures urinary flow and temperature, the latter to adjust for confounding effects of temperature changes. Urinary flow is measured to compensate for the effects of oxygen ingress during periods of low urine flow. This article describes a porcine model of hemorrhagic shock to study the relationship between noninvasive PuO2, renal hypoxia, and AKI development. A key element of the model is the ultrasound-guided surgical placement in the renal medulla of an oxygen probe, which is based on an unsheathed optical microfiber. PuO2 will also be measured in the bladder and compared to the kidney and noninvasive PuO2 measurements. This model can be used to test PuO2 as an early marker of AKI and assess PuO2 as a resuscitative endpoint after hemorrhage that is indicative of end-organ rather than systemic oxygenation.
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Affiliation(s)
- Lars R Lofgren
- Department of Biomedical Engineering, University of Utah;
| | - Guillaume L Hoareau
- Department of Emergency Medicine, University of Utah; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah
| | - Kai Kuck
- Department of Biomedical Engineering, University of Utah; Department of Anesthesiology, University of Utah
| | - Natalie A Silverton
- Department of Anesthesiology, University of Utah; Geriatric Research, Education, and Clinical Centre, VAMC
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14
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Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, Govil D, Savio RD, Subbarayan B, Arora N, Chatterjee R, Chacko J, Khasne RW, Chakravarthi RM, George N, Ahmed A, Javeri Y, Chhallani AK, Khanikar RG, Margabandhu S, Lopa AJ, Chaudhry D, Samavedam S, Kar A, Dixit SB, Gopal P. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022; 26:S13-S42. [PMID: 36896356 PMCID: PMC9989875 DOI: 10.5005/jp-journals-10071-24109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/31/2022] [Indexed: 11/09/2022] Open
Abstract
Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI. How to cite this article Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.
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Affiliation(s)
- Rajesh C Mishra
- EPIC Hospital, Sanjivani Super Speciality Hospital, Ahmedabad, Gujarat, India
| | | | | | - Niraj Tyagi
- Institute of Critical Care Medicine, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Rajeev A Annigeri
- Department of Nephrology, Apollo Hospital, Chennai, Tamil Nadu, India
| | - Deepak Govil
- Institute of Critical Care and Anaesthesiology, Medanta, Gurugram, Haryana, India
| | - Raymond D Savio
- Department of Critical Care Medicine, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | | | - Nitin Arora
- Department of Intensive Care, University Hospitals Birmingham, Birmingham, West Midlands, United Kingdom
| | - Ranajit Chatterjee
- Department of Anaesthesiology and Critical Care, Swami Dayanand Hospital, New Delhi, India
| | - Jose Chacko
- Narayana Health City, Bengaluru, Karnataka, India
| | - Ruchira W Khasne
- Department of Critical Care Medicine, SMBT Institute of Medical Sciences and Research Centre, Nashik, Maharashtra, India
| | | | - Nita George
- VPS Lakeshore Hospital, Kochi, Kerala, India
| | - Ahsan Ahmed
- KPC Medical College and Hospital, Kolkata, West Bengal, India
| | - Yash Javeri
- Department of Critical Care, Anesthesia and Emergency Medicine, Regency Super Speciality Hospital, Lucknow, Uttar Pradesh, India
| | | | - Reshu G Khanikar
- Department of Critical Care Medicine, Health City Hospital, Guwahati, Assam, India
| | | | - Ahsina J Lopa
- Intensive Care Unit, MH Samorita Hospital and Medical College, Tejgaon, Dhaka, Bangladesh
| | | | - Srinivas Samavedam
- Department of Critical Care, Vrinchi Hospital, Hyderabad, Telangana, India
| | - Arindam Kar
- Reliance Hospital, Mumbai, Maharashtra, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Palepu Gopal
- Department of Critical Care Medicine, Continental Hospitals, Hyderabad, Telangana, India
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15
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Yoshimoto H, Fukui S, Higashio K, Endo A, Takasu A, Yamakawa K. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: A systematic review and meta-analysis. Front Physiol 2022; 13:962670. [PMID: 36051909 PMCID: PMC9424848 DOI: 10.3389/fphys.2022.962670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
While the Surviving Sepsis Campaign guidelines recommend an initial target value of 65 mmHg as the mean arterial pressure (MAP) in patients with septic shock, the optimal MAP target for improving outcomes remains controversial. We performed a meta-analysis to evaluate the optimal MAP for patients with vasodilatory shock, which included three randomized controlled trials that recruited 3,357 patients. Between the lower (60–70 mmHg) and higher (>70 mmHg) MAP target groups, there was no significant difference in all-cause mortality (risk ratio [RR], 1.06; 95% confidence intervals [CI], 0.98–1.16) which was similar in patients with chronic hypertension (RR, 1.10; 95% CI, 0.98–1.24) and patients aged ≥65 years (RR, 1.10; 95% CI, 0.99–1.21). No significant difference in adverse events was observed between the different MAP groups (RR, 1.04; 95% CI, 0.87–1.24); however, supraventricular arrhythmia was significantly higher in the higher MAP group (RR, 1.73; 95% CI, 1.15–2.60). Renal replacement therapy was reduced in the higher MAP group of patients with chronic hypertension (RR, 0.83; 95% CI, 0.71–0.98). Though the higher MAP control did not improve the mortality rate, it may be beneficial in reducing renal replacement therapy in patients with chronic hypertension. Systematic review registration: UMIN Clinical Trials Registry, identifier UMIN000042624
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Affiliation(s)
- Hidero Yoshimoto
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- Department of Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Satoshi Fukui
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Koki Higashio
- Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital, Bunkyo-ku, Tokyo, Japan
| | - Akira Takasu
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
- *Correspondence: Kazuma Yamakawa,
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16
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Abdominal compartment syndrome: an often overlooked cause of acute kidney injury. J Nephrol 2022; 35:1595-1603. [PMID: 35380354 DOI: 10.1007/s40620-022-01314-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/19/2022] [Indexed: 10/18/2022]
Abstract
Abdominal compartment syndrome (ACS) is defined as any organ dysfunction caused by intra-abdominal hypertension (IAH), referred as intra-abdominal pressure (IAP) ≥ 12 mm Hg according to the World Society of Abdominal Compartment Syndrome. Abdominal compartment syndrome develops in most cases when IAP rises above 20 mmHg. Abdominal compartment syndrome, while being a treatable and even preventable condition if detected early in the stage of intra-abdominal hypertension, is associated with high rates of morbidity and mortality if diagnosis is delayed: therefore, early detection is essential. Acute kidney injury (AKI) is a common comorbidity, affecting approximately one in every five hospitalized patients, with a higher incidence in surgical patients. AKI in response to intra-abdominal hypertension develops as a result of a decline in cardiac output and compression of the renal vasculature and renal parenchyma. In spite of the high incidence of intra-abdominal hypertension, especially in surgical patients, its potential role in the pathophysiology of AKI has been investigated in very few clinical studies and is commonly overlooked in clinical practice despite being potentially treatable and reversible. Aim of the present review is to illustrate the current evidence on the pathophysiology, diagnosis and therapy of intra-abdominal hypertension and abdominal compartment syndrome in the context of AKI.
