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Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, Kola VR, Kothekar AT, Kumar P, Maharaj M, Munjal M, Nandakumar SM, Nikalje A, Nongthombam R, Ray S, Sinha MK, Sodhi K, Myatra SN. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024; 28:S4-S19. [PMID: 39234230 PMCID: PMC11369916 DOI: 10.5005/jp-journals-10071-24682] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/25/2024] [Indexed: 09/06/2024] Open
Abstract
Sepsis poses a significant global health challenge in low- and middle-income countries (LMICs). Several aspects of sepsis management recommended in international guidelines are often difficult or impossible to implement in resource-limited settings (RLS) due to issues related to cost, infrastructure, or lack of trained healthcare workers. The Indian Society of Critical Care Medicine (ISCCM) drafted a position statement for the management of sepsis in RLS focusing on India, facilitated by a task force of 18 intensivists using a Delphi process, to achieve consensus on various aspects of sepsis management which are challenging to implement in RLS. The process involved a comprehensive literature review, controlled feedback, and four iterative surveys conducted between 21 August 2023 and 21 September 2023. The domains addressed in the Delphi process included the need for a position statement, challenges in sepsis management, considerations for diagnosis, patient management while awaiting an intensive care unit (ICU) bed, and treatment of sepsis and septic shock in RLS. Consensus was achieved when 70% or more of the task force members voted either for or against statements using a Likert scale or a multiple-choice question (MCQ). The Delphi process with 100% participation of Task Force members in all rounds, generated consensus in 32 statements (91%) from which 20 clinical practice statements were drafted for the management of sepsis in RLS. The clinical practice statements will complement the existing international guidelines for the management of sepsis and provide valuable insights into tailoring sepsis interventions in the context of RLS, contributing to the global discourse on sepsis management. Future international guidelines should address the management of sepsis in RLS. How to cite this article Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, et al. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024;28(S2):S4-S19.
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Affiliation(s)
- Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Gunjan Chanchalani
- Department of Critical Care Medicine, K.J. Somaiya Hospital & Research Center, Mumbai, Maharashtra, India
| | - Anusha Cherian
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Yash Javeri
- Department of Critical Care and Emergency Medicine, Regency Super Speciality Hospital, Lucknow, Uttar Pradesh, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Amol T Kothekar
- Department of Anesthesiology, Critical Care and Pain, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Prashant Kumar
- Department of Critical Care Medicine, Yatharth Hospital, Noida, Uttar Pradesh, India
| | - Mohan Maharaj
- Department of Critical Care, Medicover Hospitals, Visakhapatnam, Andhra Pradesh, India
| | - Manish Munjal
- Department of Critical Care, ManglamPlus Medicity Hospital, Jaipur, Rajasthan, India
| | - Sivakumar M Nandakumar
- Department of Critical Care Medicine, Royal Care Super Speciality Hospital, Coimbatore, Tamil Nadu, India
| | - Anand Nikalje
- Department of Medicine, Medical Centre and Research Institute (MCRI) ICU, MGM Medical College and Hospital, Aurangabad, Maharashtra, India
| | - Rakesh Nongthombam
- Department of Anaesthesiology and Intensive Care, J.N. Institute of Medical Sciences, Imphal, Manipur, India
| | - Sumit Ray
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi, India
| | - Mahesh K Sinha
- Department of Critical Care Medicine, Ramkrishna CARE Hospitals, Raipur, Chhattisgarh, India
| | | | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Division of Critical Care Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Mund C, Asmus K, Safi W, Ritter O, Petrus D, Patschan S, Patschan D. Clinically Evident Cardiopulmonary Congestion Does Not Significantly Impact the Prognosis of Patients With Septic Acute Kidney Injury. J Clin Med Res 2024; 16:302-309. [PMID: 39027814 PMCID: PMC11254307 DOI: 10.14740/jocmr5190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 05/20/2024] [Indexed: 07/20/2024] Open
Abstract
Background Acute kidney injury (AKI) is a common issue among in-hospital patients, with high mortality rates. Sepsis is a primary cause of AKI, particularly in the intensive care unit. Patients with septic AKI often experience cardiovascular congestion, leading to the formal classification of cardiorenal syndrome type 5. The study aimed to evaluate the prognosis of septic AKI patients with and without clinical evidence of cardiovascular congestion. Methods This was a retrospective observational study. AKI patients were identified using the in-hospital AKI alert system. Sepsis was diagnosed based on laboratory, clinical, and hemodynamic characteristics, with additional consideration of the quickSOFA score. Cardiovascular congestion was diagnosed by assessing clinical (edema), radiographic (pulmonary congestion), echocardiographic (e.g., wall motion abnormalities), and laboratory variables (e.g., N-terminal pro-B-type natriuretic peptide). Endpoints included in-hospital survival, the need for kidney replacement therapy (KRT), and recovery of kidney function (ROKF). Results In total, 102 patients were included, and cardiopulmonary congestion was diagnosed in 78.4%. Individuals with congestion did not differ from patients without congestion in any of the pre-defined endpoints. Conclusions It is justified not to consider clinically apparent cardiovascular congestion in septic AKI patients as a risk factor for death per se. Rather, especially in the case of sepsis, clinically apparent positive fluid balance does not seem to be a disadvantage in terms of survival, KRT, and ROKF.
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Affiliation(s)
- Charlotte Mund
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Katharina Asmus
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Wajima Safi
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Oliver Ritter
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
- Faculty of Health Sciences (FGW), Joint Faculty of the University of Potsdam, the Brandenburg Medical School Theodor Fontane and the Brandenburg Technical University Cottbus-Senftenberg, Cottbus, Germany
| | - Dominique Petrus
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Susann Patschan
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
| | - Daniel Patschan
- Department of Internal Medicine I - Cardiology, Nephrology and Internal Intensive Medicine, Brandenburg University Hospital, Brandenburg Medical School (Theodor Fontane), Brandenburg an der Havel, Germany
- Faculty of Health Sciences (FGW), Joint Faculty of the University of Potsdam, the Brandenburg Medical School Theodor Fontane and the Brandenburg Technical University Cottbus-Senftenberg, Cottbus, Germany
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Estrada-Moya F, González-Garay AG, Flores-López A, Serralde-Zúñiga AE. Total and segmental phase angle in a cohort of hospitalised patients with COVID-19: mortality prediction and changes throughout hospitalisation. Br J Nutr 2024; 131:1397-1404. [PMID: 38149452 PMCID: PMC10950452 DOI: 10.1017/s0007114523002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/10/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023]
Abstract
Body composition and phase angle (PhA) have been used to predict mortality in multiple diseases. However, little has been studied regarding segmental measurements, which could potentially help assess subtle changes in specific tissue segments. This study aimed to identify the total PhA cut-off point associated with mortality risk and changes in body composition within a week of hospitalisation in non-critical hospitalised patients with COVID-19. A cohort study was conducted where patients underwent to a complete nutritional assessment upon admission and after seven days, and followed up until hospital discharge or death. A receiver operating characteristic curve was constructed to determine the PhA cut-off point, and the Kaplan–Meier estimator was used to determine survival analysis. Segmental and complete body compositions on admission and after 7 d were compared. We included 110 patients (60 men) with a mean age of 50·5 ± 15·0 years and a median BMI of 28·5 (IQR, 25·6–33·5) kg/m2. The median length of hospital stay was 6 (IQR, 4–9) d, and the mortality rate was 13·6 %. The PhA cut-off point obtained was 4°, with significant differences in the survival rate (P < 0·001) and mortality (HR = 5·81, 95 % CI: 1·80, 18·67, P = 0·003). Segmental and whole-body compositions were negatively affected within one week of hospitalisation, with changes in the approach by the graphical method in both sexes. Nutritional status deteriorates within a week of hospitalisation. PhA < 4° is strongly associated with increased mortality in non-critical hospitalised patients with COVID-19.
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Affiliation(s)
- Fernando Estrada-Moya
- Servicio de Nutriología Clínica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Sección de Estudios de Posgrado e Investigación, Instituto Politécnico Nacional “Escuela Superior de Medicina”, Mexico City, Mexico
| | | | - Adriana Flores-López
- Servicio de Nutriología Clínica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Aurora E. Serralde-Zúñiga
- Servicio de Nutriología Clínica, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
- Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
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Yébenes JC, Bordeje-Laguna ML, Lopez-Delgado JC, Lorencio-Cardenas C, Martinez De Lagran Zurbano I, Navas-Moya E, Servia-Goixart L. Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC). Nutrients 2024; 16:1157. [PMID: 38674847 PMCID: PMC11054493 DOI: 10.3390/nu16081157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.
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Affiliation(s)
- Juan Carlos Yébenes
- Institut d’Assistència Sanitària (IAS)—Hospital Santa Caterina, 17007 Girona, Spain
| | | | - Juan Carlos Lopez-Delgado
- Hospital Clinic, Medical ICU, Clinical Institute of Internal Medicine & Dermatology (ICMiD), 08036 Barcelona, Spain;
| | | | | | | | - Lluis Servia-Goixart
- Intensive Care Department, Hospital Universitari Arnau de Vilanova, LLeida, 25198 Lleida, Spain;
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Sanson G, Doriguzzi L, Garbari P, Ruggiero MJ, Valentinuzzo I, Mettulio T, Stolfa E, Fisicaro M, Vecchiet S, Mazzaro E, Zanetti M, Fabiani A. The severity of early fluid overload assessed by bioelectrical vector impedance as an independent risk factor for longer patient care after cardiac surgery. Clin Nutr 2024; 43:803-814. [PMID: 38350288 DOI: 10.1016/j.clnu.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND AND AIMS Fluid overload is a common postoperative complication in patients undergoing cardiac surgery. Although this condition is notably associated with relevant adverse outcomes, assessment of hydration status in clinical practice is challenging. Bioelectrical impedance vector analysis (BIVA) has emerged as a potentially effective method to monitor hydration changes, but the available evidence in critically ill patients undergoing cardiac surgery is limited and sometimes conflicting. The aim of this study was to explore by mean of BIVA the evolution over time of hydration status and its impact on relevant outcomes. METHODS Prospective observational study enrolling 130 patients undergoing cardiac surgery. Height normalized impedance was calculated both before surgery (baseline) and in the first five postoperative days. Relevant clinical and laboratory data were collected daily close to BIVA measurements. Length of mechanical ventilation (MV), intensive care unit (ICU) and hospital stay exceeding the 75th percentile of the study population were considered as study endpoints. RESULTS Compared to baseline, a significant reduction in impedance was found at first postoperative day, demonstrating a relevant fluid overload. An adjusted impedance at first postoperative day shorter than the best respective threshold was associated to longer MV (7.4 times), ICU stay (4.7 times) and hospital stay (5.6 times). A significant change in impedance and phase angle was documented throughout the observation days (p < 0.001), without returning to the baseline value. The co-existence of low impedance and high plasma osmolarity increased significantly the risk of incurring the study outcomes. CONCLUSIONS In patients with cardiac surgery-induced fluid overload, recovery to baseline conditions occurs slowly. A relevant early fluid overload should be considered predictive for longer time of MV, ICU and total hospital stay.
