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Titlestad I, Watne LO, Caplan GA, McCann A, Ueland PM, Neerland BE, Myrstad M, Halaas NB, Pollmann CT, Henjum K, Ranhoff AH, Solberg LB, Figved W, Cunningham C, Giil LM. Impaired glucose utilization in the brain of patients with delirium following hip fracture. Brain 2024; 147:215-223. [PMID: 37658825 PMCID: PMC10766236 DOI: 10.1093/brain/awad296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 07/08/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Abstract
Alterations in brain energy metabolism have long been proposed as one of several neurobiological processes contributing to delirium. This is supported by previous findings of altered CSF lactate and neuron-specific enolase concentrations and decreased glucose uptake on brain-PET in patients with delirium. Despite this, there are limited data on metabolic alterations found in CSF samples, and targeted metabolic profiling of CSF metabolites involved in energy metabolism has not been performed. The aim of the study was to investigate whether metabolites related to energy metabolism in the serum and CSF of patients with hip fracture are associated with delirium. The study cohort included 406 patients with a mean age of 81 years (standard deviation 10 years), acutely admitted to hospital for surgical repair of a hip fracture. Delirium was assessed daily until the fifth postoperative day. CSF was collected from all 406 participants at the onset of spinal anaesthesia, and serum samples were drawn concurrently from 213 participants. Glucose and lactate in CSF were measured using amperometry, whereas plasma glucose was measured in the clinical laboratory using enzymatic photometry. Serum and CSF concentrations of the branched-chain amino acids, 3-hydroxyisobutyric acid, acetoacetate and β-hydroxybutyrate were measured using gas chromatography-tandem mass spectrometry (GC-MS/MS). In total, 224 (55%) patients developed delirium pre- or postoperatively. Ketone body concentrations (acetoacetate, β-hydroxybutyrate) and branched-chain amino acids were significantly elevated in the CSF but not in serum among patients with delirium, despite no group differences in glucose concentrations. The level of 3-hydroxyisobutyric acid was significantly elevated in both CSF and serum. An elevation of CSF lactate during delirium was explained by age and comorbidity. Our data suggest that altered glucose utilization and a shift to ketone body metabolism occurs in the brain during delirium.
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Affiliation(s)
- Irit Titlestad
- Department of Clinical Medicine, University of Bergen, 5020 Bergen, Norway
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, 5009 Bergen, Norway
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Leiv Otto Watne
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
- Department of Geriatric Medicine, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, 2031 Sydney, Australia
- Prince of Wales Clinical School, University of New South Wales, 2031 Sydney, Australia
| | | | | | - Bjørn Erik Neerland
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Marius Myrstad
- Department of Internal Medicine, Bærum Hospital Vestre Viken Hospital Trust, 1346 Gjettum, Norway
| | - Nathalie Bodd Halaas
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | | | - Kristi Henjum
- Oslo Delirium Research Group, Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
- Geriatric Unit, Clinic of Medicine, Diakonhjemmet Hospital, 0319 Oslo, Norway
| | - Lene B Solberg
- Division of Orthopaedic Surgery, Oslo University Hospital, 0424 Oslo, Norway
| | - Wender Figved
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
- Orthopaedic Department, Bærum Hospital, Vestre Viken Hospital Trust, 1349 Gjettum, Norway
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute and Trinity College Institute of Neuroscience, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Lasse M Giil
- Neuro-SysMed, Department of Internal Medicine, Haraldsplass Deaconess Hospital, 5009 Bergen, Norway
- Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
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Huang W, Xiang H, Hu C, Wu T, Zhang D, Ma S, Hu B, Li J. Association of Sublingual Microcirculation Parameters and Capillary Refill Time in the Early Phase of ICU Admission. Crit Care Med 2023; 51:913-923. [PMID: 36942969 PMCID: PMC10262986 DOI: 10.1097/ccm.0000000000005851] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVES This observational study was conducted to investigate capillary refill time (CRT) during the early phase of ICU admission in relationship with microvascular flow alteration and outcome in critically ill patients. DESIGN Prospective, observational, pilot study. SETTING ICU in a university hospital. PATIENTS Two hundred eighty-two critically ill adult patients admitted to the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients underwent simultaneous measurements by CRT and sidestream dark field imaging within 24 hours of ICU admission. Other clinical data such as demographic characteristics, hemodynamics, laboratory values, treatment, and physiologic parameters were also included simultaneously. Microcirculatory measurements were performed at 10.2 ± 5.7 hours after ICU admission. Of the 282 included patients, 106 (37.6%) were female, the median (interquartile range) age was 63 years (53-74 yr), and the median Sequential Organ Failure Assessment (SOFA) score was 5 (2-7). The primary finding was the association between CRT and simultaneous the condition of peripheral circulation (microvascular flow index [MFI]: r = -0.4430, p < 0.001; proportion of perfused vessels: r = -0.3708, p < 0.001; heterogeneity index: r = 0.4378, p < 0.001; perfused vessel density: r = -0.1835, p = 0.0020; except total vessel density: p = 0.9641; and De Backer score: p = 0.5202) in critically ill patients. In addition, this relationship was also maintained in subgroups. Microcirculatory flow abnormalities, 28-day mortality, and SOFA score appeared to be more severe for increasing CRT. In a multivariable analysis, prolonged CRT was independently associated with microvascular flow abnormalities (MFI < 2.6; odds ratio [OR], 1.608; 95% CI, 2.1-10.2; p < 0.001). Similarly, multivariable analysis identified CRT as an independent predictor of 28-day mortality (OR, 1.296; 95% CI, 1.078-1.558; p = 0.006). CONCLUSIONS In our ICU population, a single-spot prolonged CRT was independently associated with abnormal microcirculation and increased mortality.
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Affiliation(s)
- Weipeng Huang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Hui Xiang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Tong Wu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Dandan Zhang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Siqing Ma
- Department of Critical Care Medicine, Qinghai Provincial People's Hospital, Xining, Qinghai, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
| | - Jianguo Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan Hubei, China
- Clinical Research Center of Hubei Critical Care Medicine, Wuhan, Hubei, China
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De Backer D. Novelties in the evaluation of microcirculation in septic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:124-130. [PMID: 37188120 PMCID: PMC10175708 DOI: 10.1016/j.jointm.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 05/17/2023]
Abstract
Microvascular alterations were first described in critically ill patients about 20 years ago. These alterations are characterized by a decrease in vascular density and presence of non-perfused capillaries close to well-perfused vessels. In addition, heterogeneity in microvascular perfusion is a key finding in sepsis. In this narrative review, we report our actual understanding of microvascular alterations, their role in the development of organ dysfunction, and the implications for outcome. Herein, we discuss the state of the potential therapeutic interventions and the potential impact of novel therapies. We also discuss how recent technologic development may affect the evaluation of microvascular perfusion.