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17
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Huo Y, Wang X, Li B, Rello J, Kim WY, Wang X, Hu Z. Impact of central venous pressure on the mortality of patients with sepsis-related acute kidney injury: a propensity score-matched analysis based on the MIMIC IV database. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:199. [PMID: 35280402 PMCID: PMC8908183 DOI: 10.21037/atm-22-588] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/21/2022] [Indexed: 12/03/2022]
Abstract
Background Sepsis has long been a life-threatening organ dysfunction. Sepsis associated acute kidney injury (SA-AKI) is an important complication of sepsis, as an important hemodynamic index, the impact of central venous pressure (CVP) on sepsis patients needs to be explored. Thus this study aimed to investigate the relationship between CVP and the mortality of SA-AKI. Methods Clinical data of adult patients with sepsis-related acute kidney injury, defined as met both the Sepsis 3.0 criteria and the Kidney Disease Improving Global Outcomes Clinical Practice Guideline (KDIGO) criteria, were obtained from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. The included cohort was divided into a high CVP and a low CVP group were determined based on the cuf-off value from receiver operating characteristic curve, with propensity score-matched analysis of the 28-day mortality for both groups and sensitivity analysis using inverse the probability-weighting model, multifactorial regression, and doubly robust estimation, patients acquired chronic coronary syndrome (CCS) and diabetes were also taken into consideration. Results Of 1,377 patients with sepsis-related acute kidney injury, low CVP group (<13 mmHg) was 67.4% (n=928) and high CVP group (≥13 mmHg) was 32.6% (n=449). The two groups were matched 1:1 by propensity score to obtain a matched cohort (n=288). The mortality rates in the low versus high CVP group (19.4% vs. 34.7%) were statistically difference (odds ratio OR: 0.454; 95% confidence interval 0.263, 0.771). Moreover, the bistable analysis of logistic regression of the matched cohort (OR: 0.434; 95% CI: 0.244, 0.757), propensity score inverse probability weighting (IPW) (OR: 0.547; 95% CI: 0.454, 0.658), and multifactorial logistic regression (OR: 0.352; 95% CI: 0.127, 0.932) all yielded the same results. Conclusions In patients with sepsis-related acute kidney injury, a lower CVP level (<13 mmHg) is an independent variable associated with decreased mortality. The threshold of CVP needs to be controlled in clinical work to improve the prognosis of patients with SA-AKI.
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Affiliation(s)
- Yan Huo
- Department of Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Xinrui Wang
- Department of Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Bo Li
- Department of Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
| | - Jordi Rello
- Clinical Research/Epidemiology in Pneumonia and Sepsis, Vall d'Hebron Institute of Research, Barcelona, Spain & Clinical Research, CHU Nîmes, Nimes, France
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhenjie Hu
- Department of Intensive Care Unit, Hebei Medical University Fourth Affiliated Hospital and Hebei Provincial Tumor Hospital, Shijiazhuang, China
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18
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Ko CH, Lan YW, Chen YC, Cheng TT, Yu SF, Cidem A, Liu YH, Kuo CW, Yen CC, Chen W, Chen CM. Effects of Mean Artery Pressure and Blood pH on Survival Rate of Patients with Acute Kidney Injury Combined with Acute Hypoxic Respiratory Failure: A Retrospective Study. Medicina (B Aires) 2021; 57:medicina57111243. [PMID: 34833461 PMCID: PMC8623837 DOI: 10.3390/medicina57111243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/04/2022] Open
Abstract
Background and Objectives: In the intensive care unit (ICU), renal failure and respiratory failure are two of the most common organ failures in patients with systemic inflammatory response syndrome (SIRS). These clinical symptoms usually result from sepsis, trauma, hypermetabolism or shock. If this syndrome is caused by septic shock, the Surviving Sepsis Campaign Bundle suggests that vasopressin be given to maintain mean arterial pressure (MAP) > 65 mmHg if the patient is hypotensive after fluid resuscitation. Nevertheless, it is important to note that some studies found an effect of various mean arterial pressures on organ function; for example, a MAP of less than 75 mmHg was associated with the risk of acute kidney injury (AKI). However, no published study has evaluated the risk factors of mortality in the subgroup of acute kidney injury with respiratory failure, and little is known of the impact of general risk factors that may increase the mortality rate. Materials and Methods: The objective of this study was to determine the risk factors that might directly affect survival in critically ill patients with multiple organ failure in this subgroup. We retrospectively constructed a cohort study of patients who were admitted to the ICUs, including medical, surgical, and neurological, over 24 months (2015.1 to 2016.12) at Chiayi Chang Gung Memorial Hospital. We only considered patients who met the criteria of acute renal injury according to the Acute Kidney Injury Network (AKIN) and were undergoing mechanical ventilator support due to acute respiratory failure at admission. Results: Data showed that the overall ICU and hospital mortality rate was 63.5%. The most common cause of ICU admission in this cohort study was cardiovascular disease (31.7%) followed by respiratory disease (28.6%). Most patients (73%) suffered sepsis during their ICU admission and the mean length of hospital stay was 24.32 ± 25.73 days. In general, the factors independently associated with in-hospital mortality were lactate > 51.8 mg/dL, MAP ≤ 77.16 mmHg, and pH ≤ 7.22. The risk of in-patient mortality was analyzed using a multivariable Cox regression survival model. Adjusting for other covariates, MAP ≤ 77.16 mmHg was associated with higher probability of in-hospital death [OR = 3.06 (1.374–6.853), p = 0.006]. The other independent outcome predictor of mortality was pH ≤ 7.22 [OR = 2.40 (1.122–5.147), p = 0.024]. Kaplan-Meier survival curves were calculated and the log rank statistic was highly significant. Conclusions: Acute kidney injury combined with respiratory failure is associated with high mortality. High mean arterial pressure and normal blood pH might improve these outcomes. Therefore, the acid–base status and MAP should be considered when attempting to predict outcome. Moreover, the blood pressure targets for acute kidney injury in critical care should not be similar to those recommended for the general population and might prevent mortality.
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Affiliation(s)
- Chi-Hua Ko
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan; (C.-H.K.); (Y.-W.L.); (A.C.); (Y.-H.L.); (C.-W.K.)
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
| | - Ying-Wei Lan
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan; (C.-H.K.); (Y.-W.L.); (A.C.); (Y.-H.L.); (C.-W.K.)
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (T.-T.C.); (S.-F.Y.)
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (T.-T.C.); (S.-F.Y.)
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (T.-T.C.); (S.-F.Y.)
| | - Abdulkadir Cidem
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan; (C.-H.K.); (Y.-W.L.); (A.C.); (Y.-H.L.); (C.-W.K.)
- Department of Molecular Biology and Genetics, Erzurum Technical University, Erzurum 25250, Turkey
| | - Yu-Hsien Liu
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan; (C.-H.K.); (Y.-W.L.); (A.C.); (Y.-H.L.); (C.-W.K.)
- Department of Nephrology, Jen-Ai Hospital, Dali, Taichung 412, Taiwan
| | - Chia-Wen Kuo
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan; (C.-H.K.); (Y.-W.L.); (A.C.); (Y.-H.L.); (C.-W.K.)
- Department of Internal Medicine, Taichung Armed Forces General Hospital, Taichung 411, Taiwan
| | - Chih-Ching Yen
- Department of Internal Medicine, China Medical University Hospital, and College of Health Care, China Medical University, Taichung 404, Taiwan;
| | - Wei Chen
- Division of Pulmonary and Critical Care Medicine, Chia-Yi Christian Hospital, Chiayi 600, Taiwan;
| | - Chuan-Mu Chen
- Department of Life Sciences, and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan; (C.-H.K.); (Y.-W.L.); (A.C.); (Y.-H.L.); (C.-W.K.)
- The iEGG and Animal Biotechnology Center, and the Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Correspondence: ; Tel.: +886-4-22856309
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Monitoring, management, and outcome of hypotension in Intensive Care Unit patients, an international survey of the European Society of Intensive Care Medicine. J Crit Care 2021; 67:118-125. [PMID: 34749051 DOI: 10.1016/j.jcrc.2021.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/24/2021] [Accepted: 10/09/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Hypotension in the ICU is common, yet management is challenging and variable. Insight in management by ICU physicians and nurses may improve patient care and guide future hypotension treatment trials and guidelines. METHODS We conducted an international survey among ICU personnel to provide insight in monitoring, management, and perceived consequences of hypotension. RESULTS Out of 1464 respondents, 1197 (81.7%) were included (928 physicians (77.5%) and 269 nurses (22.5%)). The majority indicated that hypotension is underdiagnosed (55.4%) and largely preventable (58.8%). Nurses are primarily in charge of monitoring changes in blood pressure, physicians are in charge of hypotension treatment. Balanced crystalloids, dobutamine, norepinephrine, and Trendelenburg position were the most frequently reported fluid, inotrope, vasopressor, and positional maneuver used to treat hypotension. Reported complications believed to be related to hypotension were AKI and myocardial injury. Most ICUs do not have a specific hypotension treatment guideline or protocol (70.6%), but the majority would like to have one in the future (58.1%). CONCLUSIONS Both physicians and nurses report that hypotension in ICU patients is underdiagnosed, preventable, and believe that hypotension influences morbidity. Hypotension management is generally not protocolized, but the majority of respondents would like to have a specific hypotension management protocol.