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Affiliation(s)
- Gianfranco Sanson
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, Italy.
| | - Lisa Doriguzzi
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Pierpaolo Garbari
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Maria Josè Ruggiero
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Ilaria Valentinuzzo
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Tanja Mettulio
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Elisa Stolfa
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Manuela Fisicaro
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Sara Vecchiet
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Enzo Mazzaro
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
| | - Michela Zanetti
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume 447, Trieste, Italy.
| | - Adam Fabiani
- Cardiac Surgery Unit, Azienda Sanitaria Universitaria Giuliano-Isontina, Strada di Fiume 447, Trieste, Italy.
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Venczel K, Lesh N, Jouriles N, Seaberg D, Gothard D, Harrell C, Reuter Q. Beyond SEP-1 Compliance: Assessing the Impact of Antibiotic Overtreatment and Fluid Overload in Suspected Septic Patients. J Emerg Med 2024; 66:74-82. [PMID: 38278684 DOI: 10.1016/j.jemermed.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/04/2023] [Accepted: 08/31/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) developed the Severe Sepsis and Septic Shock Performance Measure bundle (SEP-1) metric to improve sepsis care, but evidence supporting this bundle is limited and harms secondary to compliance have not been investigated. OBJECTIVE This study investigates the effect of an emergency department (ED) sepsis quality-improvement (QI) effort to improve CMS SEP-1 compliance, looking specifically at antibiotic overtreatment and harm from fluid resuscitation. METHODS This was a retrospective observational study conducted between March and July 2021 with patients for whom a sepsis order set was initiated. The primary outcomes included the number of patients treated with antibiotics who were ultimately deemed nonseptic and the number of patients who developed pulmonary edema, with or without need for positive pressure ventilation (PPV), within 48 h of receiving a 30 mL/kg fluid bolus. Data were collected via nonblinded chart reviews, with a free marginal κ-calculation indicating excellent interrater reliability. RESULTS The study cohort included 273 patients, 170 (62.3%) who were ultimately determined to be septic and 103 (37.7%) who were nonseptic. Of the 103 nonseptic patients, 82 (79.6%) received antibiotics in the ED. Of the 121 patients (44.3%) who received a 30 mL/kg bolus, 5 patients (4.1%) developed pulmonary edema and 0 of 121 patients required PPV within 48 h. CONCLUSIONS The QI effort led to moderate rates of antibiotic overtreatment and very few patients developed pulmonary edema due to a 30 mL/kg fluid bolus.
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Affiliation(s)
- Kevin Venczel
- Department of Emergency, Summa Health System, Akron, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | | | - Nicholas Jouriles
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | - David Seaberg
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | - David Gothard
- Department of Emergency, Summa Health System, Akron, Ohio
| | - Caleb Harrell
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
| | - Quentin Reuter
- Department of Emergency, Summa Health System, Akron, Ohio; Northeast Ohio Medical University, Rootstown, Ohio; U.S. Acute Care Solutions, Canton, Ohio
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Cleymaet R, D’Hondt M, Scheinok T, Malbrain L, De Laet I, Schoonheydt K, Dits H, Van Regenmortel N, Mekeirele M, Cordemans C, Minini A, Severgnini P, Dabrowski W, Wong A, Malbrain MLNG. Comparison of Bioelectrical Impedance Analysis (BIA)-Derived Parameters in Healthy Volunteers and Critically Ill Patients. Life (Basel) 2023; 14:27. [PMID: 38255643 PMCID: PMC10821189 DOI: 10.3390/life14010027] [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: 04/24/2023] [Revised: 11/21/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE To compare bioelectrical impedance analysis (BIA)-derived parameters in healthy volunteers and critically ill patients and to assess its prognostic value in an ICU patient cohort. DESIGN Retrospective, observational data analysis. SETTING Single centre, tertiary-level ICU (Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg Hospital). PATIENTS 101 patients and 101 healthy subjects, participants of International Fluid Academy Days. MEASUREMENTS AND MAIN RESULTS Compared to healthy volunteers, both male and female ICU patients had significantly higher values for total body water (TBW), extracellular water (ECW), extracellular fluid (ECF), plasma, and interstitial fluid volumes. The phase angle was significantly lower and the malnutrition index was significantly higher in ICU patients, regardless of gender. Non-survivors in the ICU had significantly higher extracellular water content (ECW, 50.7 ± 5.1 vs. 48.9 ± 4.3%, p = 0.047) and accordingly significantly lower intracellular water (ICW, 49.2 ± 5.1 vs. 51.1 ± 4.3%, p = 0.047). The malnutrition index was also significantly higher in non-survivors compared to survivors (0.94 ± 0.17 vs. 0.87 ± 0.16, p = 0.048), as was the capillary leak index (ECW/ICW). CONCLUSIONS Compared to healthy volunteers, this study observed a higher malnutrition index and TBW in ICU patients with an accumulation of fluids in the extracellular compartment. ICU non-survivors showed similar results, indicating that ICU patients and a fortiori non-survivors are generally overhydrated, with increased TBW and ECW, and more undernourished, as indicated by a higher malnutrition index.
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Affiliation(s)
- Robbert Cleymaet
- Department of Oromaxillofacial and Plastic Surgery, Ghent University Hospital, 9000 Ghent, Belgium
| | - Marvin D’Hondt
- Department of Oromaxillofacial and Plastic Surgery, Ghent University Hospital, 9000 Ghent, Belgium
| | - Thomas Scheinok
- Department of Neurology, University Hospital Brussels (UZB), 1090 Jette, Belgium
| | - Luca Malbrain
- University School of Medicine, Katholieke Universiteit Leuven (KUL), 3000 Leuven, Belgium
| | - Inneke De Laet
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, 2000 Antwerp, Belgium
| | - Karen Schoonheydt
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, 2000 Antwerp, Belgium
| | - Hilde Dits
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, 2000 Antwerp, Belgium
| | - Niels Van Regenmortel
- Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, 2000 Antwerp, Belgium
| | - Michael Mekeirele
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), 1090 Jette, Belgium
| | - Colin Cordemans
- Department of Intensive Care, AZ Sint-Maria Hospital, 1500 Halle, Belgium;
| | - Andrea Minini
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), 1090 Jette, Belgium
- School of Anaesthesia and Intensive Care, Dipartimento di Biotecnologie e Scienze della Vita, Insubria University, 21100 Varese, Italy;
| | - Paolo Severgnini
- School of Anaesthesia and Intensive Care, Dipartimento di Biotecnologie e Scienze della Vita, Insubria University, 21100 Varese, Italy;
- Department of Anestesia e Rianimazione Cardiologica, ASST dei Sette Laghi, Ospedale di Circolo e Fondazione Macchi, 21100 Varese, Italy
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University Lublin, 20-954 Lublin, Poland
| | - Adrian Wong
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), 1090 Jette, Belgium
- Department of Intensive Care Medicine and Anaesthesia, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Manu L. N. G. Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University Lublin, 20-954 Lublin, Poland
- International Fluid Academy, 3360 Lovenjoel, Belgium
- Medaman, Medical Data Management, 2440 Geel, Belgium
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8
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Saravi B, Goebel U, Hassenzahl LO, Jung C, David S, Feldheiser A, Stopfkuchen-Evans M, Wollborn J. Capillary leak and endothelial permeability in critically ill patients: a current overview. Intensive Care Med Exp 2023; 11:96. [PMID: 38117435 PMCID: PMC10733291 DOI: 10.1186/s40635-023-00582-8] [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: 09/18/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023] Open
Abstract
Capillary leak syndrome (CLS) represents a phenotype of increased fluid extravasation, resulting in intravascular hypovolemia, extravascular edema formation and ultimately hypoperfusion. While endothelial permeability is an evolutionary preserved physiological process needed to sustain life, excessive fluid leak-often caused by systemic inflammation-can have detrimental effects on patients' outcomes. This article delves into the current understanding of CLS pathophysiology, diagnosis and potential treatments. Systemic inflammation leading to a compromise of endothelial cell interactions through various signaling cues (e.g., the angiopoietin-Tie2 pathway), and shedding of the glycocalyx collectively contribute to the manifestation of CLS. Capillary permeability subsequently leads to the seepage of protein-rich fluid into the interstitial space. Recent insights into the importance of the sub-glycocalyx space and preserving lymphatic flow are highlighted for an in-depth understanding. While no established diagnostic criteria exist and CLS is frequently diagnosed by clinical characteristics only, we highlight more objective serological and (non)-invasive measurements that hint towards a CLS phenotype. While currently available treatment options are limited, we further review understanding of fluid resuscitation and experimental approaches to target endothelial permeability. Despite the improved understanding of CLS pathophysiology, efforts are needed to develop uniform diagnostic criteria, associate clinical consequences to these criteria, and delineate treatment options.
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Affiliation(s)
- Babak Saravi
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center, University of Freiburg, University of Freiburg, Freiburg, Germany.
| | - Ulrich Goebel
- Department of Anesthesiology and Critical Care, St. Franziskus-Hospital, Muenster, Germany
| | - Lars O Hassenzahl
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Duesseldorf, Germany
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Aarne Feldheiser
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Evang. Kliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, University of Essen, Essen, Germany
| | - Matthias Stopfkuchen-Evans
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Koch EB, Madsen JM, Wichmann S, Bestle MH, Itenov TS. Bioimpedance and Duration of Organ Dysfunction in Septic Shock-A Prospective Observational Study. J Intensive Care Med 2023; 38:966-974. [PMID: 37186782 DOI: 10.1177/08850666231175819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Rationale: Bioimpedance may be a useful tool to guide fluid treatment and avoid organ dysfunction related to fluid overload. Objective: We examined the correlation between bioimpedance and organ dysfunction in patients with septic shock. Methods: Prospective observational study of adult intensive care unit patients fulfilling the sepsis-3 criteria. Bioimpedance was measured using a body composition monitor (BCM) and BioScan Touch i8 (MBS). We measured impedance at inclusion and after 24 h and reported the impedance, change in impedance, bioimpedance-derived fluid balance, and changes in bioimpedance-derived fluid balance. Organ markers on respiratory, circulatory, and kidney function and overall disease severity were ascertained on days 1-7. The effect of bioimpedance on the change in organ function was assessed by mixed effects linear models. We considered P < .01 as significant. Measurements and Main Results: Forty-nine patients were included. None of the single baseline measurements or derived fluid balances were associated with the course of organ dysfunction. Changes in impedance were associated with the course of overall disease severity (P < .001; with MBS), and with changes in noradrenaline dose (P < .001; with MBS) and fluid balance (P < .001; with BCM). The changes in bioimpedance-derived fluid balance were associated with changes in noradrenaline dose (P < .001; with BCM), cumulative fluid balances (P < .001; with MBS), and lactate concentrations (P < .001; with BCM). Conclusions: Changes in bioimpedance were correlated with the duration of overall organ failure, circulatory failure, and fluid status. Single measurements of bioimpedance were not associated with any changes in organ dysfunction.
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Affiliation(s)
- Ellen Bjerre Koch
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janne M Madsen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sine Wichmann
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Theis S Itenov
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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10
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Moschopoulos CD, Dimopoulou D, Dimopoulou A, Dimopoulou K, Protopapas K, Zavras N, Tsiodras S, Kotanidou A, Fragkou PC. New Insights into the Fluid Management in Patients with Septic Shock. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1047. [PMID: 37374251 PMCID: PMC10301281 DOI: 10.3390/medicina59061047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023]
Abstract
The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.