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Li H, Chen J, Xing X, Lou D. Association of lactate detection with in-hospital mortality in critically ill patients with acute myocardial infarction: a retrospective cohort study. BMJ Open 2023; 13:e069129. [PMID: 37085300 PMCID: PMC10124257 DOI: 10.1136/bmjopen-2022-069129] [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] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES To assess the associations of lactate level or lactate clearance at different time points with in-hospital mortality in critically ill patients with acute myocardial infarction (AMI). DESIGN A cohort study. SETTING The Medical Information Mart for Intensive Care III database. PARTICIPANT 490 AMI patients. INTERVENTION None. PRIMARY AND SECONDARY OUTCOME MEASURES In-hospital mortality of patients. RESULTS In total, 120 (24.49%) patients died at the end of follow-up. After adjusting for confounders, increased risk of in-hospital mortality in patients with AMI was observed in those with high lactate level (24 hours) (HR=1.156, 95%CI: 1.002 to 1.333). Increased lactate clearance (24 hours) was correlated with a decreased risk of in-hospital mortality in patients with AMI (HR=0.995, 95% CI: 0.994 to 0.997). The area under the curves (AUCs) of lactate level (24 hours) and lactate clearance (24 hours) were 0.689 (95% CI: 0.655 to 0.723) and 0.672 (95% CI: 0.637 to 0.706), respectively. The AUC of lactate level (24 hours) and lactate clearance (24 hours) was higher than lactate level (baseline). CONCLUSIONS Increased lactate level (24 hours) was associated with an elevated risk of in-hospital mortality in patients with AMI and increased lactate clearance (24 hours) was correlated with a decreased risk of in-hospital mortality in patients with AMI despite the age and genders.
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Affiliation(s)
- Hongwu Li
- Department of Cardiology, Peking Union Medical College Hospital, Dongcheng-qu, Beijing, China
| | - Jingyi Chen
- Emergency Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xinyue Xing
- Emergency Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Danfei Lou
- Emergency Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Kaefer K, Pierrakos C, Nguyen T, Velissaris D, Attou R, Devriendt J, Scolletta S, Taccone FS. Ratio of carbon dioxide veno-arterial difference to oxygen arterial-venous difference is not associated with lactate decrease after fluid bolus in critically ill patients with hyperlactatemia: results from a prospective observational study. BMC Anesthesiol 2023; 23:37. [PMID: 36721083 PMCID: PMC9887917 DOI: 10.1186/s12871-023-01993-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND High ratio of the carbon dioxide veno-arterial difference to the oxygen arterial-venous difference (PvaCO2/CavO2) is associated with fluid bolus (FB) induced increase in oxygen consumption (VO2). This study investigated whether PvaCO2/CavO2 was associated with decreases in blood-lactate levels FB in critically ill patients with hyperlactatemia. METHODS This prospective observational study examined adult patients in the intensive care unit (ICU) with lactate levels > 1.5 mmol/L who received FBs. Blood-lactate levels were measured before and after FB under unchanged metabolic, respiratory, and hemodynamic conditions. The primary outcome was blood-lactate levels after FB. Significant decreases in blood-lactate levels were considered as blood-lactate levels < 1.5 mmol/L or a decrease of more than 10% compared to baseline. RESULTS The study enrolled 40 critically ill patients, and their median concentration of blood lactate was 2.6 [IQR:1.9 - 3.8] mmol/L. There were 27 (68%) patients with PvaCO2/CavO2 ≥ 1.4 mmHg/ml, and 10 of them had an increase in oxygen consumption (dVO2) ≥ 15% after FB, while 13 (32%) patients had PvaCO2/CavO2 < 1.4 mmHg/ml before FB, and none of them had dVO2 ≥ 15% after FB. FB increased the cardiac index in patients with high and low preinfusion PvaCO2/CavO2 (13.4% [IQR: 8.3 - 20.2] vs. 8.8% [IQR: 2.9 - 17.4], p = 0.34). Baseline PvaCO2/CavO2 was not found to be associated with a decrease in blood lactate after FB (OR: 0.88 [95% CI: 0.39 - 1.98], p = 0.76). A positive correlation was observed between changes in blood lactate and baseline PvaCO2/CavO2 (r = 0.35, p = 0.02). CONCLUSIONS In critically ill patients with hyperlactatemia, PvaCO2/CavO2 before FB cannot be used to predict decreases in blood-lactate levels after FB. Increased PvaCO2/CavO2 is associated with less decrease in blood-lactate levels.