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20
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Mohebbati R, Abbassian H, Shafei MN, Gorji A, Negah SS. The alteration of neuronal activities of the cuneiform nucleus in non-hypovolemic and hypovolemic hypotensive conditions. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:871-878. [PMID: 34706016 DOI: 10.1590/0004-282x-anp-2020-0549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/05/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The cuneiform nucleus is located in the center of the circuit that mediates autonomic responses to stress. Hemorrhagic hypotension leads to chemoreceptor anoxia, which consequently results in the reduction of baroreceptor discharge and stimulation of the chemoreceptor. OBJECTIVE Using the single-unit recording technique, the neuronal activities of the cuneiform nucleus were investigated in hypotensive states induced by hemorrhage and administration of an anti-hypertensive drug (hydralazine). METHODS Thirty male rats were divided into the control, hemorrhage, and hydralazine groups. The femoral artery was cannulated for the recording of cardiovascular responses, including systolic blood pressure, mean arterial pressure, and heart rate. Hydralazine was administered via tail vein. The single-unit recording was performed from the cuneiform nucleus. RESULTS The maximal systolic blood pressure and the mean arterial pressure significantly decreased and heart rate significantly increased after the application of hydralazine as well as the following hemorrhage compared to the control group. Hypotension significantly increased the firing rate of the cuneiform nucleus in both the hemorrhage and hydralazine groups compared to the control group. CONCLUSIONS The present data indicate that the cuneiform nucleus activities following hypotension may play a crucial role in blood vessels and vasomotor tone.
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Affiliation(s)
- Reza Mohebbati
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Abbassian
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Sleep Clinic, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Naser Shafei
- Department of Physiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Gorji
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran.,Epilepsy Research Center, Department of Neurosurgery and Department of Neurology, Westfälische Wilhelms-Universität Münster, Münster, Germany
| | - Sajad Sahab Negah
- Neuroscience Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Shefa Neuroscience Research Center, Khatam Alanbia Hospital, Tehran, Iran
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21
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Alam A, Sovic W, Gill J, Ragula N, Salem M, Hughes GJ, Colbert GB, Mooney JL. Angiotensin II: A Review of Current Literature. J Cardiothorac Vasc Anesth 2021; 36:1180-1187. [PMID: 34452817 DOI: 10.1053/j.jvca.2021.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 01/11/2023]
Abstract
Up to one-third of all patients admitted to intensive care units carry a diagnosis of shock. The use of angiotensin II is becoming widespread in all forms of shock, including cardiogenic, after the U.S. Food and Drug Administration's (FDA's) initial approval for vasoplegic shock in 2017. Here, the authors review the literature on angiotensin II's mechanism of action, benefits, and future therapeutic opportunities.
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Affiliation(s)
- Amit Alam
- Baylor University Medical Center, Dallas, TX; Texas A&M University College of Medicine, Bryan, TX.
| | | | | | | | | | | | - Gates B Colbert
- Baylor University Medical Center, Dallas, TX; Texas A&M University College of Medicine, Bryan, TX
| | - Jennifer L Mooney
- Baylor University Medical Center, Dallas, TX; Texas A&M University College of Medicine, Bryan, TX
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22
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Associations Between Mean Arterial Pressure and Poor ICU Outcomes in Critically Ill Patients With Cirrhosis: Is 65 The Sweet Spot? Crit Care Med 2021; 48:e753-e760. [PMID: 32618694 DOI: 10.1097/ccm.0000000000004442] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Mean arterial pressure is critically important in patients with cirrhosis in the ICU, however, there is limited data to guide therapies and targets. DESIGN Retrospective observational study. SETTING Tertiary care ICU. PATIENTS Two hundred and seventy-three critically ill patients with cirrhosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed a comprehensive time-weighted mean arterial pressure analysis (time-weighted-average-mean arterial pressure and cumulative-time-below various mean arterial pressure-thresholds) during the first 24-hours after ICU admission (median: 25 mean arterial pressure measurements per-patient). Time-weighted-average-mean arterial pressure captures both the severity and duration of hypotension below a mean arterial pressure threshold and cumulative-time-below is the total time spent below a mean arterial pressure threshold. Individual univariable and multivariable logistic regression models were assessed for each time-weighted-average-mean arterial pressure and cumulative-time-below mean arterial pressure threshold (55, 60, 65, 70, and 75 mm Hg) for ICU-mortality. Time-weighted-average-mean arterial pressure: for 1 mm Hg decrease in mean arterial pressure below 75, 70, 65, 60, and 55 mm Hg, the odds for ICU-mortality were 14%, 18%, 26%, 41%, and 74%, respectively (p < 0.01, all thresholds). The association between time-weighted-average-mean arterial pressure and ICU-mortality for each threshold remained significant after adjusting for model for end-stage liver disease-sodium score, mechanical ventilation, vasopressor use, renal replacement therapy, grade 3/4 hepatic encephalopathy, WBC count, and albumin. Cumulative-time-below: odds for ICU-mortality were 4%, 6%, 10%, 12%, and 12% for each-hour spent below 75, 70, 65, 60, and 55 mm Hg, respectively. In the adjusted models, significant associations only remained for mean arterial pressure less than 65 mm Hg (odds ratio, 1.07; 95% CI, 1.00-1.14; p = 0.05) and < 60 mm Hg (odds ratio, 1.10; 95% CI, 1.01-1.18; p = 0.04). CONCLUSIONS These data suggest that maintaining a mean arterial pressure of greater than 65 mm Hg may be a reasonable target in patients with cirrhosis admitted to the ICU. However, further prospective randomized trials are needed to determine the optimal mean arterial pressure-targets in this patient population.
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Baeg SI, Jeon J, Yoo H, Na SJ, Kim K, Chung CR, Yang JH, Jeon K, Lee JE, Huh W, Suh GY, Kim YG, Kim DJ, Jang HR. A Scoring Model with Simple Clinical Parameters to Predict Successful Discontinuation of Continuous Renal Replacement Therapy. Blood Purif 2021; 50:779-789. [PMID: 33735858 DOI: 10.1159/000512350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) is the standard treatment for severe acute kidney injury in critically ill patients. However, a practical consensus for discontinuing CRRT is lacking. We aimed to develop a prediction model with simple clinical parameters for successful discontinuation of CRRT. METHODS Adult patients who received CRRT at Samsung Medical Center from 2007 to 2017 were included. Patients with preexisting ESRD and patients who progressed to ESRD within 1 year or died within 7 days after CRRT were excluded. Successful discontinuation of CRRT was defined as no requirement for renal replacement therapy for 7 days after discontinuing CRRT. Patients were assigned to either a success group or failure group according to whether discontinuation of CRRT was successful or not. RESULTS A total of 1,158 patients were included in the final analyses. The success group showed greater urine output on the day before CRRT discontinuation (D-1) and the discontinuation day (D0). Multivariable analysis identified that urine output ≥300 mL on D-1, and mean arterial pressure 50∼78 mm Hg, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 were predictive factors for successful discontinuation of CRRT. A scoring system using the 4 variables above (area under the receiver operating curve: 0.731) was developed. CONCLUSIONS Scoring system composed of urine output ≥300 mL/day on D-1, and adequate blood pressure, serum potassium <4.1 mmol/L, and BUN <35 mg/dL (12.5 mmol/L) on D0 was developed to predict successful discontinuation of CRRT.
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Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Heejin Yoo
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyunga Kim
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoon-Goo Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dae Joong Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,
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Effects of dexmedetomidine on renal microcirculation in ischemia/reperfusion-induced acute kidney injury in rats. Sci Rep 2021; 11:2026. [PMID: 33479346 PMCID: PMC7820577 DOI: 10.1038/s41598-021-81288-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 12/31/2020] [Indexed: 11/25/2022] Open
Abstract
Microcirculatory dysfunction plays a crucial role in renal ischemia/reperfusion (IR)-induced injury. Dexmedetomidine was reported to ameliorate IR-induced acute kidney injury. This study investigated the effects of dexmedetomidine on renal microcirculation after IR-induced acute kidney injury in rats. In total, 50 rats were randomly allocated to the following five groups (10 in each group): Sham, Control‒IR, Dex (dexmedetomidine) ‒Sham, Dex‒IR, and IR‒Dex group. The microcirculation parameters included total small vessel density, perfused small vessel density (PSVD), proportion of perfused small vessels, microvascular flow index, and tissue oxygen saturation (StO2) were recorded. The repeated measures analysis showed that PSVD on renal surface was higher in the Dex‒IR group than in the Control‒IR group (3.5 mm/mm2, 95% confidence interval [CI] 0.6 to 6.4 mm/mm2, P = 0.01). At 240 min, StO2 on renal surface was lower in the Control‒IR group than in the Sham group (– 7%, 95% CI − 13 to − 1%, P = 0.021), but StO2 did not differ significantly among the Sham, Dex‒IR, and IR‒Dex groups. Our results showed that pretreatment with dexmedetomidine improved renal microcirculation in rats with IR-induced acute kidney injury. However, the adverse effects of low mean arterial pressure and heart rate might offset the protective effect of dexmedetomidine on organ injury.