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Affiliation(s)
- Charalampos D. Moschopoulos
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Dimitra Dimopoulou
- Second Department of Pediatrics, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece;
| | - Anastasia Dimopoulou
- First Department of Pediatric Surgery, “Aghia Sophia” Children’s Hospital, 11527 Athens, Greece
| | | | - Konstantinos Protopapas
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Nikolaos Zavras
- Department of Pediatric Surgery, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Sotirios Tsiodras
- Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece; (C.D.M.); (S.T.)
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
| | - Paraskevi C. Fragkou
- First Department of Critical Care Medicine and Pulmonary Services, School of Medicine, Evangelismos Hospital, National and Kapodistrian University of Athens, 10676 Athens, Greece
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11
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Bioimpedance spectroscopy fluid analysis in acute high-risk abdominal surgery, a prospective clinician-blinded observational feasibility study. J Clin Monit Comput 2023; 37:619-627. [PMID: 36333575 PMCID: PMC9638275 DOI: 10.1007/s10877-022-00934-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Objective assessment of fluid status in critical surgical care may help optimize perioperative fluid administration and prevent postoperative fluid retention. We evaluated the feasibility of hydration status and fluid distribution assessment by Bioimpedance spectroscopy Analysis (BIA) in patients undergoing acute high-risk abdominal (AHA) surgery. This observational study included 73 patients undergoing AHA surgery. During the observational period (0-120 h), we registered BIA calculated absolute fluid overload (AFO) and relative fluid overload (RFO), defined as AFO/extracellular water ratio, as well as cumulative fluid balance and weight. Based on RFO values, hydration status was classified into three categories: dehydrated (RFO < - 10%), normohydrated (- 10% ≤ RFO ≤ + 15%), overhydrated RFO > 15%. We performed a total of 365 BIA measurements. Preoperative overhydration was found in 16% of patients, increasing to 66% by postoperative day five. The changes in BIA measured AFO correlated with the cumulative fluid balance (r2 = 0.44, p < .001), and change in weight (r2 = 0.55, p < .0001). Perioperative overhydration measured with BIA was associated with worse outcome compared to patients with normo- or dehydration. We have demonstrated the feasibility of obtaining perioperative bedside BIA measurements in patients undergoing AHA surgery. BIA measurements correlated with fluid balance, weight changes, and postoperative clinical complications. BIA-assessed fluid status might add helpful information to guide fluid management in patients undergoing AHA surgery.
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Affiliation(s)
- M Cihoric
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark.
| | - H Kehlet
- Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark, Denmark
| | - J Højlund
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark
| | - M L Lauritsen
- Gastrounit, Surgical Section, Hvidovre University Hospital, Hvidovre, Capital Region of Denmark, Denmark
| | - K Kanstrup
- Gastrounit, Surgical Section, Hvidovre University Hospital, Hvidovre, Capital Region of Denmark, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark
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12
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Madsen JM, Itenov TS, Koch EB, Bestle MH. Bioimpedance as a measure of fluids in patients with septic shock. A prospective observational study. Acta Anaesthesiol Scand 2023; 67:319-328. [PMID: 36537040 DOI: 10.1111/aas.14180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/17/2022] [Accepted: 12/04/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Septic shock is often treated with aggressive fluid resuscitation leading to profound fluid overload. The assessment of fluid status relies on suboptimal measures making treatment difficult. Bioelectrical impedance analysis is an alternative but the validity is unclear. The aim of this study was to determine the validity of bioelectrical impedance analysis for fluid measures in patients with septic shock. METHODS Single-center, prospective observational cohort study. We included adult ICU patients with septic shock. We evaluated the agreement between measures on the left and right side of the patient and measures 1 h apart by two bioelectrical impedance devices. Results are presented as Bland Altman plots with 95% Limits of Agreements (LoA) and as correlations between bioelectrical impedance analysis results and clinical markers of fluids. RESULTS Forty-nine patients were included. The agreement between measures on the left and the right side of the patient and after 1 h was overall without bias, but with wide LoA's. Fluid overload 1 h apart showed the most narrow 95% LoA (-2.4-2.9 L). The same wide limits of agreements were observed when comparing devices. For example, total body water with 95% LoA of -14.8 -16.7 L. Correlations between bioelectrical impedance analysis and clinical measures were low but statistically significant. CONCLUSIONS In patients with septic shock bioelectrical impedance analysis had no systematic errors or bias, but wide limits of agreement, indicating that the devices have a large and uncorrectable random error. Fluid status by bioelectrical impedance analysis is not sufficiently accurate to guide treatment in this group of patients.
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Affiliation(s)
- Janne Meisner Madsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Theis S Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Ellen Bjerre Koch
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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13
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Perioperative changes in fluid distribution and haemodynamics in acute high-risk abdominal surgery. Crit Care 2023; 27:20. [PMID: 36647120 PMCID: PMC9841944 DOI: 10.1186/s13054-023-04309-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Understanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies. METHODS Seventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise. RESULTS We observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration. CONCLUSION Despite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could lead to overhydration. Trial registration clinicaltrials.gov. (NCT03997721), Registered 23 May 2019, first participant enrolled 01 June 2019.
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Affiliation(s)
- Mirjana Cihoric
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Henrik Kehlet
- grid.475435.4Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark Denmark
| | - Jakob Højlund
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
| | - Morten Laksáfoss Lauritsen
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Katrine Kanstrup
- grid.411905.80000 0004 0646 8202Gastrounit, Surgical Section, Copenhagen University Hospital Hvidovre, Hvidovre, Capital Region of Denmark Denmark
| | - Nicolai Bang Foss
- grid.411905.80000 0004 0646 8202Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Hvidovre, Kettegaard Allé 30, 2650 Hvidovre, Copenhagen, Capital Region of Denmark Denmark
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14
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Lima J, Eckert I, Gonzalez MC, Silva FM. Prognostic value of phase angle and bioelectrical impedance vector in critically ill patients: A systematic review and meta-analysis of observational studies. Clin Nutr 2022; 41:2801-2816. [PMID: 36395589 DOI: 10.1016/j.clnu.2022.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/21/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS Assessment of the raw parameters derived from bioelectrical impedance analysis (BIA) has gained emphasis in critically ill patients. The phase angle (PhA) reflects the integrity of the cell membrane, and bioelectrical impedance vector analysis (BIVA) is indicative of patients' hydration status. The aim of this study was to investigate whether these parameters are associated with clinical outcomes in the intensive care unit (ICU) setting. METHODS We conducted a systematic review with meta-analysis. We searched PubMed, Embase, Scopus and Web of Science for all published observational studies without language restrictions up to April 2022. Two reviewers independently performed study selection and data extraction. We judged the risk of bias by the Newcastle-Ottawa Scale and the certainty of evidence by the GRADE approach. Mortality was the primary outcome. Secondary outcomes included ICU length of stay, hospital length of stay, duration of mechanical ventilation, nutritional risk, and malnutrition. A meta-analysis with a random-effect model was performed to combine data on R version 3.6.2. RESULTS Twenty-seven studies were included in the systematic review (4872 participants). Pooled analysis revealed that patients with low PhA had a higher risk of death (14 studies; RR = 1.82, 95% CI 1.46 to 2.26; I2 = 42%) and spent more days in ICU (6 studies; MD = 1.79, 95% CI 0.33 to 3.24, I2 = 69%) in comparison to patients with normal PhA. The pooled analysis also showed higher PhA values in survivors compared to non-survivor patients (12 studies; MD = 0.75°, 95% CI 0.60° to 0.91°, I2 = 31%). Overhydration defined by BIVA was not a predictor of mortality (4 studies; RR = 1.01, 95% CI 0.70 to 1.46; I2 = 0%). More than 40% of primary studies were classified with a high risk of bias, and the quality of evidence ranged from low to very low. CONCLUSIONS This meta-analysis revealed, with limited evidence, that low PhA was associated with higher mortality and ICU length of stay, while overhydration identified by BIVA was not a predictor of death in critically ill patients.
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Affiliation(s)
- Júlia Lima
- Master Student at Nutrition Science Graduate Program Federal University of Health Sciences of Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Maria Cristina Gonzalez
- Professor at Graduate Program in Health and Behavior, Catholic University of Pelotas, Rio Grande do Sul, Brazil
| | - Flávia Moraes Silva
- Professor at Nutrition Department and Nutrition Science Graduate Program of Federal University of Health Science of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
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15
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Rashid Farokhi F, Kalateh E, Shafaghi S, Schneider AG, Mortazavi SM, Jamaati H, Hashemian SMR. Applying bio-impedance vector analysis (BIVA) to adjust ultrafiltration rate in critically ill patients on continuous renal replacement therapy: A randomized controlled trial. J Crit Care 2022; 72:154146. [PMID: 36116287 DOI: 10.1016/j.jcrc.2022.154146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bioimpedance vector analysis (BIVA) has been suggested as a valuable tool in assessing volume status in critically ill patients. However, its effectiveness in guiding fluid removal by continuous renal replacement therapy (CRRT) has not been evaluated. METHODS In this randomized controlled trial, 65 critically ill patients receiving CRRT were allocated on a 1:1 ratio to have UF prescribed and adjusted using BIVA fluid assessment in the intervention group (32 patients) or conventional clinical parameters (33 patients). The primary outcome was the lean body mass (LBM) water content at CRRT discontinuation, and the secondary outcomes included the mortality rate, urinary output, the duration of ventilation support, and ICU stay. RESULTS The study group was associated with a lower water content of LBM (80.7 ± 9.4 vs. 85.9 ± 10.4%; p < 0.05), and a higher mean UF-rate and urinary output (1.5 ± 0.8 vs. 1.2 ± 0.5 ml/kg/h and 0.9 ± 0.9 vs 0.5 ± 0.6 ml/kg/h, both: p < 0.05). The mortality rate, the length of ICU stay, and ventilation support duration were similar. CONCLUSION BIVA guided UF prescription may be associated with a lower rate of fluid overload. Larger studies are required to evaluate its impact on patients' outcomes.
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Affiliation(s)
- Farin Rashid Farokhi
- CKD Research Centre, Shahid Beheshti University of Medical Science, Tehran, Iran; Nephrology Department, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran; Telemedicine Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran.
| | - Effat Kalateh
- Internal Medicine Department, Shahid Beheshti University of Medical Science, Tehran, Iran.
| | - Shadi Shafaghi
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran.
| | - Antoine Guillaume Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; University of Lausanne, Lausanne, Switzerland.
| | - Seyed Mehdi Mortazavi
- Critical Care Department, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Hamidreza Jamaati
- Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran.
| | - Seyed Mohammad Reza Hashemian
- Critical Care Department, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran; Chronic Respiratory Disease Research Center, National Research Institute of Tuberculosis and Lung Disease, Shahid Beheshti University of Medical Science, Tehran, Iran.