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Affiliation(s)
- Keitiane Kaefer
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Charalampos Pierrakos
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Nguyen
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Dimitrios Velissaris
- grid.412458.eInternal Medicine Department, University Hospital of Patras, Patras, Greece
| | - Rachid Attou
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devriendt
- grid.4989.c0000 0001 2348 0746Intensive Care Department, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sabino Scolletta
- grid.411477.00000 0004 1759 0844Department of Emergency-Urgency and Organ Transplantation, Anesthesia and Intensive Care, University Hospital of Siena, Siena, Italy
| | - Fabio Silvio Taccone
- grid.412157.40000 0000 8571 829XIntensive Care Department, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Li L, Bai M, Zhang Q, Sun S. Characteristics and predictors of ICU-mortality in critically ill patients with hyperlactatemia requiring CRRT: A retrospective cohort study. Int J Artif Organs 2022; 45:973-980. [PMID: 36151706 DOI: 10.1177/03913988221126728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hyperlactatemia is a common complication in critically ill patients with high morbidity and mortality. Hyperlactatemia patients who require continuous renal replacement therapy (CRRT) constitute a subgroup with increased mortality risk. The clinical significance of serum lactate in these patients was not well understood and clearance of lactate using CRRT shown no survival benefits. The aim of this study is to investigate the incidence and non-lactate risk factors for ICU mortality in hyperlactatemia patients who underwent CRRT. METHOD Hyperlactatemia patients with a serum lactate level >2 μmol/L who underwent CRRT between January, 2014 and May, 2021 were retrospectively investigated. Demographic characteristics and clinical data were collected from the electronic medical record system. The primary endpoint was predictors for ICU mortality which were identified by using multivariate logistic regression analysis. RESULTS A total of 178 eligible patients were finally included with a mean age of 56.6 ± 17.9 years and a median APACHE II score of 18 (IQR (14-22)). The multivariate regression results showed that male gender (OR 0.55 (95%CI 0.27-1.12), p = 0.1), mechanical ventilation (OR 2.60 (95%CI 1.27-5.34), p = 0.008), history of hypertension (OR 2.40 (95%CI 1.12-5.14), p = 0.02), SOFA score (OR 1.16 (95%CI 1.05-1.28), p = 0.002), AST (OR 1.0005 (95%CI 0.99-1.001), p = 0.08), and PT (OR 1.08 (95%CI 0.99-1.17), p = 0.06) were independently associated with ICU mortality. After adjusting for age, illness severity (APACHE II score), and serum lactate level, the statistical significances of SOFA score (OR 1.16 (95%CI 1.04-1.29), p = 0.005), hypertension (OR 2.25 (95%CI 1.02-4.95), p = 0.04), and mechanical ventilation (OR 2.54 (95%CI 1.22-5.25), p = 0.01) were not affected. The overall ICU mortality was 58.4% (104/178). CONCLUSION The hyperlactatemia patients who underwent CRRT were at increased ICU mortality. Gender, AST, PT, SOFA score, history of hypertension, and mechanical ventilation were independent predictors for ICU mortality. Future studies with prospectively design, large sample size, and subgroup analyses are warranted to validate these findings.
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Affiliation(s)
- Lu Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China.,Department of Nephrology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiaona Zhang
- Department of Nephrology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi, China
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Gelbart M, Nahum E, Gelbart M, Kaplan E, Kadmon G, Kershenovich A, Toledano H, Weissbach A. Hyperlactatemia in children following brain tumor resection: prevalence, associated factors, and clinical significance. Childs Nerv Syst 2022; 38:739-745. [PMID: 34859290 DOI: 10.1007/s00381-021-05424-0] [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: 08/27/2021] [Accepted: 11/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Hyperlactatemia is associated with worse outcome among critically ill patients. The prevalence of hyperlactatemia in children following craniotomy for intracranial tumor resection is unknown. This study was designed to assess the prevalence, associated factors, and significance of postoperative hyperlactatemia in this context. METHODS A retrospective study was conducted at an intensive care unit of a tertiary, pediatric medical center. Children younger than 18 years admitted following craniotomy for brain tumor resection between October 2004 and November 2019 were included. RESULTS Overall, 222 elective craniotomies performed in 178 patients were analyzed. The mean age ± SD was 8.5 ± 5.5 years. All but two patients survived to discharge. All were hemodynamically stable. Early hyperlactatemia, defined as at least one blood lactate level ≥ 2.0 mmol/L during the first 24 h into admission, presented following 74% of the craniotomies; lactate normalized within a mean ± SD of 11 ± 6.1 h. The fluid balance per body weight at 12 h and 24 h into the intensive care unit admission was similar in children with and without hyperlactatemia [7.0 ± 17.6 vs 3.5 ± 16.4 ml/kg, p = 0.23 and 4.0 ± 27.2 vs 4.6 ± 29.4 ml/kg, p = 0.96; respectively]. Hyperlactatemia was associated with higher maximal blood glucose, older age, and a pathological diagnosis of glioma. Intensive care unit length of stay was similar following craniotomies with and without hyperlactatemia (p = 0.57). CONCLUSIONS Hyperlactatemia was common in children following craniotomy for brain tumor resection. It was not associated with hemodynamic impairment or with a longer length of stay.
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Affiliation(s)
- Miri Gelbart
- Department of Pediatrics A, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Elhanan Nahum
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 4920235, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maoz Gelbart
- The Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Kaplan
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 4920235, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kadmon
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 4920235, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Kershenovich
- Pediatric Neurosurgery Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Helen Toledano
- Pediatric Hematology-Oncology Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Weissbach
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, 4920235, Petach Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Greenwood JC, Jang DH, Spelde AE, Gutsche JT, Horak J, Acker MA, Kilbaugh TJ, Shofer FS, Augoustides JG, Bakker J, Abella BS. Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated With Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass. Shock 2021; 56:245-254. [PMID: 33394972 PMCID: PMC9887933 DOI: 10.1097/shk.0000000000001713] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass include cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L. METHODS We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on intensive care unit admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 h after surgery. Lactate area under the curve (AUC) was calculated over the first 6 h. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD < 18 mm/mm2), high microcirculatory heterogeneity index (MHI > 0.4), and low vessel-by-vessel microvascular flow index (MFIv < 2.6). RESULTS Thirteen (26%) patients had a low postoperative PVD, 20 patients (40%) had a high MHI, and 26 (52%) patients had a low MFIv. Patients with low perfused vessel density had higher lactate AUC compared with subjects with a normal PVD (22.3 [9.4-31.0] vs. 2.6 [0-8.8]; P < 0.0001). Patients with high microcirculatory heterogeneity had a higher lactate AUC compared with those with a normal MHI (2.5 [0.1-8.2] vs. 13.1 [3.7-31.1]; P < 0.001). We did not find a difference in lactate AUC when comparing high and low MFIv. CONCLUSION Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass.