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Yang J, Zhou J, Wang X, Wang S, Tang Y, Yang L. Risk factors for severe acute kidney injury among patients with rhabdomyolysis. BMC Nephrol 2020; 21:498. [PMID: 33225908 PMCID: PMC7681970 DOI: 10.1186/s12882-020-02104-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 10/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis (RM). The aim of the present study was to assess patients at high risk for the occurrence of severe AKI defined as stage II or III of KDIGO classification and in-hospital mortality of AKI following RM. METHODS We performed a retrospective study of patients with creatine kinase levels > 1000 U/L, who were admitted to the West China Hospital of Sichuan University between January 2011 and March 2019. The sociodemographic, clinical and laboratory data of these patients were obtained from an electronic medical records database, and univariate and multivariate regression analyses were subsequently conducted. RESULTS For the 329 patients included in our study, the incidence of AKI was 61.4% and the proportion of stage I, stage II, stage III were 18.8, 14.9 and 66.3%, respectively. The overall mortality rate was 19.8%; furthermore, patients with AKI tended to have higher mortality rates than those without AKI (24.8% vs. 11.8%; P < 0.01). The clinical conditions most frequently associated with RM were trauma (28.3%), sepsis (14.6%), bee sting (12.8%), thoracic and abdominal surgery (11.2%) and exercise (7.0%). Furthermore, patients with RM resulting from sepsis, bee sting and acute alcoholism were more susceptible to severe AKI. The risk factors for the occurrence of stage II-III AKI among RM patients included hypertension (OR = 2.702), high levels of white blood cell count (OR = 1.054), increased triglycerides (OR = 1.260), low level of high-density lipoprotein cholesterol (OR = 0.318), elevated serum phosphorus (OR = 5.727), 5000<CK ≤ 10,000 U/L (OR = 2.617) and CK>10,000 U/L (OR = 8.093). Age ≥ 60 years (OR = 2.946), sepsis (OR = 3.206) and elevated prothrombin time (OR = 1.079) were independent risk factors for in-hospital mortality in RM patients with AKI. CONCLUSIONS AKI is independently associated with mortality in patients with RM, and several risk factors were found to be associated with the occurrence of severe AKI and in-hospital mortality. These findings suggest that, to improve the quality of medical care, the early prevention of AKI should focus on high-risk patients and more effective management.
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Affiliation(s)
- Jia Yang
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jiaojiao Zhou
- Division of Ultrasound, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Xin Wang
- Department of Pediatric Nephrology, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Siwen Wang
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yi Tang
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Lichuan Yang
- Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China.
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26
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Jiang YY, Kong XR, Xue FL, Chen HL, Zhou W, Chai JW, Wu F, Jiang SS, Li ZL, Wang K. Incidence, risk factors and clinical outcomes of acute kidney injury after heart transplantation: a retrospective single center study. J Cardiothorac Surg 2020; 15:302. [PMID: 33028372 PMCID: PMC7541173 DOI: 10.1186/s13019-020-01351-4] [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] [Received: 05/18/2020] [Accepted: 09/28/2020] [Indexed: 02/08/2023] Open
Abstract
Objectives This study aimed to identify the incidence rate of Acute kidney injury (AKI) in our center and predict in-hospital mortality and long-term survival after heart transplantation (HTx). Methods This single-center, retrospective study from October 2009 and March 2020 analyzed the pre-, intra-, and postoperative characteristics of 95 patients who underwent HTx. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Risk factors were analyzed by multivariable logistic regression models. The log-rank test was used to compare long-term survival. Results Thirty-three (34.7%) patients developed AKI. The mortality in hospital in HTx patients with and without AKI were 21.21 and 6.45%, respectively (P < 0.05). Recipients in AKI who required renal replacement therapy (RRT) had a hospital mortality rate of 43.75% compared to 6.45% in those without AKI or RRT (P < 0.0001). A long cardiopulmonary bypass (CPB) time (OR:11.393, 95% CI: 2.183 to 59.465, P = 0.0039) was positively related to the occurrence of AKI. A high intraoperative urine volume (OR: 0.031, 95% CI: 0.005 to 0.212, P = 0.0004) was negatively correlated with AKI. AKI requiring RRT (OR, 11.348; 95% CI, 2.418–53.267, P = 0.002) was a risk factor for mortality in hospital. Overall survival in patients without AKI at 1 and 3 years was not different from that in patients with AKI (P = 0.096). Conclusions AKI is common after HTx. AKI requiring RRT could contribute powerful prognostic information to predict mortality in hospital. A long CPB time and low intraoperative urine volume are associated with the occurrence of AKI.
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Affiliation(s)
- Yi-Yao Jiang
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China.,Department of Cardiovascular Surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, China
| | - Xiang-Rong Kong
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China.
| | - Fen-Long Xue
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Hong-Lei Chen
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Wei Zhou
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Jun-Wu Chai
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Fei Wu
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Shan-Shan Jiang
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Zhi-Long Li
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
| | - Kai Wang
- Department of Cardiovascular Surgery, Tianjin First Center Hospital and NanKai University, Tianjin, China
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27
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Beier L, Davis J, Esener D, Grant C, Fields JM. Carotid Ultrasound to Predict Fluid Responsiveness: A Systematic Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1965-1976. [PMID: 32314817 DOI: 10.1002/jum.15301] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To perform a systematic review of the accuracy of carotid ultrasound measures in determining volume responsiveness in adults. METHODS We conducted a systematic review of Ovid MEDLINE and Scopus from conception until January 1, 2019. Two independent reviewers used an iterative process to identify relevant articles and abstract information from them. The quality and risk of bias were assessed with the Quality Assessment of Diagnostic Accuracy Studies version 2 tool. RESULTS We identified 17 relevant articles with 956 patients. The 2 most frequently cited carotid measures of fluid responsiveness were corrected flow time and peak velocity or change in peak velocity with respiration (ΔCDPV). Accordingly, the diagnostic characteristics of corrected flow time in these studies varied widely, with sensitivities from 60% to 73%, specificities from 82% to 92%, and areas under the receiver operating characteristic curves from 0.75 to 0.88. Optimal cutoff values for ΔCDPV ranged from 9.1% to 14%, with areas under the receiver operating characteristic curves from 0.81 to 0.91, sensitivities from 73% to 86%, and specificities from 78% to 86%. Other measures, such as carotid blood flow and carotid diameter, had limited data to support their use. Heterogeneity of the studies prohibited a meta-analysis. Most studies had a moderate risk of bias and high applicability. CONCLUSIONS Preliminary research suggests that carotid ultrasound measures may be useful adjunct measures of fluid status; however, they should not be interpreted as absolute and should be placed in a clinical context. The most well-defined and supported measure currently is ΔCDPV, with cutoffs from 9% to 14%. Corrected flow time shows promise, because of heterogeneity of how this value is measured, an optimal cutoff has not been established.