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16
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Diagnostic significance of highly sensitive troponins in cardiac surgery. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract111002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: The level of troponins after cardiac surgery always exceeds the reference values, however, the interpretation of these changes is difficult. Aim: To determine the relationship between the high-sensitivity cardiac troponin I and troponin T levels and the risk of heart failure (HF) development within 24 hours after the heart surgery. Methods: A prospective, observational, single-center study included 70 patients undergoing elective heart surgery. The patients were retrospectively divided into two groups based on the development of HF in the first 12 hours after the surgery. The group without HF included 57 patients, the group with HF included 13 patients. Results: The levels of highly sensitive Troponin I (HsTI) in patients who underwent elective heart surgery without complications were 61 times higher than the upper limit of the normal values, in those with the development of HF they were 111 times higher than the upper limit of the normal values. The levels of highly sensitive Troponin T (HsTT) were 25.5 times and 51 times the upper limit of the normal values, respectively. The level of HsTI at the end of the surgery can be a predictor of the HF development, regardless of the use of cardiac bypass (threshold value =1483 ng/l), as well as a predictor of the need for inotropic support for 2 days or more, regardless of the operation type (threshold value = 1573 ng/l). There was a direct moderate correlation of the HsTI level at the end of the operation and 6 hours after the operation with cumulative hemohydrobalance for 24 hours, which was 60% higher in patients with HF than that in patients without complications. Conclusion: In uncomplicated patients, the level of highly sensitive troponins T and I in the postoperative period is 2561 times higher than the upper limit of the normal values, and with the HF development it is 51111 times higher. Highly sensitive troponins can be considered as predictors of the HF development and the duration of inotropic support. The increase in the level of troponins is influenced by the duration of cardiac bypass and the volume of infusion therapy in the perioperative period.
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17
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Golino G, Greco M, Rigobello A, Danzi V, De Cal M, Malchiorna N, Zannella M, Navalesi P, Costa-Pinto R, Ronco C, De Rosa S. Incidence of Acute Kidney Injury in Polytrauma Patients and Predictive Performance of TIMP2 × IGFBP7 Biomarkers for Early Identification of Acute Kidney Injury. Diagnostics (Basel) 2022; 12:diagnostics12102481. [PMID: 36292170 PMCID: PMC9601128 DOI: 10.3390/diagnostics12102481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/18/2022] [Accepted: 10/12/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a common cause of organ failure in trauma patients who survive their initial injuries. It is independently associated with increased morbidity and mortality and prolongs the length of hospital stays. The objectives of this study were to describe the incidence of early AKI and influence of risk factors in polytrauma patients and evaluate the predictive potential of TIMP2 × IGFBP7 biomarkers in this patient cohort. Methods: We conducted a retrospective cohort study of severely injured adult patients who were consecutively admitted to a multidisciplinary ICU from May 2017 to May 2019. Detailed patient data was retrieved from ICU medical records. Fluid balance, urinary output, and sCr values up to 72 h were collected. Urine samples for measuring TIMP2 × IGFBP7 concentrations were obtained and analyzed from ICU admission to 72 h. Results: Among the 153 patients eligible for analysis, 45 were included in the AKI, and 108 in the no AKI cohorts. The incidence of AKI within 72 h, based on KDIGO criteria, was 28.8%. There were no differences in ISS, type and mechanism of injury, heart rate, and systolic BP at admission between groups. Patients with early AKI were older (68 vs. 49 years, p < 0.001), obese (BMI 26.2 vs. 24.7, p < 0.048), and more likely to have previous cardiac disease (27% vs. 5.6%, p < 0.001). TIMP2 × IGFBP7 values on ICU admission were associated with subsequent AKI in patients without evidence of AKI at the time of ICU admission. They were also higher in the AKI cohort and significantly correlated with renal replacement therapy (RRT) and episodes of hypotension. Multivariable analysis confirmed age, previous cardiac disease, and NephroCheck as the variables mostly associated with AKI, with AUC 0.792. Conclusions: TIMP2 × IGFBP7 may help identify trauma patients with tubular damage that may evolve into a clinically manifested syndrome. Prospective studies of TIMP2 × IGFBP7, as a trigger for early AKI bundle care, are warranted.
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Affiliation(s)
- Gianlorenzo Golino
- International Renal Research Institute of Vicenza, 36100 Vicenza, Italy
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, 36100 Vicenza, Italy
- Department of Medicine—DIMED, Section of Anesthesiology and Intensive Care Medicine, University of Padova, 35100 Padova, Italy
| | - Massimiliano Greco
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20100 Milan, Italy
- Department of Biomedical Science, Humanitas University, 20100 Milan, Italy
| | - Alessandro Rigobello
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Vinicio Danzi
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Massimo De Cal
- International Renal Research Institute of Vicenza, 36100 Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute of Vicenza, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Nicola Malchiorna
- International Renal Research Institute of Vicenza, 36100 Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute of Vicenza, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Monica Zannella
- International Renal Research Institute of Vicenza, 36100 Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute of Vicenza, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Paolo Navalesi
- Department of Medicine—DIMED, Section of Anesthesiology and Intensive Care Medicine, University of Padova, 35100 Padova, Italy
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Melbourne, VIC 3084, Australia
- Department of Critical Care, the University of Melbourne, Melbourne, VIC 3010, Australia
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, 36100 Vicenza, Italy
- Department of Nephrology, Dialysis and Transplantation and International Renal Research Institute of Vicenza, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza, 36100 Vicenza, Italy
- Department of Anesthesiology and Intensive Care, San Bortolo Hospital, 36100 Vicenza, Italy
- Correspondence: ; Tel.: +39-0444-757-710 or +39-3933-098-583; Fax: +39-0444-753-973
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18
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Murugan R, Kazory A, Sgarabotto L, Ronco C. Fluid Overload and Precision Net Ultrafiltration in Critically Ill Patients. Cardiorenal Med 2022; 13:9-18. [PMID: 36202071 PMCID: PMC10076441 DOI: 10.1159/000527390] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fluid overload is present in two-thirds of critically ill patients with acute kidney injury and is associated with morbidity, mortality, and increased healthcare resource utilization. Kidney replacement therapy (KRT) is frequently used for net fluid removal (i.e., net ultrafiltration [UFNET]) in patients with severe oliguric acute kidney injury. However, ultrafiltration has considerable risks associated with it, and there is a need for newer technology to perform ultrafiltration safely and to improve outcomes. SUMMARY Caring for a critically ill patient with oliguric acute kidney injury and fluid overload is one of the most challenging problems. Although diuretics are the first-line treatment for management of fluid overload, diuretic resistance is common. Various clinical practice guidelines support fluid removal using ultrafiltration during KRT. Emerging evidence from observational studies in critically ill patients suggests that both slow and fast rates of net fluid removal during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of hemodynamic instability, organ injury, and improved outcomes in critically ill patients. There is a need for newer technology for fluid removal in patients who do not meet traditional criteria for initiation of KRT. Emerging newer and miniaturized ultrafiltration devices may address an unmet clinical need. KEY MESSAGES Among critically ill patients with acute kidney injury and fluid overload requiring continuous kidney replacement therapy, use of higher and slower UFNET rates compared with moderate UFNET rates might be associated with poor outcomes. Newer minimally invasive technologies may allow for safe and efficient UFNET in patients with acute kidney injury who do not meet criteria for initiation of KRT.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA
| | - Luca Sgarabotto
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Italy
| | - Claudio Ronco
- Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy
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19
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Weimann A, Hartl WH, Adolph M, Angstwurm M, Brunkhorst FM, Edel A, de Heer G, Felbinger TW, Goeters C, Hill A, Kreymann KG, Mayer K, Ockenga J, Petros S, Rümelin A, Schaller SJ, Schneider A, Stoppe C, Elke G. [Assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units : Position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI)]. Med Klin Intensivmed Notfmed 2022; 117:37-50. [PMID: 35482063 PMCID: PMC9046715 DOI: 10.1007/s00063-022-00918-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/26/2022]
Abstract
At the time of admission to an intensive or intermediate care unit, assessment of the patients' nutritional status may have both prognostic and therapeutic relevance with regard to the planning of individualized medical nutrition therapy (MNT). MNT has definitely no priority in the initial treatment of a critically ill patient, but is often also neglected during the course of the disease. Especially with prolonged length of stay, there is an increasing risk of malnutrition with considerable prognostic macro- and/or micronutrient deficit. So far, there are no structured, evidence-based recommendations for assessing nutritional status in intensive or intermediate care patients. This position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) presents consensus-based recommendations for the assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units. These recommendations supplement the current S2k guideline "Clinical Nutrition in Intensive Care Medicine" of the German Society for Nutritional Medicine (DGEM) and the DIVI.
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Affiliation(s)
- Arved Weimann
- Abteilung für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Str. 141, 04129, Leipzig, Deutschland.
| | - Wolfgang H Hartl
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Großhadern, München, Deutschland
| | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Matthias Angstwurm
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Innenstadt, München, Deutschland
| | - Frank M Brunkhorst
- Zentrum für Klinische Studien, Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Jena, Deutschland
| | - Andreas Edel
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Thomas W Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching und Neuperlach, Städtisches Klinikum München GmbH, München, Deutschland
| | - Christiane Goeters
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Münster, Deutschland
| | - Aileen Hill
- Kliniken für Anästhesiologie und Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen, Deutschland
| | | | - Konstantin Mayer
- Klinik für Pneumologie und Schlafmedizin, St. Vincentius-Kliniken, Karlsruhe, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte, Bremen, Deutschland
| | - Sirak Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Andreas Rümelin
- Anästhesie, Intensivmedizin und Notfallmedizin, Helios St. Elisabeth-Krankenhaus Bad Kissingen, Bad Kissingen, Deutschland
| | - Stefan J Schaller
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andrea Schneider
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Christian Stoppe
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Deutschland.
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20
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Malbrain MLNG, Martin G, Ostermann M. Everything you need to know about deresuscitation. Intensive Care Med 2022; 48:1781-1786. [PMID: 35932335 PMCID: PMC9362613 DOI: 10.1007/s00134-022-06761-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland. .,International Fluid Academy, Lovenjoel, Belgium. .,Medical Data Management, Medaman, Geel, Belgium.
| | - Greg Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
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21
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Overhydration Assessed Using Bioelectrical Impedance Vector Analysis Adversely Affects 90-Day Clinical Outcome among SARS-CoV2 Patients: A New Approach. Nutrients 2022; 14:nu14132726. [PMID: 35807907 PMCID: PMC9268688 DOI: 10.3390/nu14132726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background: COVID-19 has taken on pandemic proportions with growing interest in prognostic factors. Overhydration is a risk factor for mortality in several medical conditions with its role in COVID-19, assessed with bioelectrical impedance (BI), gaining research interest. COVID-19 affects hydration status. The aim was to determine the hydration predictive role on 90 d survival COVID-19 and to compare BI assessments with traditional measures of hydration. Methods: We studied 127 consecutive COVID-19 patients. Hydration status was estimated using a 50 kHz phase-sensitive BI and estimated, compared with clinical scores and laboratory markers to predict mortality. Results: Non-surviving COVID-19 patients had significantly higher hydration 85.2% (76.9−89.3) vs. 73.7% (73.2−82.1) and extracellular water/total body water (ECW/TBW) 0.67 (0.59−0.75) vs. 0.54 (0.48−0.61) (p = 0.001, respectively), compared to surviving. Patients in the highest hydration tertile had increased mortality (p = 0.012), Intensive Care Unit (ICU) admission (p = 0.027), COVID-19 SEIMC score (p = 0.003), and inflammation biomarkers [CRP/prealbumin (p = 0.011)]. Multivariate analysis revealed that hydration status was associated with increased mortality. HR was 2.967 (95%CI, 1.459−6.032, p < 0.001) for hydration and 2.528 (95%CI, 1.664−3.843, p < 0.001) for ECW/TBW, which were significantly greater than traditional measures: CRP/prealbumin 3.057(95%CI, 0.906−10.308, p = 0.072) or BUN/creatinine 1.861 (95%CI, 1.375−2.520, p < 0.001). Hydration > 76.15% or ECW/TBW > 0.58 were the cut-off values predicting COVID-19 mortality with 81.3% and 93.8% sensitivity and 64 and 67.6% specificity, respectively. Hydration status offers a sensitive and specific prognostic test at admission, compared to established poor prognosis parameters. Conclusions and Relevance: Overhydration, indicated as high hydration (>76.15%) and ECW/TBW (>0.58), were significant predictors of COVID-19 mortality. These findings suggest that hydration evaluation with 50 kHz phase-sensitive BI measurements should be routinely included in the clinical assessment of COVID-19 patients at hospital admission, to identify increased mortality risk patients and assist medical care.