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Affiliation(s)
- John C. Greenwood
- Division of Critical Care Medicine, Department of Emergency Medicine, Department of Anesthesiology and Critical Care, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David H. Jang
- Division of Medical Toxicology and Critical Care Medicine, Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Audrey E. Spelde
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob T. Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiri Horak
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A. Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Frances S. Shofer
- Department of Epidemiology and Biostatistics, Department of Emergency Medicine Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John G.T. Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jan Bakker
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Intensive Medicine, The Pontifical Catholic University of Chile, Santiago, Región Metropolitana, Chile
| | - Benjamin S. Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Time of dissociation between microcirculation, macrocirculation, and lactate levels in a rabbit model of early endotoxemic shock. Chin Med J (Engl) 2021; 133:2153-2160. [PMID: 32826608 PMCID: PMC7508437 DOI: 10.1097/cm9.0000000000000887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The relationship between macrocirculation and microcirculation remains controversial. The loss of coherence between microcirculation and macrocirculation has already been found in late-stage sepsis shock. The objective of this study was to determine the earliest possible time of detecting the loss of coherence between microcirculation and macrocirculation in early-stage endotoxemic shock. Methods We randomized 24 female New Zealand white rabbits into two groups: endotoxemic shock group (n = 14) and control group (n = 10). Rabbits in the endotoxemic shock group were equipped with arterial and venous catheters and received an intravenous infusion of Escherichia coli lipopolysaccharide (LPS, 2 mg/kg over 10 min). Rabbits in the control group received the same dose of saline infusion. Microcirculatory perfusion parameters were assessed in the sublingual mucosa using sidestream dark-field video microscopy. Systemic hemodynamics and blood lactate levels were measured at baseline and over a 120-min period. Results Ninety minutes after completing LPS infusion, all animals in the endotoxemic shock group developed a hypodynamic septic condition, characterized by low cardiac output and increased systemic vascular resistance; 120 min after completing LPS infusion, the mean arterial pressure decreased by 25% (P = 0.01), confirming ongoing endotoxemic shock. However, significant decreases in sublingual microcirculatory parameters of small vessels (microvascular flow index, perfused vessel density, and proportion of small perfused vessels) were observed 30 min after completing LPS infusion (P = 0.01, for all), and threshold decreases of 30% were found 60 min after completing LPS infusion (P = 0.001, for all) in the endotoxemic shock group. Lactate levels significantly increased to more than 2 mm/L at 90 min and more than 4 mm/L at 120 min in the endotoxemic shock group (P = 0.02 and P = 0.01, respectively). Conclusions Changes in microcirculatory perfusion precede changes in macrocirculation and lactate levels in a rabbit model of endotoxemia shock. Microcirculation, macrocirculation, and oxygen metabolism are distinct in early-stage endotoxic shock.
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Microcirculatory Changes in Pediatric Patients During Congenital Heart Defect Corrective Surgery. J Cardiovasc Transl Res 2021; 14:1173-1185. [PMID: 33948868 DOI: 10.1007/s12265-021-10132-w] [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: 02/28/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
A prospective, observational single-center study was carried out. Pediatric patients undergoing congenital heart defect surgery were evaluated before, during, and after surgery. At each time point, sublingual microcirculation and clinical parameters were assessed, along with analytical variables. Twenty-four patients were included. All microcirculatory parameters worsened during cardiopulmonary bypass and returned to baseline values after surgery (p ≤ 0.001). In the intraoperative evaluation, body temperature correlated with perfused small vessel density (p = 0.014), proportion of perfused small vessels (p < 0.001), small vessel microvascular flow index (p = 0.003), and small vessel heterogeneity index (p < 0.002). Patients with cyanotic disease exhibited higher small vessel density (p < 0.008) and higher density of perfused small vessels (p < 0.022) at baseline, and a lower microvascular flow index (p = 0.022) and higher heterogeneity (p = 0.026) in the intraoperative phase. Children with congenital heart disease exhibited decreased vascular density and microvascular blood flow and increased heterogeneity during cardiopulmonary bypass. All these parameters returned to baseline values after surgery.
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11
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Monitoring skin blood flow to rapidly identify alterations in tissue perfusion during fluid removal using continuous veno-venous hemofiltration in patients with circulatory shock. Ann Intensive Care 2021; 11:59. [PMID: 33855645 PMCID: PMC8046875 DOI: 10.1186/s13613-021-00847-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/29/2021] [Indexed: 12/13/2022] Open
Abstract
Background Continuous veno-venous hemofiltration (CVVH) can be used to reduce fluid overload and tissue edema, but excessive fluid removal may impair tissue perfusion. Skin blood flow (SBF) alters rapidly in shock, so its measurement may be useful to help monitor tissue perfusion. Methods In a prospective, observational study in a 35-bed department of intensive care, all patients with shock who required fluid removal with CVVH were considered for inclusion. SBF was measured on the index finger using skin laser Doppler (Periflux 5000, Perimed, Järfälla, Sweden) for 3 min at baseline (before starting fluid removal, T0), and 1, 3 and 6 h after starting fluid removal. The same fluid removal rate was maintained throughout the study period. Patients were grouped according to absence (Group A) or presence (Group B) of altered tissue perfusion, defined as a 10% increase in blood lactate from T0 to T6 with the T6 lactate ≥ 1.5 mmol/l. Receiver operating characteristic curves were constructed and areas under the curve (AUROC) calculated to identify variables predictive of altered tissue perfusion. Data are reported as medians [25th–75th percentiles]. Results We studied 42 patients (31 septic shock, 11 cardiogenic shock); median SOFA score at inclusion was 9 [8–12]. At T0, there were no significant differences in hemodynamic variables, norepinephrine dose, lactate concentration, ScvO2 or ultrafiltration rate between groups A and B. Cardiac index and MAP did not change over time, but SBF decreased in both groups (p < 0.05) throughout the study period. The baseline SBF was lower (58[35–118] vs 119[57–178] perfusion units [PU], p = 0.03) and the decrease in SBF from T0 to T1 (ΔSBF%) higher (53[39–63] vs 21[12–24]%, p = 0.01) in group B than in group A. Baseline SBF and ΔSBF% predicted altered tissue perfusion with AUROCs of 0.83 and 0.96, respectively, with cut-offs for SBF of ≤ 57 PU (sensitivity 78%, specificity 87%) and ∆SBF% of ≥ 45% (sensitivity 92%, specificity 99%). Conclusion Baseline SBF and its early reduction after initiation of fluid removal using CVVH can predict worsened tissue perfusion, reflected by an increase in blood lactate levels. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00847-z.