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Affiliation(s)
- Lance Beier
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - Joshua Davis
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - Charles Grant
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, California, USA
| | - J Matthew Fields
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Busse LW, Ostermann M. Vasopressor Therapy and Blood Pressure Management in the Setting of Acute Kidney Injury. Semin Nephrol 2020; 39:462-472. [PMID: 31514910 DOI: 10.1016/j.semnephrol.2019.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is common in the setting of shock. Hemodynamic instability is a risk factor for the development of AKI, and pathophysiological mechanisms include loss of renal perfusion pressure and impaired microcirculation. Although restoration of mean arterial pressure (MAP) may mitigate the risk of AKI to some extent, evidence on this is conflicting. Also debatable is the optimal blood pressure needed to minimize the risk of kidney injury. A MAP of 65 mm Hg traditionally has been considered adequate to maintain renal perfusion pressure, and studies have failed to consistently show improved outcomes at higher levels of MAP. Therapeutic options to support renal perfusion consist of catecholamines, vasopressin, and angiotensin II. Although catecholamines are the most studied, they are associated with adverse events at higher doses, including AKI. Vasopressin and angiotensin II are noncatecholamine options to support blood pressure and may improve microcirculatory hemodynamics through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. Future areas of study include methods by which clinicians can measure renal blood flow in a macrocirculatory and microcirculatory way, a personalized approach to blood pressure management in septic shock using patient-specific measures of perfusion adequacy, and novel agents that may improve the microcirculation within the kidneys without causing adverse microcirculatory effects in other organs.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' National Health Service Foundation Hospital, London, United Kingdom
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29
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Rogers-Smith E, Hammerton R, Mathis A, Allison A, Clark L. Twelve previously healthy non-geriatric dogs present for acute kidney injury after general anaesthesia for non-emergency surgical procedures in the UK. J Small Anim Pract 2020; 61:363-367. [PMID: 32196674 DOI: 10.1111/jsap.13134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/03/2020] [Accepted: 02/04/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To characterise common factors after a suspected increase in the incidence of post-procedure acute kidney injury in healthy dogs presenting for non-emergency surgical procedures. MATERIALS AND METHODS Retrospective analysis of the medical records of 12 dogs that presented for acute kidney injury after general anaesthesia for non-emergency surgical procedures. RESULTS The 12 non-geriatric dogs re-presented with acute kidney injury at a median of 4 days after surgery to four different veterinary centres, including three multidisciplinary referral practices in the UK. All dogs in this case series weighed more than 20 kg and had a median age of 17 months. There was no apparent association with breed, type of surgery, duration of anaesthesia, perioperative drug choice or non-steroidal anti-inflammatory drug administration. CLINICAL SIGNIFICANCE Although well-defined in human medicine, there is very little information regarding the association between general anaesthesia and acute kidney injury in animals. No definitive causal link was found in this case series. Clinicians with similar cases are requested to contact the corresponding author so a more representative incidence rate can be obtained.
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Affiliation(s)
- E Rogers-Smith
- Internal Medicine, Davies Veterinary Specialists, Higham Gobion, SG53HR, UK
| | - R Hammerton
- Internal Medicine, Davies Veterinary Specialists, Higham Gobion, SG53HR, UK
| | - A Mathis
- Anaesthesia, Willows Veterinary Centre and Referral Service, Solihull, B90 4NH, UK
| | - A Allison
- Anaesthesia, Scarsdale Veterinary Group, Derby, DE24 8HX, UK
| | - L Clark
- Internal Medicine, Davies Veterinary Specialists, Higham Gobion, SG53HR, UK
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Ahuja S, Mascha EJ, Yang D, Maheshwari K, Cohen B, Khanna AK, Ruetzler K, Turan A, Sessler DI. Associations of Intraoperative Radial Arterial Systolic, Diastolic, Mean, and Pulse Pressures with Myocardial and Acute Kidney Injury after Noncardiac Surgery: A Retrospective Cohort Analysis. Anesthesiology 2020; 132:291-306. [PMID: 31939844 DOI: 10.1097/aln.0000000000003048] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. METHODS The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients' lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. RESULTS Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding. CONCLUSIONS Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.
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Affiliation(s)
- Sanchit Ahuja
- From the Departments of OUTCOMES RESEARCH, (S.A., E.J.M., D.Y., K.M., B.C., A.K.K., K.R., A.T., D.I.S.) Quantitative Health Sciences (E.J.M., D.Y.) General Anesthesiology (K.M., K.R., A.T.), Cleveland Clinic, Cleveland, Ohio the Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, Detroit, Michigan (S.A.) the Division of Anesthesia, Critical Care, and Pain Management, Tel-Aviv Medical Center, Tel Aviv University, Tel-Aviv, Israel (B.C.) the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Center for Biomedical Informatics, and the Critical Injury, Illness and Recovery Research Center, Winston-Salem, North Carolina (A.K.K.)
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Antal O, Ștefănescu E, Mleșnițe M, Bălan AM, Caziuc A, Hagău N. Hemodynamic Predictors for Sepsis-Induced Acute Kidney Injury: A Preliminary Study. J Clin Med 2020; 9:jcm9010151. [PMID: 31935904 PMCID: PMC7019750 DOI: 10.3390/jcm9010151] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/03/2020] [Accepted: 01/04/2020] [Indexed: 01/22/2023] Open
Abstract
The aim of our study was to assess the association between the macrohemodynamic profile and sepsis induced acute kidney injury (AKI). We also investigated which minimally invasive hemodynamic parameters may help identify patients at risk for sepsis-AKI. We included 71 patients with sepsis and septic shock. We performed the initial fluid resuscitation using local protocols and continued to give fluids guided by the minimally invasive hemodynamic parameters. We assessed the hemodynamic status by transpulmonary thermodilution technique. Sequential organ failure assessment (SOFA score) (AUC 0.74, 95% CI 0.61–0.83, p < 0.01) and cardiovascular SOFA (AUC 0.73, 95% CI 0.61–0.83, p < 0.01) were found to be predictors for sepsis-induced AKI, with cut-off values of 9 and 3 points respectively. Persistent low stroke volume index (SVI) ≤ 32 mL/m2/beat (AUC 0.67, 95% CI 0.54–0.78, p < 0.05) and global end-diastolic index (GEDI) < 583 mL/m2 (AUC 0.67, 95% CI 0.54–0.78, p < 0.05) after the initial fluid resuscitation are predictive for oliguria/anuria at 24 h after study inclusion. The combination of higher vasopressor dependency index (VDI, calculated as the (dobutamine dose × 1 + dopamine dose × 1 + norepinephrine dose × 100 + vasopressin × 100 + epinephrine × 100)/MAP) and norepinephrine, lower systemic vascular resistance index (SVRI), and mean arterial blood pressure (MAP) levels, in the setting of normal preload parameters, showed a more severe vasoplegia. Severe vasoplegia in the first 24 h of sepsis is associated with a higher risk of sepsis induced AKI. The SOFA and cardiovascular SOFA scores may identify patients at risk for sepsis AKI. Persistent low SVI and GEDI values after the initial fluid resuscitation may predict renal outcome.
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Affiliation(s)
- Oana Antal
- Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania (M.M.); (A.M.B.); (A.C.); (N.H.)
- Department of Anaesthesia and Intensive Care, Cluj Emergency Clinical County Hospital, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania
- Correspondence: ; Tel.: +40-74449-9883
| | - Elena Ștefănescu
- Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania (M.M.); (A.M.B.); (A.C.); (N.H.)
- Department of Anaesthesia and Intensive Care, Cluj Emergency Clinical County Hospital, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania
| | - Monica Mleșnițe
- Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania (M.M.); (A.M.B.); (A.C.); (N.H.)
- Department of Anaesthesia and Intensive Care, Cluj Emergency Clinical County Hospital, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania
| | - Andrei Mihai Bălan
- Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania (M.M.); (A.M.B.); (A.C.); (N.H.)
| | - Alexandra Caziuc
- Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania (M.M.); (A.M.B.); (A.C.); (N.H.)
| | - Natalia Hagău
- Department of Anaesthesia and Intensive Care, “Iuliu Hațieganu” University of Medicine and Pharmacy, No 3-5 Clinicilor Street, Cluj-Napoca, 400005 Cluj, Romania (M.M.); (A.M.B.); (A.C.); (N.H.)