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22
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial. Acta Anaesthesiol Scand 2022; 66:640-650. [PMID: 35124808 DOI: 10.1111/aas.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction. AIM To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV. METHODS AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol. DISCUSSION The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
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23
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Madsen JM, Wichmann S, Bestle MH, Itenov TS. Bioimpedance as a measure of fluid status in critically ill patients: A systematic review. Acta Anaesthesiol Scand 2021; 65:1155-1167. [PMID: 34036559 DOI: 10.1111/aas.13924] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Precise measurements of fluid status lack valid methods. Bioimpedance is an attractive diagnostic tool because it is noninvasive, quick, and relatively cheap. This systematic review aims to assess the existing evidence of bioimpedance as an accurate measure of fluid status in critically ill patients. DATA SOURCES PubMed and Embase up till March 2021 were systematically searched (PROSPERO: CRD42020157436). STUDY SELECTION Eligibility criteria were studies reporting original data from cohorts of adult patients in intensive care units and doing at least one whole-body bioimpedance and one reference test. In addition, studies assessing internal reproducibility were included. DATA EXTRACTION An extraction form was designed for the purpose. DATA SYNTHESIS Nine hundred five studies were screened for eligibility, and 28 studies, comprising 1482 individual patients, were included in the final analysis. Eight studies compared bioimpedance with a gold standard, and two of those reported the results adequate. We found a low mean difference, but the 95% limits of agreements had wide limits. The remaining studies applied different surrogates as reference tests. Correlations ranged from 0.05 to 0.99. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) certainty of evidence for all outcomes was very low. CONCLUSIONS The accuracy of bioimpedance as a measure for fluids in critically ill patients in the intensive care unit cannot be determined. Due to the lack of a gold standard, numerous studies compared bioimpedance with surrogate outcomes with great variability in both designs and results. Assessing the internal reproducibility of bioimpedance had the same limitations, but the studies overall reported good internal reproducibility.
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Affiliation(s)
- Janne M. Madsen
- Department of Anaesthesiology Copenhagen University Hospital—North Zealand Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Sine Wichmann
- Department of Anaesthesiology Copenhagen University Hospital—North Zealand Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Morten H. Bestle
- Department of Anaesthesiology Copenhagen University Hospital—North Zealand Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Theis S. Itenov
- Department of Anaesthesiology Copenhagen University Hospital—North Zealand Copenhagen Denmark
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24
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Liu Y, Chen G, Gao J, Chi M, Mao M, Shi Y, Ji Z, Fu Q, Zhang H, Xu Z. Effect of different levels of stroke volume variation on the endothelial glycocalyx of patients undergoing colorectal surgery: A randomized clinical trial. Exp Physiol 2021; 106:2124-2132. [PMID: 34347918 DOI: 10.1113/ep089348] [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: 04/26/2021] [Accepted: 08/03/2021] [Indexed: 12/28/2022]
Abstract
NEW FINDINGS What is the central question of this study? Massive infusion can destroy the endothelial glycocalyx. We compared the serum concentrations of endothelial glycocalyx components and atrial natriuretic peptide and the outcomes of patients with different levels of stroke volume variation (SVV). What is the main finding and its importance? With a decrease in SVV, the serum concentrations of endothelial glycocalyx components and atrial natriuretic peptide increased, whereas the oxygenation index decreased. When the intraoperative SVV was maintained at 7-10%, the patients had better postoperative recovery and shorter postoperative hospital stays. Therefore, it is advisable to maintain the SVV between 7 and 10%. ABSTRACT Dynamic haemodynamic parameters, such as stroke volume variation (SVV), can be used for blood volume monitoring. However, studies have determined the SVV threshold but not the optimal level. The endothelial glycocalyx (EG) plays an important role in maintaining vascular permeability. Moreover, rapid and massive infusion can lead to the degradation, shedding and destruction of the EG. We aimed to explore the effects of different SVV values (11-14, 7-10 or 3-6%) on the EG in 54 patients who were scheduled for elective colorectal tumour surgery and to identify the optimal peri-operative fluid therapy strategy. The concentrations of EG degradation products (heparin sulphate, hyaluronic acid and syndecan-1) and atrial natriuretic peptide were higher when the SVV was maintained between 3 and 6% after fluid therapy compared with pre-infusion (P < 0.05). Comparison of postoperative complications and hospitalization time among the three SVV levels was not statistically significant (P > 0.05). The postoperative hospitalization time in patients with SVV of 7-10% was shorter than that in patients with SVV of 3-6%. Infusion of a large volume of fluid, with increasing EG degeneration and atrial natriuretic peptide concentrations, might be related to postoperative outcomes.
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Affiliation(s)
- Yi Liu
- Department of Anesthesiology, The Third Medical Center of Chinese PLA General Hospital, No. 69 Yongding Road, Beijing, 100039, China.,Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Gang Chen
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Jie Gao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Menglin Chi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Mengmeng Mao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Yizheng Shi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Zexuan Ji
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Qiang Fu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Hong Zhang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
| | - Zhipeng Xu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China
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25
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Moonen HPFX, Van Zanten ARH. Bioelectric impedance analysis for body composition measurement and other potential clinical applications in critical illness. Curr Opin Crit Care 2021; 27:344-353. [PMID: 33967207 PMCID: PMC8270506 DOI: 10.1097/mcc.0000000000000840] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Insight into body composition is of great value in the ICU. Bioelectric impedance analysis (BIA) is the most applicable bedside technique. However, bioimpedance has not been validated in the critically ill, and the interpretation of the measurements poses challenges. This review discusses the potential clinical applications of BIA and explores caveats and solutions to its use in the intensive care setting. RECENT FINDINGS A correlation is repeatedly found between raw impedance parameters, fluid ratios, overhydration, and adverse outcome of critical illness. However, cut-off and reference values remain elusive. Experience with BIA-guided fluid management in the ICU is limited. BIA-derived muscle mass appears a promising biomarker for sarcopenia, correlating well with CT-analysis. Body cell mass and fat-free mass provide potential use in estimation of metabolic rate, protein requirements and pharmacokinetics. Several methods of reducing bias in BIA parameters in critical illness require validation. SUMMARY There are currently too many uncertainties and discrepancies regarding interpretation of bioimpedance in critical illness, to justify therapeutic consequences. However, there are several promising areas of research, concerning some of the most urgent clinical problems in intensive care, emphasizing the need to evaluate further the use and interpretation of bioimpedance in the intensive care setting.
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Affiliation(s)
| | - Arthur Raymond Hubert Van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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26
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Osuna-Padilla IA, Rodríguez-Moguel NC, Rodríguez-Llamazares S, Aguilar-Vargas A, Casas-Aparicio GA, Ríos-Ayala MA, Hernández-Cardenas CM. Low phase angle is associated with 60-day mortality in critically ill patients with COVID-19. JPEN J Parenter Enteral Nutr 2021; 46:828-835. [PMID: 34291834 PMCID: PMC8420520 DOI: 10.1002/jpen.2236] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Malnutrition status, body composition indicators, and bioelectrical impedance analysis (BIA) parameters have been associated with increased risk of death in several pathologies. The aim of this study was to describe the associations between phase angle (PhA) indicators obtained by BIA with length of hospital stay, days on mechanical ventilation, and 60‐day mortality in critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Methods This is a prospective cohort of mechanically ventilated patients with coronavirus disease 2019 (COVID‐19). We assessed nutrition risk and body composition with BIA within 48 h from intensive care unit admission. Logistic and linear regression models were used to analyze the association between variables and clinical outcomes. Survival analysis by PhA value was performed using Kaplan‐Meier curves. Results Sixty‐seven patients were included. PhA (odds ratio [OR], 0.36; P = .002), standardized PhA (SPA) (OR, 0.45; P = .001), and extracellular water/total body water ratio (OR, 3.25; P = .002) were significant predictors of 60‐day mortality. PhA <3.85° in females and <5.25° in males showed good and fair discrimination, respectively, for mortality prediction. Using cutoff values, low PhA was associated with a significantly increased risk of 60‐day mortality (hazard ratio, 3.08; 95% CI, 1.12–8.41; P = .02). No association was detected for SPA. Conclusion Low PhA values could be a predictor of 60‐day mortality in critically ill patients with COVID‐19. This biological marker could be incorporated as part of nutrition and mortality risk assessment in this population.
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Affiliation(s)
- Iván Armando Osuna-Padilla
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico.,Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Nadia Carolina Rodríguez-Moguel
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Sebastián Rodríguez-Llamazares
- Departamento de Investigación en Tabaquismo y EPOC, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Adriana Aguilar-Vargas
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Gustavo Alejandro Casas-Aparicio
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Martin Armando Ríos-Ayala
- Departamento de Áreas Críticas, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
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27
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Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial. Mil Med Res 2021; 8:36. [PMID: 34099065 PMCID: PMC8180439 DOI: 10.1186/s40779-021-00329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients. METHODS A pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan-Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built. RESULTS A total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications. CONCLUSION Among postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.
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28
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Karpavičiūtė J, Skarupskienė I, Balčiuvienė V, Vaičiūnienė R, Žiginskienė E, Bumblytė IA. Assessment of Fluid Status by Bioimpedance Analysis and Central Venous Pressure Measurement and Their Association with the Outcomes of Severe Acute Kidney Injury. ACTA ACUST UNITED AC 2021; 57:medicina57060518. [PMID: 34067299 PMCID: PMC8224573 DOI: 10.3390/medicina57060518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022]
Abstract
Background and Objectives: Fluid disbalance is associated with adverse outcomes in critically ill patients with acute kidney injury (AKI). In this study, we intended to assess fluid status using bioimpedance analysis (BIA) and central venous pressure (CVP) measurement and to evaluate the association between hyperhydration and hypervolemia with the outcomes of severe AKI. Materials and Methods: A prospective study was conducted in the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos. Forty-seven patients treated at the Intensive Care Unit (ICU) with severe AKI and a need for renal replacement therapy (RRT) were examined. The hydration level was evaluated according to the ratio of extracellular water to total body water (ECW/TBW) of bioimpedance analysis and volemia was measured according to CVP. All of the patients were tested before the first hemodialysis (HD) procedure. Hyperhydration was defined as ECW/TBW > 0.39 and hypervolemia as CVP > 12 cm H2O. Results: According to bioimpedance analysis, 72.3% (n = 34) of patients were hyperhydrated. According to CVP, only 51.1% (n = 24) of the patients were hypervolemic. Interestingly, 69.6% of hypovolemic/normovolemic patients were also hyperhydrated. Of all study patients, 57.4% (n = 27) died, in 29.8% (n = 14) the kidney function improved, and in 12.8% (n = 6) the demand for RRT remained after in-patient treatment. A tendency of higher mortality in hyperhydrated patients was observed, but no association between hypervolemia and outcomes of severe AKI was established. Conclusions: Three-fourths of the patients with severe AKI were hyperhydrated based on bioimpedance analysis. However, according to CVP, only half of these patients were hypervolemic. A tendency of higher mortality in hyperhydrated patients was observed.