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12
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Rovas A, Sackarnd J, Rossaint J, Kampmeier S, Pavenstädt H, Vink H, Kümpers P. Identification of novel sublingual parameters to analyze and diagnose microvascular dysfunction in sepsis: the NOSTRADAMUS study. Crit Care 2021; 25:112. [PMID: 33741036 PMCID: PMC7980588 DOI: 10.1186/s13054-021-03520-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/01/2021] [Indexed: 11/28/2022] Open
Abstract
Background The availability of handheld, noninvasive sublingual video-microscopes allows for visualization of the microcirculation in critically ill patients. Recent studies demonstrate that reduced numbers of blood-perfused microvessels and increased penetration of erythrocytes into the endothelial glycocalyx are essential components of microvascular dysfunction. The aim of this study was to identify novel microvascular variables to determine the level of microvascular dysfunction in sepsis and its relationship with clinical variables. Methods This observational, prospective, cross-sectional study included 51 participants, of which 34 critically ill sepsis patients were recruited from intensive care units of a university hospital. Seventeen healthy volunteers served as controls. All participants underwent sublingual videomicroscopy by sidestream darkfield imaging. A new developed version of the Glycocheck™ software was used to quantify vascular density, perfused boundary region (PBR-an inverse variable of endothelial glycocalyx dimensions), red blood cell (RBC) velocity, RBC content, and blood flow in sublingual microvessels with diameters between 4 and 25 µm. Results A detailed analysis of adjacent diameter classes (1 µm each) of vessels between 4 and 25 µm revealed a severe reduction of vascular density in very small capillaries (5–7 µm), which correlated with markers of sepsis severity. Analysis of RBC velocity (VRBC) revealed a strong dependency between capillary and feed vessel VRBC in sepsis patients (R2 = 0.63, p < 0.0001) but not in healthy controls (R2 = 0.04, p = 0.43), indicating impaired capillary (de-)recruitment in sepsis. This finding enabled the calculation of capillary recruitment and dynamic capillary blood volume (CBVdynamic). Moreover, adjustment of PBR to feed vessel VRBC further improved discrimination between sepsis patients and controls by about 50%. By combining these dynamic microvascular and glycocalyx variables, we developed the microvascular health score (MVHSdynamic™), which decreased from 7.4 [4.6–8.7] in controls to 1.8 [1.4–2.7] in sepsis patients (p < 0.0001) and correlated with sepsis severity. Conclusion We introduce new important diameter-specific quantification and differentiated analysis of RBC kinetics, a key to understand microvascular dysfunction in sepsis. MVHSdynamic, which has a broad bandwidth to detect microvascular (dys-) function, might serve as a valuable tool to detect microvascular impairment in critically ill patients. ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03520-w.
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Affiliation(s)
- Alexandros Rovas
- Department of Medicine D, Division of General Internal and Emergency Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jan Sackarnd
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Jan Rossaint
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Stefanie Kampmeier
- Institute of Hygiene, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Hermann Pavenstädt
- Department of Medicine D, Division of General Internal and Emergency Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Hans Vink
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Philipp Kümpers
- Department of Medicine D, Division of General Internal and Emergency Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.
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13
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Bruno RR, Schemmelmann M, Wollborn J, Kelm M, Jung C. Evaluation of a shorter algorithm in an automated analysis of sublingual microcirculation. Clin Hemorheol Microcirc 2020; 76:287-297. [PMID: 32925005 DOI: 10.3233/ch-209201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Diagnostic and risk stratification in intensive and emergency medicine must be fast, accurate, and reliable. The assessment of sublingual microcirculation is a promising tool for this purpose. However, its value is limited because the measurement is time-consuming in unstable patients. This proof-of-concept validation study examines the non-inferiority of a reduced frame rate in image acquisition regarding quality, measurement results, and time. METHODS This prospective observational study included healthy volunteers. Sublingual measurement of microcirculation was performed using a sidestream dark field camera (SDF, MicroVision Medical®). Video-quality was evaluated with a modified MIQS (microcirculation image quality score). AVA 4.3C software calculated microcirculatory parameters. RESULTS Thirty-one volunteers were included. There was no impact of the frame rate on the time needed by the software algorithm to measure one video (4.5 ± 0.5 minutes) for AVA 4.3C. 86 frames per video provided non inferior video quality (MIQS 1.8 ± 0.7 for 86 frames versus MIQS 2.2 ± 0.6 for 215 frames, p < 0.05), equal results for all microcirculatory parameters, but did not result in an advantage in terms of speed. No complications occurred. CONCLUSION Video captures with 86 frames offer equal video quality and results for consensus parameters compared to 215 frames. However, there was no advantage regarding the time needed for the overall measurement procedure.
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Affiliation(s)
- Raphael Romano Bruno
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mara Schemmelmann
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Malte Kelm
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
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Ezaka M, Tsukamoto J, Matsuo K, Kin N, Yamaoka K. Hyperlactatemia of dialysis-dependent patients after cardiac surgery impacts on in-hospital mortality: a two-center retrospective study. JA Clin Rep 2020; 6:47. [PMID: 32529341 PMCID: PMC7290016 DOI: 10.1186/s40981-020-00348-1] [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: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Background Lactate is a well-known marker to estimate prognosis after cardiac surgery and critically ill patients. The liver and kidney have a major role in lactate metabolism; however, there was less characterized about the change of lactate and threshold to predict in-hospital mortality in dialysis-dependent patients undertaking cardiac surgery. We conducted this retrospective observational study to characterize when and how lactate values after cardiac surgery affected in-hospital mortality. Methods This two-center retrospective study included dialysis-dependent patients who underwent cardiac surgery with a cardiopulmonary bypass from January 2014 to December 2018. Lactate values were collected at three points: at ICU admission (T1), the maximum level of lactate within 24 h postoperatively (T2), and 24 h after ICU admission (T3). We determined hyperlactatemia as more than 2 mmol/L following previous studies. Results We enrolled 122 dialysis-dependent patients. The mean age was 73 ± 8 years and hyperlactatemia was observed in 100 patients (81.9%). In-hospital mortality was 11.4%. Univariate analysis and area under curve in ROC suggested that T2 lactate was the most significantly associated with in-hospital mortality (AUC = 0.845). Multivariate logistic analysis showed a significant association between in-hospital mortality when patients showed early peak lactate levels of > 4.5 mmol/L after ICU admission (adjusted OR 8.35; 95% CI: 1.44–57.13). Conclusions In dialysis-dependent patients after cardiac surgery, the early-onset of a maximum arterial lactate concentration of > 4.5 mmol/L was significantly associated with in-hospital mortality.