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Grand J, Bro-Jeppesen J, Hassager C, Rundgren M, Winther-Jensen M, Thomsen JH, Nielsen N, Wanscher M, Kjærgaard J. Cardiac output during targeted temperature management and renal function after out-of-hospital cardiac arrest. J Crit Care 2019; 54:65-73. [DOI: 10.1016/j.jcrc.2019.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 01/20/2023]
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Korang SK, Safi S, Feinberg J, Gluud C, Perner A, Jakobsen JC. Higher versus lower blood pressure targets in adults with shock. Hippokratia 2019. [DOI: 10.1002/14651858.cd013470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Baek SH, Chin HJ, Na KY, Chae DW, Kim S. Optimal systolic blood pressure in noncritically ill patients with acute kidney injury: A retrospective cohort study. Kidney Res Clin Pract 2019; 38:356-364. [PMID: 31474093 PMCID: PMC6727888 DOI: 10.23876/j.krcp.19.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/17/2019] [Accepted: 06/18/2019] [Indexed: 12/30/2022] Open
Abstract
Background Few data showed the optimal blood pressure (BP) in noncritically ill patients with acute kidney injury (AKI) relative to mortality or severe AKI. We therefore sought to analyze the data that exist for the ideal target range for BP in noncritically ill patients with AKI. Methods We performed a retrospective cohort study involving 1,612 hospitalized patients who were diagnosed with AKI using the Kidney Disease: Improving Global Outcomes definition based on serum creatinine measurements for a period of 1 year. The average systolic BP (SBP) was categorized into 10-mmHg increments (within 48 hours after the development of AKI). The primary outcome was a composite of severe AKI or 90-day mortality. Results The composite outcome rate in patients was 18.7% (302/1,612). The relationship between BP and the composite outcome followed a U-shaped curve, with an increased event rate observed at both low and high BP values. The average SBP after AKI predicted the composite outcome after adjusting for baseline variables (reference SBP: 120–129 mmHg; < 100 mmHg: hazard ratio [HR] 1.84, P = 0.015; 100–109 mmHg: HR 1.56, P = 0.038; 110–119 mmHg: HR 1.15, P = 0.483; 130–139 mmHg: HR 1.51, P = 0.045; ≥ 140 mmHg: HR 1.73, P = 0.005). Conclusion Among noncritically ill patients with AKI, a U-shaped curve association was observed between the average SBP within 48 hours after AKI and the composite primary outcome of this study, with the lowest event rate for SBP ranging from approximately 110 to 129 mmHg.
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Affiliation(s)
- Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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35
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Ehrmann S, Helms J, Joret A, Martin-Lefevre L, Quenot JP, Herbrecht JE, Benzekri-Lefevre D, Robert R, Desachy A, Bellec F, Plantefeve G, Bretagnol A, Dargent A, Lacherade JC, Meziani F, Giraudeau B, Tavernier E, Dequin PF. Nephrotoxic drug burden among 1001 critically ill patients: impact on acute kidney injury. Ann Intensive Care 2019; 9:106. [PMID: 31549274 PMCID: PMC6757082 DOI: 10.1186/s13613-019-0580-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022] Open
Abstract
Background Nephrotoxic drug prescription may contribute to acute kidney injury (AKI) occurrence and worsening among critically ill patients and thus to associated morbidity and mortality. The objectives of this study were to describe nephrotoxic drug prescription in a large intensive-care unit cohort and, through a case–control study nested in the prospective cohort, to evaluate the link of nephrotoxic prescription burden with AKI. Results Six hundred and seventeen patients (62%) received at least one nephrotoxic drug, among which 303 (30%) received two or more. AKI was observed in 609 patients (61%). A total of 351 patients were considered as cases developing or worsening AKI a given index day during the first week in the intensive-care unit. Three hundred and twenty-seven pairs of cases and controls (patients not developing or worsening AKI during the first week in the intensive-care unit, alive the case index day) matched on age, chronic kidney disease, and simplified acute physiology score 2 were analyzed. The nephrotoxic burden prior to the index day was measured in drug.days: each drug and each day of therapy increasing the burden by 1 drug.day. This represents a semi-quantitative evaluation of drug exposure, potentially easy to implement by clinicians. Nephrotoxic burden was significantly higher among cases than controls: odds ratio 1.20 and 95% confidence interval 1.04–1.38. Sensitivity analysis showed that this association between nephrotoxic drug prescription in the intensive-care unit and AKI was predominant among the patients with lower severity of disease (simplified acute physiology score 2 below 48). Conclusions The frequently observed prescription of nephrotoxic drugs to critically ill patients may be evaluated semi-quantitatively through computing drug.day nephrotoxic burden, an index significantly associated with subsequent AKI occurrence, and worsening among patients with lower severity of disease.
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Affiliation(s)
- Stephan Ehrmann
- INSERM CIC 1415, CHRU de Tours, Médecine intensive réanimation, 2, Bd Tonnellé, 37044, Tours Cedex 9, France. .,Université de Tours, faculté de médecine, Tours, France.
| | - Julie Helms
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, FHU OMICARE, FMTS, Université de Strasbourg, Strasbourg, France.,Médecine Intensive Réanimation, Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Aurélie Joret
- INSERM CIC 1415, CHRU de Tours, Médecine intensive réanimation, 2, Bd Tonnellé, 37044, Tours Cedex 9, France
| | | | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Jean-Etienne Herbrecht
- Réanimation médicale, Hôpitaux universitaires de Strasbourg, Hôpital Hautepierre, Strasbourg, France
| | | | - René Robert
- Réanimation médicale, CHU de Poitiers, Poitiers, France
| | - Arnaud Desachy
- Réanimation polyvalente, CH d'Angoulême, Angoulême, France
| | | | | | - Anne Bretagnol
- Médecine intensive réanimation, CHR d'Orléans, Orléans, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | | | - Ferhat Meziani
- ImmunoRhumatologie Moléculaire, INSERM UMR_S1109, LabEx TRANSPLANTEX, FHU OMICARE, FMTS, Université de Strasbourg, Strasbourg, France.,Médecine Intensive Réanimation, Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,INSERM UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Université de Strasbourg, Strasbourg, France
| | | | | | - Pierre-François Dequin
- INSERM CIC 1415, CHRU de Tours, Médecine intensive réanimation, 2, Bd Tonnellé, 37044, Tours Cedex 9, France.,Université de Tours, faculté de médecine, Tours, France
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Validation and Clinical Evaluation of a Method for Double-Blinded Blood Pressure Target Investigation in Intensive Care Medicine. Crit Care Med 2019; 46:1626-1633. [PMID: 29994882 DOI: 10.1097/ccm.0000000000003289] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES No double-blinded clinical trials have investigated optimal mean arterial pressure targets in the ICU. The aim of this study was to develop and validate a method for blinded investigation of mean arterial pressure targets in patients monitored with arterial catheter in the ICU. DESIGN Prospective observational study (substudy A) and prospective, randomized, controlled clinical study (substudy B). SETTING ICU, Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark. PATIENTS Adult patients resuscitated from out-of-hospital cardiac arrest. INTERVENTIONS Standard blood pressure measuring modules were offset to display 10% lower or higher blood pressure values. We then: 1) confirmed this modification in vivo by comparing offset to standard modules in 22 patients admitted to the ICU. Thereafter we 2) verified the method in two randomized, clinical trials, each including 50 out-of-hospital cardiac arrest patients, where the offset of the blood pressure module was blinded to the treating staff. MEASUREMENTS AND MAIN RESULTS Substudy A showed that the expected separation of blood pressure measurements was achieved with an excellent correlation of the offset and standard modules (R = 0.997). Bland-Altman plots showed no bias of modified modules over a clinically relevant range of mean arterial pressure. The primary endpoint of the clinical trials was between-group difference of norepinephrine dose needed to achieve target mean arterial pressure. Trial 1 aimed at a 10% difference between groups in mean arterial pressure (targets: 65 and 72 mm Hg, respectively) and demonstrated a separation of 5 ± 1 mm Hg (p < 0.001). The difference in norepinephrine dose was not significantly different (0.03 ± 0.03 µg/kg/min; p = 0.42). Trial 2 aimed at a 20% difference between groups in mean arterial pressure (targets: 63 and 77 mm Hg, respectively). Separation was 12 ± 1 mm Hg (p < 0.01) in mean arterial pressure and 0.07 ± 0.03 µg/kg/min (p < 0.01) in norepinephrine dose. CONCLUSIONS The present method is feasible and robust and provides a platform for double-blinded comparison of mean arterial pressure targets in critically ill patients.
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Farag E, Makarova N, Argalious M, Cywinski JB, Benzel E, Kalfas I, Sessler DI. Vasopressor Infusion During Prone Spine Surgery and Acute Renal Injury: A Retrospective Cohort Analysis. Anesth Analg 2019; 129:896-904. [PMID: 31425235 DOI: 10.1213/ane.0000000000003982] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function. METHODS In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables. RESULTS In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m (95% CI, -0.6 to 2.2 mL/min/1.73 m) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage. CONCLUSIONS Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy.