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Affiliation(s)
- Justina Karpavičiūtė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Correspondence:
| | - Inga Skarupskienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Vilma Balčiuvienė
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Rūta Vaičiūnienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Edita Žiginskienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Inga Arūnė Bumblytė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
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Stocking JC, Drake C, Aldrich JM, Ong MK, Amin A, Marmor RA, Godat L, Cannesson M, Gropper MA, Romano PS, Utter GH. Risk Factors Associated With Early Postoperative Respiratory Failure: A Matched Case-Control Study. J Surg Res 2021; 261:310-319. [PMID: 33485087 PMCID: PMC10062707 DOI: 10.1016/j.jss.2020.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/02/2020] [Accepted: 12/16/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative respiratory failure is the most common serious postoperative pulmonary complication, yet little is known about factors that can reduce its incidence. We sought to elucidate modifiable factors associated with respiratory failure that developed within the first 5 d after an elective operation. MATERIALS AND METHODS Matched case-control study of adults who had an operation at five academic medical centers between October 1, 2012 and September 30, 2015. Cases were identified using administrative data and confirmed via chart review by critical care clinicians. Controls were matched 1:1 to cases based on hospital, age, and surgical procedure. RESULTS Our total sample (n = 638) was 56.4% female, 71.3% white, and had a median age of 62 y (interquartile range 51, 70). Factors associated with early postoperative respiratory failure included male gender (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.12-2.63), American Society of Anesthesiologists class III or greater (OR 2.85, 95% CI 1.74-4.66), greater number of preexisting comorbidities (OR 1.14, 95% CI 1.004-1.30), increased operative duration (OR 1.14, 95% CI 1.06-1.22), increased intraoperative positive end-expiratory pressure (OR 1.23, 95% CI 1.13-1.35) and tidal volume (OR 1.13, 95% CI 1.004-1.27), and greater net fluid balance at 24 h (OR 1.17, 95% CI 1.07-1.28). CONCLUSIONS We found greater intraoperative ventilator volume and pressure and 24-h fluid balance to be potentially modifiable factors associated with developing early postoperative respiratory failure. Further studies are warranted to independently verify these risk factors, explore their role in development of early postoperative respiratory failure, and potentially evaluate targeted interventions.
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Affiliation(s)
- Jacqueline C Stocking
- Department of Internal Medicine, University of California Davis, Sacramento, California.
| | - Christiana Drake
- Department of Statistics, University of California Davis, Davis, California
| | - J Matthew Aldrich
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | - Michael K Ong
- Department of Medicine, University of California Los Angeles, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Alpesh Amin
- Department of Hospital Medicine, University of California Irvine, Irvine, California
| | - Rebecca A Marmor
- Department of Surgery, University of California San Diego, San Diego, California
| | - Laura Godat
- Department of Surgery, University of California San Diego, San Diego, California
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael A Gropper
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | - Patrick S Romano
- Department of Internal Medicine, University of California Davis, Sacramento, California; Center for Healthcare Policy and Research, University of California Davis, Sacramento, California
| | - Garth H Utter
- Department of Surgery, Outcomes Research Group, University of California Davis, Sacramento, California; Center for Healthcare Policy and Research, University of California Davis, Sacramento, California
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30
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Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Abstract
Emerging evidence from observational studies suggests that both slower and faster net ultrafiltration rates during kidney replacement therapy are associated with increased mortality in critically ill patients with acute kidney injury and fluid overload. Faster rates are associated with ischemic organ injury. The net ultrafiltration rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Randomized trials are required to examine whether moderate net ultrafiltration rates compared with slower and faster rates are associated with reduced risk of hemodynamic instability, organ injury, and improved outcomes.
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Affiliation(s)
- Vikram Balakumar
- Department of Critical Care Medicine, Mercy Hospitals, Springfield, MO, USA; Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. https://twitter.com/vikrambalakumar
| | - Raghavan Murugan
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Room 206, Pittsburgh, PA 15261, USA.
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32
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Kim JS, Han BG. Assessment of body fluid in critically ill patients with acute kidney injury requiring continuous renal replacement therapy. Kidney Res Clin Pract 2020; 39:381-383. [PMID: 33318339 PMCID: PMC7770986 DOI: 10.23876/j.krcp.20.229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/01/2020] [Accepted: 11/19/2020] [Indexed: 12/29/2022] Open
Affiliation(s)
- Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Byoung-Geun Han
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
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Moonen HPFX, van Zanten FJL, Driessen L, de Smet V, Slingerland-Boot R, Mensink M, van Zanten ARH. Association of bioelectric impedance analysis body composition and disease severity in COVID-19 hospital ward and ICU patients: The BIAC-19 study. Clin Nutr 2020; 40:2328-2336. [PMID: 33129597 PMCID: PMC7577288 DOI: 10.1016/j.clnu.2020.10.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022]
Abstract
Background The current severe acute respiratory syndrome coronavirus 2 pandemic is unprecedented in its impact. It is essential to shed light on patient characteristics that predispose to a more severe disease course. Obesity, defined as a BMI>30 kg/m2, is suggested to be one of these characteristics. However, BMI does not differentiate between fat mass and lean body mass, or the distribution of fat tissue. The aim of the present study was to assess the body composition of COVID-19 patients admitted to the ward or the ICU and identify any associations with severity of disease. Methods We performed an observational cross-sectional cohort study. Bioelectric impedance analysis was conducted amongst all confirmed COVID-19 patients admitted to the ward or ICU of our hospital in the Netherlands, between April 10 and 17, 2020. Body water measurements and derived values were recalculated to dry weight, using a standard ratio of extracellular water to total body water of 0.38. Data were compared between the ward and ICU patients, and regression models were used to assess the associations between baseline characteristics, body composition, and several indicators of disease severity, including a composite score composed of mortality, morbidity, and ICU admission. Results Fifty-four patients were included, of which 30 in the ward and 24 in the ICU. The mean age was 67 years (95%-CI 64–71), and 34 (63%) were male. Mean BMI was 29.7 (95%-CI 28.2–31.1) kg/m2 and did not differ between groups. Body composition values were not independently associated with disease severity. In multiple logistic regression analyses, a low phase angle was associated with COVID-19 severity in the composite score (OR 0.299, p = 0.046). Conclusion We found no significant associations between body composition, including fat mass, visceral fat area, and fat-free mass, and disease severity in our population of generally overweight COVID-19 patients. A lower phase angle did increase the odds of severe COVID-19. We believe that factors other than body composition play a more critical role in the development of severe COVID-19.
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Affiliation(s)
| | | | - Luuk Driessen
- Wageningen University& Research, Division of Human Nutrition and Health, Wageningen, the Netherlands
| | - Vivienne de Smet
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands
| | | | - Marco Mensink
- Wageningen University& Research, Division of Human Nutrition and Health, Wageningen, the Netherlands
| | - Arthur Raymond Hubert van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, the Netherlands; Wageningen University& Research, Division of Human Nutrition and Health, Wageningen, the Netherlands.
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34
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Sim J, Kwak JY, Jung YT. Association between postoperative fluid balance and mortality and morbidity in critically ill patients with complicated intra-abdominal infections: a retrospective study. Acute Crit Care 2020; 35:189-196. [PMID: 32811137 PMCID: PMC7483013 DOI: 10.4266/acc.2020.00031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/05/2020] [Indexed: 12/29/2022] Open
Abstract
Background Postoperative fluid overload may increase the risk of developing pulmonary complications and other adverse outcomes. We evaluated the impact of excessive fluid administration on postoperative outcomes in critically ill patients. Methods We reviewed the medical records of 320 patients admitted to intensive care unit (ICU) after emergency abdominal surgery for complicated intra-abdominal infection (cIAI) between January 2013 and December 2018. The fluid balance data of the patients were reviewed for a maximum of 7 days. The patients were grouped based on average daily fluid balance with a cutoff value of 20 ml/kg/day. Propensity score matching was performed to reduce the underlying differences between the groups. Results Patients with an average daily fluid balance of ≥20 ml/kg/day were associated with higher rates of 30-day mortality (11.8% vs. 2.4%; P=0.036) than those with lower fluid balance (<20 ml/kg/day). Kaplan-Meier survival curves for 30-day mortality in these groups also showed a better survival rate in the lower fluid balance group with a statistical significance (P=0.020). The percentage of patients who developed pulmonary consolidation during ICU stay (47.1% vs. 24.7%; P=0.004) was higher in the fluid-overloaded group. Percentages of newly developed pleural effusion (61.2% vs. 57.7%; P=0.755), reintubation (18.8% vs. 10.6%; P=0.194), and infectious complications (55.3% vs. 49.4%; P=0.539) showed no significant differences between the two groups. Conclusions Postoperative fluid overload in patients who underwent emergency surgery for cIAI was associated with higher 30-day mortality and more frequent occurrence of pulmonary consolidation. Postoperative fluid balance should be adjusted carefully to avoid adverse clinical outcomes.
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Affiliation(s)
- Joohyun Sim
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jae Young Kwak
- Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Yun Tae Jung
- Department of Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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35
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Myatchin I, Abraham P, Malbrain MLNG. Bio-electrical impedance analysis in critically ill patients: are we ready for prime time? J Clin Monit Comput 2020; 34:401-410. [PMID: 31808061 PMCID: PMC7223384 DOI: 10.1007/s10877-019-00439-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 11/28/2019] [Indexed: 01/10/2023]
Affiliation(s)
- Ivan Myatchin
- Department Intensive Care Medicine, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium
- Department Anaesthesiology, Sint-Trudo Regional Hospital, Sint-Truiden, Belgium
| | - Paul Abraham
- Anaesthesiology and Critical Care Medicine Department, Hôpital Edouard-Herriot, Lyon Cedex 03, France
| | - Manu L N G Malbrain
- Department Intensive Care Medicine, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium.
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Elsene, Belgium.
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36
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Kammar-García A, Castillo-Martínez L, Villanueva-Juárez JL, Pérez-Pérez A, Rocha-González HI, Arrieta-Valencia J, Remolina-Schlig M, Hernández-Gilsoul T. Comparison of Bioelectrical Impedance Analysis Parameters for the Detection of Fluid Overload in the Prediction of Mortality in Patients Admitted at the Emergency Department. JPEN J Parenter Enteral Nutr 2020; 45:414-422. [PMID: 32441793 DOI: 10.1002/jpen.1848] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Fluid overload (FO) in critically ill patients is associated with increased adverse events. This study aims to compare different bioelectrical impedance analysis (BIA) parameters that demonstrate FO and their association with 30-day mortality in critical patients admitted to the emergency department (ED). METHODS Five components of the BIA were obtained by multifrequency device-total body water (TBW), extracellular water (ECW), intracellular water (ICW), resistance (R), and reactance (Xc)-to calculate parameters (impedance vectors, impedance ratio, and the ratios of ECW to TBW, ECW to ICW, ECW to body surface area, TBW to height2 , ICW to height2 , Xc to height, and R to height) that have been used for the detection of FO. A concordance analysis (κ) was performed comparing every parameter with each other. Furthermore, different regression models (Cox regression) were created associating the FO for each parameter with 30-day mortality, adjusted for age, body mass index, sex, Sequential Organ Failure Assessment score, and serum albumin level. RESULTS A total of 142 patients were included in the study. Only FO by impedance vector analysis (relative risk [RR] = 6.4; 95% CI, 1.5-27.9; P = .01), impedance ratio (RR = 2.7; 95% CI, 1.1-7.1; P = .04), and R (RR = 2.6; 95% CI, 1.2-5.5; P = .02) increased the probability of 30-day mortality. CONCLUSIONS Different parameters that determine FO by BIA were associated with the mortality of patients admitted to the ED, but the impedance vector analysis was superior to any other parameter of the BIA.