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Affiliation(s)
- Mariko Ezaka
- Department of Anesthesiology, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan. .,Teikyo University Graduate School of Public Health, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Junko Tsukamoto
- Department of Anesthesiology, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama, 330-8553, Japan
| | - Koichi Matsuo
- Department of Intensive Care Unit, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan
| | - Nobuhide Kin
- Department of Anesthesiology, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, 270-2232, Japan
| | - Kazue Yamaoka
- Teikyo University Graduate School of Public Health, 2-11-1 Kaga Itabashi-ku, Tokyo, 173-8605, Japan
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Abstract
PURPOSE OF REVIEW Adequate tissue perfusion is of utmost importance to avoid organ failure in patients with cardiogenic shock. Within the recent years, the microcirculation, defined as the perfusion of the smallest vessels, has been identified to play a crucial role. Microcirculatory changes may include capillary flow disturbances as well as changes in the density of perfused vessels. Due to the availability of new technologies to assess the microcirculation, interesting new data came up and it is the purpose of this review to summarize recent studies in the field. RECENT FINDINGS Nowadays, an increasing number of studies confirm parameters of the microcirculation, derived by intravital microscopy, to represent strong outcome predictors in cardiogenic shock. In addition, microcirculation as read-out parameter in innovative clinical studies has meanwhile been accepted as serious endpoint. Treatment strategies such as mechanical assist devices, blood pressure regulating agents or fluids use tissue perfusion and microcirculatory network density as targets in addition to clinical perfusion evaluation and decreasing serum lactate levels. SUMMARY The parameter most frequently used to detect tissue malperfusion is serum lactate. Novel, noninvasive methods to quantify microvascular perfusion have the potential to guide treatment in terms of optimizing organ perfusion and oxygenation probably paving the way for an individualized therapy.
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16
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Oh TK, Song IA, Bae HJ, Jeon YT. Serum lactate level upon admission to the neuro-intensive care unit and 90-day mortality: A retrospective study. J Clin Neurosci 2019; 70:173-177. [PMID: 31420277 DOI: 10.1016/j.jocn.2019.08.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/05/2019] [Indexed: 11/26/2022]
Abstract
The serum lactate level is a useful predictor of mortality in critically ill patients. However, little is known about the association between the serum lactate level and mortality in patients admitted to neuro-intensive care units (NCUs). The present study aimed to investigate the association between the initial lactate level and 90-day mortality in NCU patients. This retrospective observational study was conducted by reviewing the medical records of adult (age ≥18 years) patients admitted to the NCU at a single tertiary care academic hospital during 2013-2017. The initial lactate level (mmol L-1) was defined as the serum lactate level measured within 6 h following NCU admission. The final analysis included 2737 patients, of whom 280 (10.2%) died within 90 days of NCU admission. In a receiver operating characteristic (ROC) analysis, the estimated area under the curve (AUC) for the initial lactate level in predicting overall 90-day mortality was 0.55 [95% confidence interval (CI): 0.52-0.59]. The corresponding values for neurologic and non-neurologic disease-related 90-day mortality were 0.76 (95% CI: 0.71-0.82) and 0.49 (95% CI: 0.45-0.53), respectively. In a multivariable Cox regression analysis, a 1-mmol L-1 increase in the initial lactate level was associated with 1.17- and 1.22-fold increases in overall and neurologic disease-related 90-day mortality, respectively, but not with non-neurological disease-related 90-day mortality (P = 0.422). Elevated lactate levels were related with an increase in overall 90-day mortality among NCU patients. This association was specifically attributed to neurologic disease-related 90-day mortality.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea.
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17
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Improving the prognostic value of ∆PCO 2 following cardiac surgery: a prospective pilot study. J Clin Monit Comput 2019; 34:515-523. [PMID: 31292833 PMCID: PMC7223397 DOI: 10.1007/s10877-019-00352-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/01/2019] [Indexed: 11/21/2022]
Abstract
Conflicting results have been published on prognostic significance of central venous to arterial PCO2 difference (∆PCO2) after cardiac surgery. We compared the prognostic value of ∆PCO2 on intensive care unit (ICU) admission to an original algorithm combining ∆PCO2, ERO2 and lactate to identify different risk profiles. Additionally, we described the evolution of ∆PCO2 and its correlations with ERO2 and lactate during the first postoperative day (POD1). In this monocentre, prospective, and pilot study, 25 patients undergoing conventional cardiac surgery were included. Central venous and arterial blood gases were collected on ICU admission and at 6, 12 and 24 h postoperatively. High ∆PCO2 (≥ 6 mmHg) on ICU admission was found to be very frequent (64% of patients). Correlations between ∆PCO2 and ERO2 or lactate for POD1 values and variations were weak or non-existent. On ICU admission, a high ∆PCO2 did not predict a prolonged ICU length of stay (LOS). Conversely, a significant increase in both ICU and hospital LOS was observed in high-risk patients identified by the algorithm: 3.5 (3.0–6.3) days versus 7.0 (6.0–8.0) days (p = 0.01) and 12.0 (8.0–15.0) versus 8.0 (8.0–9.0) days (p < 0.01), respectively. An algorithm incorporating ICU admission values of ∆PCO2, ERO2 and lactate defined a high-risk profile that predicted prolonged ICU and hospital stays better than ∆PCO2 alone.
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18
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Cardoso FS, Abraldes JG, Sy E, Ronco JJ, Bagulho L, Mcphail MJ, Karvellas CJ. Lactate and number of organ failures predict intensive care unit mortality in patients with acute-on-chronic liver failure. Liver Int 2019; 39:1271-1280. [PMID: 30825255 DOI: 10.1111/liv.14083] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/20/2019] [Accepted: 02/21/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Patients with acute-on-chronic liver failure (ACLF) have high mortality rates. Most prognostic scores were not developed for the intensive care unit (ICU) setting. We aimed to improve risk stratification for patients with ACLF in the ICU. METHODS A training set with 240 patients with cirrhosis and organ failures (Chronic Liver Failure Sequential Organ Failure Assessment score [CLIF-SOFA]) from Curry Cabral Hospital (Portugal) and University of Alberta Hospital (Canada) in 2010-2016 was used to derive a prognostic model for ICU mortality. A validation set with 237 patients with cirrhosis and organ failures from Vancouver General Hospital (Canada) in 2000-2011 was used to evaluate its performance. RESULTS Amongst patients in the training set, ICU and hospital mortality rates were 39.2% and 54.6% respectively. Median lactate (4.4 vs 2.5 mmol/L) and number of organ failures (3 vs 2) on admission to ICU were associated with higher likelihood of ICU mortality (P < 0.001 for both). The lactate and organ failures predictive model (LacOF) was derived to predict ICU mortality: -2.420 + 0.072 × lactate + 0.569 × number of organ failures (area under-the-curve [AUC], 0.76). In the validation set, the LacOF model discriminative ability (AUC, 0.85) outperformed the CLIF-SOFA (AUC, 0.79), Chronic Liver Failure Consortium Acute-on-Chronic Liver Failure (AUC, 0.73), Model for End-stage Liver Disease score (AUC, 0.78) and Acute Physiology and Chronic Health Evaluation II scores (AUC, 0.74; P < 0.05 for all). The LacOF model calibration was good up to the 25% likelihood of ICU mortality. CONCLUSIONS In patients with ACLF, lactate and number of organ failures on admission to ICU are useful to predict ICU mortality. This early prognostic evaluation may help to better stratify the risk of ICU mortality and thus optimize organ support strategies.