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Affiliation(s)
- Ehab Farag
- From the Departments of General Anesthesiology
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Natalya Makarova
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Jacek B Cywinski
- From the Departments of General Anesthesiology
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Benzel
- Department of Neurosurgery, Center for Spine Health, Neurosurgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Iain Kalfas
- Department of Neurosurgery, Center for Spine Health, Neurosurgical Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel I Sessler
- Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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Association Between Mean Arterial Pressure and Acute Kidney Injury and a Composite of Myocardial Injury and Mortality in Postoperative Critically Ill Patients. Crit Care Med 2019; 47:910-917. [DOI: 10.1097/ccm.0000000000003763] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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39
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Lee GT, Hwang SY, Jo IJ, Kim TR, Yoon H, Park JH, Cha WC, Sim MS, Shin TG. Associations between mean arterial pressure and 28-day mortality according to the presence of hypertension or previous blood pressure level in critically ill sepsis patients. J Thorac Dis 2019; 11:1980-1988. [PMID: 31285891 DOI: 10.21037/jtd.2019.04.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background We aimed to investigate the association between average mean arterial pressure (a-MAP) and mortality in critically ill sepsis patients according to the presence of hypertension and previously measured blood pressure (BP). Methods From August 2008 to September 2014, patients with severe sepsis or septic shock presenting to the ED were categorized into four groups according to a-MAP during the initial 24 hours (group 0, a-MAP <65 mmHg; group 1, 65 mmHg ≤ a-MAP <75 mmHg; group 2, 75 mmHg ≤ a-MAP <85 mmHg; group 3, a-MAP ≥85 mmHg). A low previous BP was defined as previous a-MAP ≤85 mmHg, and a high previous BP is defined as a-MAP >85 mmHg. The primary outcome was 28-day mortality. Results A total of 1,395 patients were included. The 28-day mortality rates were 15.1% in patients overall, 39.7% in group 0, 18.3% in group 1, 10.1% in group 2, and 13.4% in group 3. In the regression analyses, mortality in group 2 was significantly lower compared with group 1 [odds ratio (OR), 0.33] or group 3 (OR, 0.31) in patients with hypertension. In the low previous BP group, there was greater mortality in group 3 compared to group 1 (OR, 2.42) and group 2 (OR, 3.88). In the high previous BP group, mortality was lower in group 2 compared with group 1 (OR, 0.32). Conclusions In critically ill sepsis patients, there were different trends in mortality according to a-MAP depending on the presence of hypertension or previous BP.
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Affiliation(s)
- Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon, Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon, Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Rim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon, Korea
| | - Joo Hyun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Gangwon, Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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40
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Grand J, Hassager C, Winther-Jensen M, Rundgren M, Friberg H, Horn J, Wise MP, Nielsen N, Kuiper M, Wiberg S, Thomsen JH, Jaeger Wanscher MC, Frydland M, Kjaergaard J. Mean arterial pressure during targeted temperature management and renal function after out-of-hospital cardiac arrest. J Crit Care 2018; 50:234-241. [PMID: 30586655 DOI: 10.1016/j.jcrc.2018.12.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/02/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE This study investigates the association between mean arterial pressure (MAP) and renal function after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS Post-hoc analysis of 851 comatose OHCA-patients surviving >48 h included in the targeted temperature management (TTM)-trial. RESULTS Patients were stratified by mean MAP during TTM in the following groups; <70 mmHg (22%), 70-80 mmHg (43%), and > 80 mmHg (35%). Median (interquartile range) eGFR (ml/min/1.73 m2) 48 h after OHCA was inversely associated with MAP-group (70 (47-102), 84 (56-113), 94 (61-124), p < .001, for the <70-group, 70-80-group and > 80-group respectively). After adjusting for potential confounders, in a mixed model including eGFR after 1, 2 and 3 days this association remained significant (pgroup_adjusted = 0.0002). Higher mean MAP was independently associated with lower odds of renal replacement therapy (odds ratioadjusted = 0.77 [95% confidence interval, 0.65-0.91] per 5 mmHg increase; p = .002]). CONCLUSIONS Low mean MAP during TTM was independently associated with decreased renal function and need of renal replacement therapy in a large cohort of comatose OHCA-patients. Increasing MAP above the recommended 65 mmHg could potentially be renal-protective. This hypothesis should be investigated in prospective trials.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark.
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Malin Rundgren
- Department of Clinical Sciences, Lund University, Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Hans Friberg
- Department of Intensive and Perioperative Care, Clinical Sciences, Lund University, Lund, Sweden
| | - Janneke Horn
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Niklas Nielsen
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Michael Kuiper
- Intensive Care Unit, Leeuwarden Medical Centrum, Borniastraat 38, NL8934, AD, Leeuwarden, the Netherlands
| | - Sebastian Wiberg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Michael C Jaeger Wanscher
- Department of Cardiothoracic Anaesthesia, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin Frydland
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
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Moman RN, Ostby SA, Akhoundi A, Kashyap R, Kashani K. Impact of individualized target mean arterial pressure for septic shock resuscitation on the incidence of acute kidney injury: a retrospective cohort study. Ann Intensive Care 2018; 8:124. [PMID: 30535664 PMCID: PMC6288098 DOI: 10.1186/s13613-018-0468-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/03/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND To examine the relationship between delta mean arterial pressure (ΔMAP; MAP change between pre-admission minus post-resuscitation) and acute kidney injury (AKI) among patients with septic shock. In this retrospective, single-center cohort study of adult patients pre-admission MAP is defined as the median MAP recorded from 365 to 7 days before admission. Post-resuscitation MAP was median MAP during the 7th hour after initiating resuscitation. RESULTS In our cohort (N = 233; 55% male), the median (interquartile range [IQR]) age was 71 (58-81) years and the median (IQR) acute physiology, age, chronic health evaluation (APACHE) III score was 81 (66-97). Although those in the lowest ΔMAP quartile (-24.5 to 3.9 mmHg) had no demographic differences compared with the rest of the cohort, the odds ratio for AKI was 0.26 (95% CI 0.11-0.57) after adjustment for other known AKI risk factors. Among patients with a history of hypertension, the lowest quartile had an odds ratio for AKI of 0.12 (95% CI 0.04-0.37) after adjusting for risk factors for AKI in this cohort. CONCLUSIONS The incidence of AKI was lowest among those whose post-resuscitation MAP was closest to or higher than their pre-admission MAP. Further study regarding the effect of targeting the pre-admission MAP for post-resuscitation on the incidence of AKI is warranted.
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Affiliation(s)
- Rajat N Moman
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stuart A Ostby
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Department of Obstetrics and Gynecology, University of Alabama Birmingham, Birmingham, AL, USA
| | - Abbasali Akhoundi
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Anesthesia Clinical Research Unit, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Lesur O, Delile E, Asfar P, Radermacher P. Hemodynamic support in the early phase of septic shock: a review of challenges and unanswered questions. Ann Intensive Care 2018; 8:102. [PMID: 30374729 PMCID: PMC6206320 DOI: 10.1186/s13613-018-0449-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/20/2018] [Indexed: 12/13/2022] Open
Abstract
Background Improving sepsis support is one of the three pillars of a 2017 resolution according to the World Health Organization (WHO). Septic shock is indeed a burden issue in the intensive care units. Hemodynamic stabilization is a cornerstone element in the bundle of supportive treatments recommended in the Surviving Sepsis Campaign (SSC) consecutive biannual reports. Main body The “Pandera’s box” of septic shock hemodynamics is an eternal debate, however, with permanent contentious issues. Fluid resuscitation is a prerequisite intervention for sepsis rescue, but selection, modalities, dosage as well as duration are subject to discussion while too much fluid is associated with worsen outcome, vasopressors often need to be early introduced in addition, and catecholamines have long been recommended first in the management of septic shock. However, not all patients respond positively and controversy surrounding the efficacy-to-safety profile of catecholamines has come out. Preservation of the macrocirculation through a “best” mean arterial pressure target is the actual priority but is still contentious. Microcirculation recruitment is a novel goal to be achieved but is claiming more knowledge and monitoring standardization. Protection of the cardio-renal axis, which is prevalently injured during septic shock, is also an unavoidable objective. Several promising alternative or additive drug supporting avenues are emerging, trending toward catecholamine’s sparing or even “decatecholaminization.” Topics to be specifically addressed in this review are: (1) mean arterial pressure targeting, (2) fluid resuscitation, and (3) hemodynamic drug support. Conclusion Improving assessment and means for rescuing hemodynamics in early septic shock is still a work in progress. Indeed, the bigger the unresolved questions, the lower the quality of evidence.