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Affiliation(s)
- Ashuin Kammar-García
- Emergency Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México.,Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, México City, México
| | - Lilia Castillo-Martínez
- Department of Clinical Nutrition, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - José Luis Villanueva-Juárez
- Department of Clinical Nutrition, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Anayeli Pérez-Pérez
- Emergency Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Héctor Isaac Rocha-González
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, México City, México
| | - Jesús Arrieta-Valencia
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, México City, México
| | - Miguel Remolina-Schlig
- Emergency Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Thierry Hernández-Gilsoul
- Emergency Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
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Denneman N, Hessels L, Broens B, Gjaltema J, Stapel SN, Stohlmann J, Nijsten MW, Oudemans-van Straaten HM. Fluid balance and phase angle as assessed by bioelectrical impedance analysis in critically ill patients: a multicenter prospective cohort study. Eur J Clin Nutr 2020; 74:1410-1419. [DOI: 10.1038/s41430-020-0622-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 02/08/2023]
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Wilken M, Oh J, Pinnschmidt HO, Singer D, Blohm ME. Effect of hemodialysis on impedance cardiography (electrical velocimetry) parameters in children. Pediatr Nephrol 2020; 35:669-676. [PMID: 31838611 DOI: 10.1007/s00467-019-04409-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pediatric hemodialysis (HD) patients have a high incidence of cardiovascular morbidity and mortality. The study aim was to investigate whether impedance cardiography (electrical velocimetry, EV) is suitable as a hemodynamic trend monitoring tool in pediatric patients during HD. METHODS Measurements by EV were obtained before, during, and after HD in a prospective single-center pediatric observational study. In total, 54 dialysis cycles in four different pediatric patients with end-stage kidney disease on chronic HD were included. EV parameters analyzed were heart rate (HR), stroke volume (SV), stroke volume index (SI), cardiac output (CO), cardiac index (CI), thoracic fluid content (TFC), index of contractility (ICON), stroke volume variation (SVV), variation of ICON (VIC), R-R interval (TRR), pre-ejection period (PEP), left ventricular ejection time (LVET), and systolic time ration (STR). Systemic vascular resistance index (SVRI) was calculated. RESULTS EV did measure significant changes in cardiovascular parameters associated with HD. The following parameters increased after HD: HR (9%), SVV (19%), VIC (33%), PEP (8%), and STR (18%). A decrease after HD was measured in SV (18%), SI (18%), CO (10%), CI (10%), TFC (10%), ICON (7%), TRR (7%), LVET (8%), and LVET (8%). SVRI was not affected by HD. The changes were correlated to ultrafiltration. HD cycles without fluid withdrawal also altered cardiovascular parameters. CONCLUSIONS Pediatric HD with and without fluid withdrawal changes hemodynamic EV monitoring parameters. Possibly EV may be useful to optimize HD management in pediatric patients.
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Affiliation(s)
- Meike Wilken
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Division of Neonatology and Pediatric Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Gynecology, University Hospital, Halle / Saale, Germany
| | - Jun Oh
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans O Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominique Singer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Division of Neonatology and Pediatric Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin E Blohm
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Division of Neonatology and Pediatric Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Neonatology and Pediatric Intensive Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
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Marik PE, Byrne L, van Haren F. Fluid resuscitation in sepsis: the great 30 mL per kg hoax. J Thorac Dis 2020; 12:S37-S47. [PMID: 32148924 DOI: 10.21037/jtd.2019.12.84] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation.
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Affiliation(s)
- Paul E Marik
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Liam Byrne
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia
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Volta CA, Dalla Corte F, Ragazzi R, Marangoni E, Fogagnolo A, Scaramuzzo G, Grieco DL, Alvisi V, Rizzuto C, Spadaro S. Expiratory flow limitation in intensive care: prevalence and risk factors. Crit Care 2019; 23:395. [PMID: 31806045 PMCID: PMC6896682 DOI: 10.1186/s13054-019-2682-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Expiratory flow limitation (EFL) is characterised by a markedly reduced expiratory flow insensitive to the expiratory driving pressure. The presence of EFL can influence the respiratory and cardiovascular function and damage the small airways; its occurrence has been demonstrated in different diseases, such as COPD, asthma, obesity, cardiac failure, ARDS, and cystic fibrosis. Our aim was to evaluate the prevalence of EFL in patients requiring mechanical ventilation for acute respiratory failure and to determine the main clinical characteristics, the risk factors and clinical outcome associated with the presence of EFL. METHODS Patients admitted to the intensive care unit (ICU) with an expected length of mechanical ventilation of 72 h were enrolled in this prospective, observational study. Patients were evaluated, within 24 h from ICU admission and for at least 72 h, in terms of respiratory mechanics, presence of EFL through the PEEP test, daily fluid balance and followed for outcome measurements. RESULTS Among the 121 patients enrolled, 37 (31%) exhibited EFL upon admission. Flow-limited patients had higher BMI, history of pulmonary or heart disease, worse respiratory dyspnoea score, higher intrinsic positive end-expiratory pressure, flow and additional resistance. Over the course of the initial 72 h of mechanical ventilation, additional 21 patients (17%) developed EFL. New onset EFL was associated with a more positive cumulative fluid balance at day 3 (103.3 ml/kg) compared to that of patients without EFL (65.8 ml/kg). Flow-limited patients had longer duration of mechanical ventilation, longer ICU length of stay and higher in-ICU mortality. CONCLUSIONS EFL is common among ICU patients and correlates with adverse outcomes. The major determinant for developing EFL in patients during the first 3 days of their ICU stay is a positive fluid balance. Further studies are needed to assess if a restrictive fluid therapy might be associated with a lower incidence of EFL.
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Affiliation(s)
- Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Francesca Dalla Corte
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Elisabetta Marangoni
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Alberto Fogagnolo
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Gaetano Scaramuzzo
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Milan, Italy
| | - Valentina Alvisi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Chiara Rizzuto
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
- Department of Anesthesia and Intensive Care Unit, ASST Fatebenefratelli Sacco, Luigi Sacco Hospital, Polo Universitario, University of Milan, Milan, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy.
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da Hora Passos R, Caldas J, Ramos JGR, Dos Santos Galvão de Melo EB, Ribeiro MPD, Alves MFC, Batista PBP, Messeder OHC, de Carvalho de Farias AM, Macedo E, Rouby JJ. Ultrasound-based clinical profiles for predicting the risk of intradialytic hypotension in critically ill patients on intermittent dialysis: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:389. [PMID: 31791373 PMCID: PMC6889608 DOI: 10.1186/s13054-019-2668-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/12/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intradialytic hypotension, a complication of intermittent hemodialysis, decreases the efficacy of dialysis and increases long-term mortality. This study was aimed to determine whether different predialysis ultrasound cardiopulmonary profiles could predict intradialytic hypotension. METHODS This prospective observational single-center study was performed in 248 critically ill patients with acute kidney injury undergoing intermittent hemodialysis. Immediately before hemodialysis, vena cava collapsibility was measured by vena cava ultrasound and pulmonary congestion by lung ultrasound. Factors predicting intradialytic hypotension were identified by multiple logistic regression analysis. RESULTS Intradialytic hypotension was observed in 31.9% (n = 79) of the patients, interruption of dialysis because of intradialytic hypotension occurred in 6.8% (n = 31) of the sessions, and overall 28-day mortality was 20.1% (n = 50). Patients were classified in four ultrasound profiles: (A) 108 with B lines > 14 and vena cava collapsibility > 11.5 mm m-2, (B) 38 with B lines < 14 and vena cava collapsibility ≤ 11.5 mm m-2, (C) 36 with B lines > 14 and vena cava collapsibility Di ≤ 11.5 mm m-2, and (D) 66 with B lines < 14 and vena cava collapsibility > 11.5 mm m-2. There was an increased risk of intradialytic hypotension in patients receiving norepinephrine (odds ratios = 15, p = 0.001) and with profiles B (odds ratios = 12, p = 0.001) and C (odds ratios = 17, p = 0.001). CONCLUSION In critically ill patients on intermittent hemodialysis, the absence of hypervolemia as assessed by lung and vena cava ultrasound predisposes to intradialytic hypotension and suggests alternative techniques of hemodialysis to provide better hemodynamic stability.
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Affiliation(s)
- Rogerio da Hora Passos
- Critical Care Unit and Nephrology Department, Hospital Português and Hospital São Rafael, Salvador, Bahia, Brazil.
| | - Juliana Caldas
- Critical Care Unit, Hospital São Rafael, Salvador, Bahia, Brazil
| | | | | | | | | | | | | | | | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California, San Diego, USA
| | - Jean Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University of Paris, Paris, France
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42
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Razzera EL, Marcadenti A, Rovedder SW, Alves FD, Fink JDS, Silva FM. Parameters of Bioelectrical Impedance Are Good Predictors of Nutrition Risk, Length of Stay, and Mortality in Critically Ill Patients: A Prospective Cohort Study. JPEN J Parenter Enteral Nutr 2019; 44:849-854. [PMID: 31423620 DOI: 10.1002/jpen.1694] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 07/01/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Assessment of nutrition risk in the intensive care unit (ICU) is limited by characteristics of critically ill patients, and new methods have been investigated for their applicability and predictive validity. The aim of the present study was to evaluate the validity of bioelectrical impedance analysis (BIA) parameters as predictors of nutrition risk and clinical outcomes in critically ill patients. METHODS This was a prospective cohort study of patients admitted to an ICU. The modified Nutrition Risk in the Critically Ill score was used for assessment of nutrition risk, and BIA was performed in the first 72 hours of admission. Phase angle (PA) measurements were obtained, and bioelectrical impedance vector analysis (BIVA) was used to classify patients by hydration status (BIVA >70%). Patients were followed until hospital discharge and evaluated for hospital mortality, ICU length of stay, length of hospitalization, and duration of mechanical ventilation. RESULTS Eighty-nine patients were included (62.5 ± 14.1 years, 50.6% female). A PA <5.5o showed an accuracy of 79% (95% CI 0.59-0.83) in identifying patients at high nutrition risk and was associated with nearly 2 times greater risk for an ICU length of stay longer than 5 days (relative risk = 2.18 [95% CI 1.39-3.40]). Hyperhydration was a significant predictor of mortality (hazard ratio = 2.24 [95% CI 1.07-4.68]). Higher resistance and reactance values, adjusted for height, were found in survivors compared with nonsurvivors. CONCLUSION The predictive validity of BIA was satisfactory for the assessment of nutrition risk, ICU length of stay, and mortality in critically ill patients.