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Affiliation(s)
- Filipe S Cardoso
- Gastroenterology and Intensive Care Divisions, Central Lisbon Hospital Center, Curry Cabral Hospital, Lisbon, Portugal
| | - Juan G Abraldes
- Gastroenterology Division (Liver Unit), University of Alberta Hospital, Edmonton, AB, Canada
| | - Eric Sy
- Critical Care Division, Vancouver General Hospital, Vancouver, BC, Canada
| | - Juan J Ronco
- Critical Care Division, Vancouver General Hospital, Vancouver, BC, Canada
| | - Luís Bagulho
- Intensive Care Division, Central Lisbon Hospital Center, Curry Cabral Hospital, Lisbon, Portugal
| | - Mark J Mcphail
- Liver Intensive Therapy Unit, King's College Hospital, London, UK
| | - Constantine J Karvellas
- Gastroenterology Division (Liver Unit), University of Alberta Hospital, Edmonton, AB, Canada.,Critical Care Department, University of Alberta Hospital, Edmonton, AB, Canada
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Dumas G, Lavillegrand JR, Joffre J, Bigé N, de-Moura EB, Baudel JL, Chevret S, Guidet B, Maury E, Amorim F, Ait-Oufella H. Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters. Crit Care 2019; 23:211. [PMID: 31182133 PMCID: PMC6558704 DOI: 10.1186/s13054-019-2496-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/28/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mottling score, a tissue perfusion parameter, is correlated with outcome in septic shock patients. However, its predictive value on mortality according to prognostic covariates such as vasopressor dose and other tissue perfusion parameters remains unknown. METHODS Mottling score and tissue perfusion parameters were recorded at ICU admission (H0), H-6, H 12, and H-24 and used to assess the predictive value of mottling score on 14-day mortality in a development cohort. Results were then validated in an independent cohort of septic shock patients in Brazil. RESULTS Overall, 259 patients with sepsis or septic shock were included, 14-day mortality was 37%. Factors associated with death were mottling score (OR 2.26 [95% CI, 1.72-2.97]), arterial lactate level (OR 1.29 [1.11-1.5]), and urine output < 0.5 ml/Kg/h (OR 3.03 [1.37-6.69]). The C statistic for the model was 0.90 in the development cohort and 0.76 in the validation cohort. The predictive value of mottling score was not affected by vasopressor doses (p for interaction = 0.33): OR for mottling score ranged from 2.34 [1.10-3.15] in patients without vasopressor to 3.84 [1.98-7.43] in patients infused with high doses of vasopressor (> 0.8 μg/kg/min). There was no difference in the effect of mottling score on mortality according to mean arterial pressure, heart rate, cardiac index, and urine output, but we found a significant interaction between arterial lactate level and mottling score (p = 0.04). The predictive value of the mottling score remains significant when using the recent SEPSIS-3 definition of septic shock. Finally, a decrease of mottling score during resuscitation was significantly associated with better outcome after adjustment on SOFA score (p = 0.001). CONCLUSIONS Our results support the high prognostic value of mottling score for 14-day mortality in septic patients, whatever vasopressor dosage and other perfusion parameters. Mottling score variations during resuscitation are also predictive of mortality.
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Affiliation(s)
- Guillaume Dumas
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Jean-Rémi Lavillegrand
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
| | - Jérémie Joffre
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | - Naïke Bigé
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | | | - Jean-Luc Baudel
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
| | - Sylvie Chevret
- ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France
| | - Bertrand Guidet
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Inserm U1136, F-75012 Paris, France
| | - Eric Maury
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Inserm U1136, F-75012 Paris, France
| | - Fabio Amorim
- Adult Intensive Care Unit, Hospital Santa Luzia, School of Medicine, Brasília, Brazil
| | - Hafid Ait-Oufella
- Assistance Publique – Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de réanimation médicale, 184 rue du Faubourg Saint-Antoine, 75571 Paris, cedex 12 France
- Sorbonne Université, Paris, France
- Université de Paris, Inserm U970, Centre de Recherche Cardiovasculaire de Paris (PARCC), Paris, France
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20
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Masyuk M, Abel P, Hug M, Wernly B, Haneya A, Sack S, Sideris K, Langwieser N, Graf T, Fuernau G, Franz M, Westenfeld R, Kelm M, Felix SB, Jung C. Real-world clinical experience with the percutaneous extracorporeal life support system: Results from the German Lifebridge ® Registry. Clin Res Cardiol 2019; 109:46-53. [PMID: 31028475 DOI: 10.1007/s00392-019-01482-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 04/15/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The concept of percutaneous extracorporeal life support (ECLS) is based on immediate cardiovascular stabilization allowing for sufficient end-organ perfusion, thus improving the outcome in patients with circulatory arrest. Lifebridge® (Zoll Medical GmbH, Germany) is a portable ECLS device designed for rapid application due to its automated set-up. METHODS A total of 60 tertiary cardiovascular centers were interrogated with regard to application and short-term results after use of Lifebridge ECLS system. Detailed data were collected by standardized case report forms in all centers consented to participate in the study. Demographic and clinical baseline characteristics of the patient population, procedural and follow-up data were recorded and analyzed. RESULTS In total, 444 patients were analyzed regarding mortality. The detailed study cohort consisted of 112 patients. A total of 80% of the study subjects represented patients post cardiopulmonary resuscitation, 43% were in cardiogenic shock and 50% suffered from acute myocardial infarction. The survival rates were 36% immediately after device implementation and 16% after 30 days. Multivariable analysis revealed that only serum lactate concentration at admission could be proven as independent predictor of patients' outcome. Patients with lactate concentrations above 10 mmol/L exhibited > 95% mortality (p < 0.05 versus below 10 mmol/L). CONCLUSION The present study provides real-world clinical data of patients treated with a transportable automated ECLS system. In conclusion, Lifebridge is a safely applicable cardiorespiratory stabilization tool associated with acceptable complication rates. Nevertheless, mortality rates were high in these critically ill patients, especially in those showing high lactate concentrations at admission.