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Affiliation(s)
- Olivier Lesur
- Division of Intensive Care Units, Department of Medicine, Faculté de Médecine et des Sciences de la Santé, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada.
| | - Eugénie Delile
- Division of Intensive Care Units, Department of Medicine, Faculté de Médecine et des Sciences de la Santé, Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire, Université d'Angers, Angers, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
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Post EH, Su F, Righy Shinotsuka C, Taccone FS, Creteur J, De Backer D, Vincent JL. Renal autoregulation in experimental septic shock and its response to vasopressin and norepinephrine administration. J Appl Physiol (1985) 2018; 125:1661-1669. [PMID: 30260750 DOI: 10.1152/japplphysiol.00783.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Evidence suggests that septic shock patients with chronic arterial hypertension may benefit from resuscitation targeted to achieve higher blood pressure values than other patients, possibly as a result of altered renal autoregulation. The effects of different vasopressor agents on renal autoregulation may be important in this context. We investigated the effects of arginine vasopressin (AVP) and norepinephrine (NE) on renal autoregulation in ovine septic shock. Sepsis was induced by fecal peritonitis. When shock developed (decrease in mean arterial pressure to <65 mmHg and no fluid-responsiveness), animals were randomized to receive NE or AVP in a crossover design. Before the switch to the second vasopressor, the first vasopressor was discontinued for 30 minutes to ensure complete washout of the first vasopressor. Renal autoregulation was evaluated by recording the change in renal blood flow (RBF) in response to manual, stepwise reductions in renal inflow pressure. In this model, the lower limit of renal autoregulation was not significantly altered 6 hours after sepsis induction (59±9 vs. 64±7 mmHg at baseline, p=0.096). After development of shock, the autoregulatory threshold was lower with AVP than with NE (59±5 vs. 65±7 mmHg, p=0.010). However, RBF was higher with NE both at the start of autoregulatory measurements (206±58 vs. 170±52 mL/min; p=0.050) and at the autoregulatory threshold (191±53 vs. 150±47 mL/min; p=0.008). As vasopressors may have different effects on renal autoregulation, blood pressure management in patients with septic shock should be individualized and take into account drug-specific effects.
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Chen X, Wang X, Honore PM, Spapen HD, Liu D. Renal failure in critically ill patients, beware of applying (central venous) pressure on the kidney. Ann Intensive Care 2018; 8:91. [PMID: 30238174 PMCID: PMC6146958 DOI: 10.1186/s13613-018-0439-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/15/2018] [Indexed: 12/20/2022] Open
Abstract
The central venous pressure (CVP) is traditionally used as a surrogate of intravascular volume. CVP measurements therefore are often applied at the bedside to guide fluid administration in postoperative and critically ill patients. Pursuing high CVP levels has recently been challenged. A high CVP might impede venous return to the heart and disturb microcirculatory blood flow which may cause tissue congestion and organ failure. By imposing an increased "afterload" on the kidney, an elevated CVP will particularly harm kidney hemodynamics and promote acute kidney injury (AKI) even in the absence of volume overload. Maintaining the lowest possible CVP should become routine to prevent and treat AKI, especially when associated with septic shock, cardiac surgery, mechanical ventilation, and intra-abdominal hypertension.
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Affiliation(s)
- Xiukai Chen
- Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, 200 Lothrop Street, BST E1240, Pittsburgh, PA 15261 USA
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100073 China
| | - Patrick M. Honore
- Department of Intensive Care, Centre Hospitalier Universitaire Brugmann, Brugmann University Hospital, 4 Place Van Gehuchtenplein, 1020 Brussels, Belgium
| | - Herbert D. Spapen
- Department of Intensive Care, University Hospital, Vrije Universiteit Brussel (VUB), 101, Laarbeeklaan, Jette 1090 Brussels, Belgium
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, 100073 China
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Perioperative myocardial injury and the contribution of hypotension. Intensive Care Med 2018; 44:811-822. [PMID: 29868971 DOI: 10.1007/s00134-018-5224-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/10/2018] [Indexed: 02/06/2023]
Abstract
Mortality in the month following surgery is about 1000 times greater than anesthesia-related intraoperative mortality, and myocardial injury appears to be the leading cause. There is currently no known safe prophylaxis for postoperative myocardial injury, but there are strong associations among hypotension and myocardial injury, renal injury, and death. During surgery, the harm threshold is a mean arterial pressure of about 65 mmHg. In critical care units, the threshold appears to be considerably greater, perhaps 90 mmHg. The threshold triggering injury on surgical wards remains unclear but may be in between. Much of the association between hypotension and serious complications surely results from residual confounding, but sparse randomized data suggest that at least some harm can be prevented by intervening to limit hypotension. Reducing hypotension may therefore improve perioperative outcomes.
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Abstract
PURPOSE OF REVIEW Among critically ill patients, acute kidney injury (AKI) is still a common and serious complication with a tremendous impact on short-term and long-term outcomes. The objective of this review is to discuss strategies for renal protection and prevention of AKI in ICU patients. RECENT FINDINGS It is fundamental to identify patients at risk for AKI as soon as possible and as accurately as possible. In order to achieve these goals, translational approaches implementing new biomarkers have shown promising results. Focusing on the role of potential preventive strategies, hemodynamic stabilization is the most important intervention with proven efficacy. Recent published data undermined any hope that high-dose statin therapy in statin-naïve patients could exert renoprotective effects. However, preliminary data revealed the renoprotective activity of dexmedetomidine when used as a sedative agent. Moreover, several studies demonstrated the protective effects of remote ischemic preconditioning in various organs including the kidneys. The use of balanced crystalloid instead of hyperchloremic solutions also contributes to the reduction of AKI in critically ill patients. SUMMARY To prevent AKI, it is crucial to identify patients at risk as early as possible. Establishing hemodynamic stability and an adequate intravascular volume state to ensure a sufficient perfusion pressure is the only effective therapeutic intervention. It is self-evident that nephrotoxic agents should be avoided whenever it is possible.
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Biomarkers of Sepsis-Induced Acute Kidney Injury. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6937947. [PMID: 29854781 PMCID: PMC5941779 DOI: 10.1155/2018/6937947] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/19/2018] [Indexed: 12/29/2022]
Abstract
Sepsis, an infection-induced systemic disease, leads to pathological, physiological, and biochemical abnormalities in the body. Organ dysfunction is caused by a dysregulated host response to infection during sepsis which is a major contributing factor to acute kidney injury (AKI) and the mortality rate for sepsis doubles due to coincidence of AKI. Sepsis-induced AKI is strongly associated with increased mortality and other adverse outcomes. More timely diagnosis would allow for earlier intervention and could improve patient outcomes. Sepsis-induced AKI is characterized by a distinct pathophysiology compared with other diseases and may also have unique patterns of plasma and urinary biomarkers. This concise review summarizes properties and perspectives of the biomarkers for their individual clinical utilization.
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Skube SJ, Katz SA, Chipman JG, Tignanelli CJ. Acute Kidney Injury and Sepsis. Surg Infect (Larchmt) 2018; 19:216-224. [DOI: 10.1089/sur.2017.261] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Steven J. Skube
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Stephen A. Katz
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota
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Toullec L, Dupouey J, Vigne C, Marsot A, Allanioux L, Blin O, Leone M, Guilhaumou R. Analytical interference during cefepime therapeutic drug monitoring in intensive care patient: About a case report. Therapie 2017; 72:587-592. [DOI: 10.1016/j.therap.2017.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/07/2017] [Indexed: 11/16/2022]
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Ripollés-Melchor J, Chappell D, Aya HD, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part III: Goal directed hemodynamic therapy. Rationale for maintaining vascular tone and contractility. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:348-359. [PMID: 28343682 DOI: 10.1016/j.redar.2017.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 06/06/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - H D Aya
- Departamento de Cuidados Intensivos, St George's University Hospitals, NHS Foundation Trust, Londres, Reino Unido
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute of Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España
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