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Affiliation(s)
- Elisa Loch Razzera
- Porto Alegre Federal University of Health Sciences, Porto Alegre, Brazil
| | - Aline Marcadenti
- Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.,Institute of Research, Coracao Hospital, São Paulo, São Paulo, Brazil.,Postgraduate Program in Health Sciences: Cardiology, Institute of Cardiology of the Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | - Flávia Moraes Silva
- Department of Nutrition and Postgraduate Program in Nutrition, Federal University of Health Sciences, Porto Alegre, Brazil
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Bioimpedance-measured volume overload predicts longer duration of mechanical ventilation in intensive care unit patients. Can J Anaesth 2019; 66:1458-1463. [DOI: 10.1007/s12630-019-01450-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 12/20/2022] Open
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Ciumanghel AI, Grigoras I, Siriopol D, Blaj M, Rusu DM, Grigorasi GR, Igna AR, Duca O, Siriopol I, Covic A. Bio-electrical impedance analysis for perioperative fluid evaluation in open major abdominal surgery. J Clin Monit Comput 2019; 34:421-432. [PMID: 31201590 PMCID: PMC7205773 DOI: 10.1007/s10877-019-00334-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 06/03/2019] [Indexed: 12/14/2022]
Abstract
Water retention and intercompartmental redistribution occur frequently in association with adverse postoperative outcomes, yet the available strategies for non-invasive assessment are limited. One such approach for evaluating body water composition in various circumstances is bio-electrical impedance analysis (BIA). This study aims to appraise the usefulness of the Body Composition Monitor (BCM, Fresenius Medical Care, Germany) in assessing body fluid composition and intercompartmental shifts before and after open major abdominal surgery. This prospective, clinician blinded observational study enrolled all the patients scheduled consecutively for elective major open abdominal surgery during a 1-year period starting from January 1st, 2016. BIA parameters—total body water (TBW), extracellular water (ECW), intracellular water (ICW), absolute fluid overload (AFO), and relative fluid overload (RFO) were measured before and after surgery. The results were compared with fluid balance and outcome parameters such as organ dysfunction, ICU-and hospital length of stay (-LOS). The study population included 71 patients aged 60.2 ± 12 of whom 60.6% men and with a BMI of 26.3 ± 5.1 kg/m2. Postoperative acute kidney injury, respiratory dysfunction, and infections occurred in 14.0%, 19.7% and 28.1% of cases, respectively. The median LOS in ICU was 20 h and the hospital-LOS was 10 days. Positive intraoperative fluid balance (2.4 ± 1.0 L) resulted in a significant increase of TBW (1.4 ± 2.4 L) and of ECW (1.4 ± 1.2 L). Intraoperative fluid balance significantly correlated with TBW change (r = 0.23, p = 0.04) and with AFO change (r = 0.31, p < 0.01). A significant correlation was found between pre- and postoperative AFO and RFO on one hand, and ICU-LOS on the other. BIA may be a useful tool for the perioperative assessment of volume status.
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Affiliation(s)
- Adi-Ionut Ciumanghel
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania. .,Anesthesia and Intensive Care Department, ‟Sf. Spiridon" University Hospital, Iasi, Romania.
| | - Ioana Grigoras
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iasi, Romania
| | - Dimitrie Siriopol
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Department, ‟Dr. C.I. Parhon" University Hospital, Iasi, Romania
| | - Mihaela Blaj
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Anesthesia and Intensive Care Department, ‟Sf. Spiridon" University Hospital, Iasi, Romania
| | - Daniel-Mihai Rusu
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iasi, Romania
| | | | - Alexandru Razvan Igna
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iasi, Romania
| | - Oana Duca
- Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iasi, Romania
| | - Ianis Siriopol
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Anesthesia and Intensive Care Department, Regional Institute of Oncology, Iasi, Romania
| | - Adrian Covic
- ‟Grigore T. Popa" University of Medicine and Pharmacy, Iasi, Romania.,Nephrology Department, ‟Dr. C.I. Parhon" University Hospital, Iasi, Romania
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Worapratya P, Wuthisuthimethawee P. Septic shock in the ER: diagnostic and management challenges. OPEN ACCESS EMERGENCY MEDICINE 2019; 11:77-86. [PMID: 31114401 PMCID: PMC6489668 DOI: 10.2147/oaem.s166086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/21/2019] [Indexed: 12/20/2022] Open
Abstract
Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient's volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.
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Affiliation(s)
- Panita Worapratya
- Department of Emergency Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Prasit Wuthisuthimethawee
- Department of Emergency Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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46
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Lukaski HC, Vega Diaz N, Talluri A, Nescolarde L. Classification of Hydration in Clinical Conditions: Indirect and Direct Approaches Using Bioimpedance. Nutrients 2019; 11:nu11040809. [PMID: 30974817 PMCID: PMC6521329 DOI: 10.3390/nu11040809] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 12/16/2022] Open
Abstract
Although the need to assess hydration is well recognized, laboratory tests and clinical impressions are impractical and lack sensitivity, respectively, to be clinically meaningful. Different approaches use bioelectrical impedance measurements to overcome some of these limitations and aid in the classification of hydration status. One indirect approach utilizes single or multiple frequency bioimpedance in regression equations and theoretical models, respectively, with anthropometric measurements to predict fluid volumes (bioelectrical impedance spectroscopy-BIS) and estimate fluid overload based on the deviation of calculated to reference extracellular fluid volume. Alternatively, bioimpedance vector analysis (BIVA) uses direct phase-sensitive measurements of resistance and reactance, measured at 50 kHz, normalized for standing height, then plotted on a bivariate graph, resulting in a vector with length related to fluid content, and direction with phase angle that indexes hydration status. Comparison with healthy population norms enables BIVA to classify (normal, under-, and over-) and rank (change relative to pre-treatment) hydration independent of body weight. Each approach has wide-ranging uses in evaluation and management of clinical groups with over-hydration with an evolving emphasis on prognosis. This review discusses the advantages and limitations of BIS and BIVA for hydration assessment with comments on future applications.
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Affiliation(s)
- Henry C Lukaski
- Department of Kinesiology and Public Health Education, University of North Dakota, Grand Forks, ND 58202-7166, USA.
| | - Nicanor Vega Diaz
- Nephrology Service, University Hospital of Grand Canary and Faculty of Science, University Los Palmas, 35019 Los Palmas, Grand Canary, Spain.
| | - Antonio Talluri
- Antonio Talluri, Fatbyte, Inc., 50012 Bagno a Ripoli, Florence, Italy.
| | - Lexa Nescolarde
- Department of Electronic Engineering, Universitat Politècnica de Catalunya, 08034 Barcelona, Spain.
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47
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da Silva AT, Hauschild DB, de Almeida Oliveira LD, de Fragas Hinnig P, Franco Moreno YM, Wazlawik E. Association of hyperhydration evaluated by bioelectrical impedance analysis and mortality in patients with different medical conditions: Systematic review and meta-analyses. Clin Nutr ESPEN 2018; 28:12-20. [DOI: 10.1016/j.clnesp.2018.08.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/31/2018] [Indexed: 01/09/2023]
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Bansal N, Zelnick LR, Himmelfarb J, Chertow GM. Bioelectrical Impedance Analysis Measures and Clinical Outcomes in CKD. Am J Kidney Dis 2018; 72:662-672. [PMID: 29885923 DOI: 10.1053/j.ajkd.2018.03.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/27/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Bioelectrical impedance analysis (BIA) provides a noninvasive assessment of body composition. BIA measures of cell integrity (phase angle) and hydration (vector length) have been associated with mortality among patients receiving dialysis. Whether these measures are associated with clinical outcomes in patients with chronic kidney disease (CKD) is unknown. STUDY DESIGN Observational study. SETTINGS & PARTICIPANTS We studied 3,751 participants with CKD in the prospective multicenter Chronic Renal Insufficiency Cohort (CRIC) who had baseline single-frequency BIA performed. PREDICTORS Predictors included phase angle and vector length, which were calculated from measurements of resistance and reactance from BIA. We ranked phase angle and vector length into quartiles and compared the 2 narrower quartiles of phase angle and shorter quartiles of vector length with the 2 upper quartiles. OUTCOMES Mortality, heart failure, atherosclerotic cardiovascular disease, and progression of CKD (30% decline in estimated glomerular filtration rate or end-stage kidney disease). ANALYTIC APPROACH We tested associations of phase angle and vector length with risks for mortality and progression of CKD using Cox proportional hazard models and the association with heart failure and atherosclerotic cardiovascular disease using Fine and Gray models. All models were adjusted for demographics, comorbid conditions, and kidney function. RESULTS Mean phase angle and vector length were 6.6°±1.8° and 470 ± 96 Ω/m, respectively. Relative to phase angle ≥ 6.40o, narrower phase angle (<5.59o) was significantly associated with mortality (HR, 1.31; 95% CI, 1.09-1.58). Relative to vector length ≥ 459 Ω/m, shorter vector length (<401 Ω/m) was significantly associated with heart failure (HR, 1.28; 95% CI, 1.01-1.61). Neither measure was associated with atherosclerotic cardiovascular disease or a composite renal end point. LIMITATIONS Observational study. CONCLUSIONS Adjusted for key confounders, BIA-derived measures of cellular integrity and tissue hydration were significantly associated with death and incident heart failure, respectively.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
| | - Leila R Zelnick
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Jonathan Himmelfarb
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
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49
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Price KL, Earthman CP. Update on body composition tools in clinical settings: computed tomography, ultrasound, and bioimpedance applications for assessment and monitoring. Eur J Clin Nutr 2018; 73:187-193. [DOI: 10.1038/s41430-018-0360-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 12/31/2022]
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50
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Sato M, Inai K, Shimizu M, Sugiyama H, Nakanishi T. Bioelectrical impedance analysis in the management of heart failure in adult patients with congenital heart disease. CONGENIT HEART DIS 2018; 14:167-175. [PMID: 30351489 DOI: 10.1111/chd.12683] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 09/01/2018] [Accepted: 09/12/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The recognition of fluid retention is critical in treating heart failure (HF). Bioelectrical impedance analysis (BIA) is a well-known noninvasive method; however, data on its role in managing patients with congenital heart disease (CHD) are limited. Here, we aimed to clarify the correlation between BIA and HF severity as well as the prognostic value of BIA in adult patients with CHD. DESIGN This prospective single-center study included 170 patients with CHD admitted between 2013 and 2015. We evaluated BIA parameters (intra- and extracellular water, protein, and mineral levels, edema index [EI, extracellular water-to-total body water ratio]), laboratory values, and HF-related admission prevalence. RESULTS Patients with New York Heart Association (NYHA) functional classes III-IV had a higher EI than those with NYHA classes I-II (mean ± SD, 0.398 ± 0.011 vs 0.384 ± 0.017, P < .001). EI was significantly correlated with brain natriuretic peptide level (r = 0.51, P < .001). During the mean follow-up period of 7.1 months, Kaplan-Meier analysis showed that a discharge EI > 0.386, the median value in the present study, was significantly associated with a future increased risk of HF-related admission (HR = 4.15, 95% CI = 1.70-11.58, P < .001). A body weight reduction during hospitalization was also related to EI reduction. CONCLUSIONS EI determined using BIA could be a useful marker for HF severity that could predict future HF-related admissions in adult patients with CHD.
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Affiliation(s)
- Masaki Sato
- Department of Pediatric Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kei Inai
- Department of Pediatric Cardiology, Tokyo Women's Medical University, Tokyo, Japan.,Division of Adult Congenital Heart Disease Pathophysiology and Lifelong Care, Tokyo Women's Medical University, Tokyo, Japan
| | - Mikiko Shimizu
- Department of Pediatric Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshio Nakanishi
- Division of Adult Congenital Heart Disease Pathophysiology and Lifelong Care, Tokyo Women's Medical University, Tokyo, Japan
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