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Affiliation(s)
- Maryna Masyuk
- Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Peter Abel
- Division of Cardiology, Pneumology and Critical Care Medicine, Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Martin Hug
- Department of Cardiology, Pulmonology and Internal Intensive Care Medicine, Städtisches Klinikum München GmbH, Klinikum Neuperlach, Munich, Germany
| | - Bernhard Wernly
- Department of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Assad Haneya
- Department of Cardiovascular Surgery, University of Schleswig, Holstein Campus Kiel, Kiel, Germany
| | - Stefan Sack
- Department of Cardiology, Pneumology, and Internal Intensive Care Medicine, Schwabing Hospital, Academic Municipal Hospital Munich, Munich, Germany
| | - Konstantinos Sideris
- Department of Cardiovascular Surgery, German Heart Center, Technische Universität München (TUM), Munich, Germany
| | - Nicolas Langwieser
- Medical Clinic I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tobias Graf
- Department of Cardiology, Angiology, Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Georg Fuernau
- Department of Cardiology, Angiology, Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Marcus Franz
- Department of Cardiology, Clinic of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany.,CARID: Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Stephan B Felix
- Division of Cardiology, Pneumology and Critical Care Medicine, Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Department of Medicine, University Hospital Düsseldorf, Düsseldorf, Germany.
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Wernly B, Lichtenauer M, Vellinga NAR, Boerma EC, Ince C, Kelm M, Jung C. Blood urea nitrogen (BUN) independently predicts mortality in critically ill patients admitted to ICU: A multicenter study. Clin Hemorheol Microcirc 2018; 69:123-131. [PMID: 29758935 DOI: 10.3233/ch-189111] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE The Microcirculatory Shock Occurrence in Acutely Ill Patients (micro-SOAP) study investigated associations of microcirculation and mortality. Risk stratification in critically ill patients is of utmost interest. Established score such as APACHE2 (Acute Physiology And Chronic Health Evaluation 2) are relatively complex and might therefore be of limited use. Blood urea nitrogen (BUN) was described to be associated with mortality in various diseases. We therefore aimed (i) to evaluate BUN for prediction of mortality in a cohort of critically ill patients and (ii) to investigate associations of BUN with microcirculation. METHODS 412 patients were included in our post-hoc analysis of the prospective multicenter microSOAP study. Assesment of the sublingual microcirculation (Sidestream Dark Field (SDF) imaging) and collection of laboratory values were performed on the same day in this point prevalence study. Evaluation of associations with mortality was done by logistic regression analysis. An optimal BUN cut-off was calculated by means of the Youden Index. RESULTS Median BUN was 9.0 mmol/L. BUN was associated with in-hospital-mortality in a logistic regression analysis (HR 1.03; 95% CI 1.01-1.05; p < 0.001). Per quartile (BUN 0-5.4 mmol/L, 5.4-9.0 mmol/L, 9.0-15.9 mmol/L and above 15.9 mmol/L) in-hospital mortality increased by as much as 51% (HR 1.51; 95% CI 1.23-1.85; p < 0.001). ROC analysis was done (AUC 0.63 95% CI 0.58-0.67) and the statistically optimal cut-off calculated by means of the Youden Index: 9.7 mmol/L. This cut-off was associated with a significant 3-fold increase in mortality (HR 2.97 95% CI 1.88-4.70; p < 0.001) and remained robustly associated with adverse outcome after correction for APACHE2 (HR 2.71 95% CI 1.61-4.59; p < 0.001), renal function as expressed by creatinine (HR 2.63 95% CI 1.59-4.33; p = 0.001), as well in an integrative model (MAP<60 mmHg, tachycardia (heart rate >90/min), lactate above 1.5 mmol/L, age above 80 years; HR 2.43 95% CI 1.50-3.92; p < 0.001). Parameters of microvascular perfusion were associated neither with BUN nor mortality. CONCLUSIONS BUN is associated with hospital mortality and a combination of BUN and clinical signs might constitute a powerful but easy-to-use tool for risk stratification in critically ill patients and help improve their outcome. BUN was not associated with parameters of microcirculation which were not associated with mortality.
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Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Namkje A R Vellinga
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Can Ince
- Department of Physiology, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany
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Wernly B, Lichtenauer M, Vellinga N, Boerma C, Ince C, Kelm M, Jung C. Model for End-Stage Liver Disease Excluding INR (MELD-XI) score is associated with hemodynamic impairment and predicts mortality in critically ill patients. Eur J Intern Med 2018; 51:80-84. [PMID: 29572092 DOI: 10.1016/j.ejim.2018.01.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE We aimed (i) to evaluate Model for End-stage Liver Disease excluding INR (MELD-XI) score for prediction of mortality in a cohort of critically ill patients and (ii) to investigate associations of MELD-XI with microcirculation and (iii) to evaluate microcirculation for prediction of mortality in high-risk patients, e.g., with high MELD-XI scores. METHODS 308 patients were included in our retrospective analysis, a subgroup of the multicenter micro-SOAP-study. Microcirculation was evaluated by Sidestream Dark Field (SDF) imaging. Evaluation of associations with mortality was done by logistic regression analysis, an optimal cut-off was calculated by means of the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points). RESULTS Patients with a MELD-XI > 12 points were of similar age (60 ± 1 years vs 62 ± 2 years; p = 0.32), but clinically sicker as mirrored by higher APACHE II scores (20 ± 1 vs 16 ± 1; p < 0.001). In the MELD-XI > 12 cohort in-hospital mortality was significantly higher compared to the MELD ≤ 12 group (48% vs 24%%; HR 2.98 95%CI 1.76-5.04; p = 0.003) and MELD-XI score was associated with mortality even after correction for relevant clinical confounders (HR 1.04 95%CI 1.01-1.07; p = 0.004) There were no associations between MELD-XI and parameters of microvascular perfusion. CONCLUSIONS MELD-XI is associated with in-hospital mortality and constitutes a useful tool for risk stratification in intensive care medicine. Interestingly, there were no associations between MELD-XI and microcirculation. Possibly parameters of the microcirculation present an online tool of hemodynamic assessment while MELD-XI presents an assessment of already established organ failure.
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Affiliation(s)
- Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria.
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria.
| | - Namkje Vellinga
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Christiaan Boerma
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Can Ince
- Department of Physiology, Academic Medical Center, University of Amsterdam, The Netherlands.
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany.
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Germany.
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