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Sinnige JS, Filippini DFL, Hagens LA, Heijnen NFL, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ, Smit MR. Associations of early changes in lung ultrasound aeration scores and mortality in invasively ventilated patients: a post hoc analysis. Respir Res 2024; 25:268. [PMID: 38978068 PMCID: PMC11232207 DOI: 10.1186/s12931-024-02893-0] [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: 04/19/2024] [Accepted: 06/26/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Lung ultrasound (LUS) in an emerging technique used in the intensive care unit (ICU). The derivative LUS aeration score has been shown to have associations with mortality in invasively ventilated patients. This study assessed the predictive value of baseline and early changes in LUS aeration scores in critically ill invasively ventilated patients with and without ARDS (Acute Respiratory Distress Syndrome) on 30- and 90-day mortality. METHODS This is a post hoc analysis of a multicenter prospective observational cohort study, which included patients admitted to the ICU with an expected duration of ventilation for at least 24 h. We restricted participation to patients who underwent a 12-region LUS exam at baseline and had the primary endpoint (30-day mortality) available. Logistic regression was used to analyze the primary and secondary endpoints. The analysis was performed for the complete patient cohort and for predefined subgroups (ARDS and no ARDS). RESULTS A total of 442 patients were included, of whom 245 had a second LUS exam. The baseline LUS aeration score was not associated with mortality (1.02 (95% CI: 0.99 - 1.06), p = 0.143). This finding was not different in patients with and in patients without ARDS. Early deterioration of the LUS score was associated with mortality (2.09 (95% CI: 1.01 - 4.3), p = 0.046) in patients without ARDS, but not in patients with ARDS or in the complete patient cohort. CONCLUSION In this cohort of critically ill invasively ventilated patients, the baseline LUS aeration score was not associated with 30- and 90-day mortality. An early change in the LUS aeration score was associated with mortality, but only in patients without ARDS. TRIAL REGISTRATION ClinicalTrials.gov, ID NCT04482621.
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Affiliation(s)
- Jante S Sinnige
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands.
| | - Daan F L Filippini
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands
| | - Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht University, Maastricht, 6229 HX, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, 6229 ER, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht University, Maastricht, 6229 HX, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
- Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Medical University of Vienna, Vienna, Austria
- Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht University, Maastricht, 6229 HX, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, 6229 ER, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands
- Department of Pulmonology, Amsterdam UMC, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
- Laboratory of Experimental Intensive Care and Anaesthesiology (L.E.I.C.A.), University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, the Netherlands
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Gavelli F, Shi R, Teboul JL, Azzolina D, Mercado P, Jozwiak M, Chew MS, Huber W, Kirov MY, Kuzkov VV, Lahmer T, Malbrain MLNG, Mallat J, Sakka SG, Tagami T, Pham T, Monnet X. Extravascular lung water levels are associated with mortality: a systematic review and meta-analysis. Crit Care 2022; 26:202. [PMID: 35794612 PMCID: PMC9258010 DOI: 10.1186/s13054-022-04061-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background The prognostic value of extravascular lung water (EVLW) measured by transpulmonary thermodilution (TPTD) in critically ill patients is debated. We performed a systematic review and meta-analysis of studies assessing the effects of TPTD-estimated EVLW on mortality in critically ill patients.
Methods Cohort studies published in English from Embase, MEDLINE, and the Cochrane Database of Systematic Reviews from 1960 to 1 June 2021 were systematically searched. From eligible studies, the values of the odds ratio (OR) of EVLW as a risk factor for mortality, and the value of EVLW in survivors and non-survivors were extracted. Pooled OR were calculated from available studies. Mean differences and standard deviation of the EVLW between survivors and non-survivors were calculated. A random effects model was computed on the weighted mean differences across the two groups to estimate the pooled size effect. Subgroup analyses were performed to explore the possible sources of heterogeneity. Results Of the 18 studies included (1296 patients), OR could be extracted from 11 studies including 905 patients (464 survivors vs. 441 non-survivors), and 17 studies reported EVLW values of survivors and non-survivors, including 1246 patients (680 survivors vs. 566 non-survivors). The pooled OR of EVLW for mortality from eleven studies was 1.69 (95% confidence interval (CI) [1.22; 2.34], p < 0.0015). EVLW was significantly lower in survivors than non-survivors, with a mean difference of −4.97 mL/kg (95% CI [−6.54; −3.41], p < 0.001). The results regarding OR and mean differences were consistent in subgroup analyses. Conclusions The value of EVLW measured by TPTD is associated with mortality in critically ill patients and is significantly higher in non-survivors than in survivors. This finding may also be interpreted as an indirect confirmation of the reliability of TPTD for estimating EVLW at the bedside. Nevertheless, our results should be considered cautiously due to the high risk of bias of many studies included in the meta-analysis and the low rating of certainty of evidence. Trial registration the study protocol was prospectively registered on PROSPERO: CRD42019126985. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04061-6.
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Atmowihardjo L, Schippers JR, Bartelink IH, Bet PM, van Rein N, Purdy K, Cavalla D, Comberiati V, McElroy A, Snape SD, Bogaard HJ, Heunks L, Juffermans N, Schultz M, Tuinman PR, Bos LDJ, Aman J. The INVENT COVID trial: a structured protocol for a randomized controlled trial investigating the efficacy and safety of intravenous imatinib mesylate (Impentri®) in subjects with acute respiratory distress syndrome induced by COVID-19. Trials 2022; 23:158. [PMID: 35172891 PMCID: PMC8848942 DOI: 10.1186/s13063-022-06055-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 01/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has led to a disruptive increase in the number of intensive care unit (ICU) admissions with acute respiratory distress syndrome (ARDS). ARDS is a severe, life-threatening medical condition characterized by widespread inflammation and vascular leak in the lungs. Although there is no proven therapy to reduce pulmonary vascular leak in ARDS, recent studies demonstrated that the tyrosine kinase inhibitor imatinib reinforces the endothelial barrier and prevents vascular leak in inflammatory conditions, while leaving the immune response intact. METHODS This is a randomized, double-blind, parallel-group, placebo-controlled, multicenter clinical trial of intravenous (IV) imatinib mesylate in 90 mechanically ventilated subjects with COVID-19-induced ARDS. Subjects are 18 years or older, admitted to the ICU for mechanical ventilation, meeting the Berlin criteria for moderate-severe ARDS with a positive polymerase chain reaction test for SARS-CoV2. Participants will be randomized in a 1:1 ratio to either imatinib (as mesylate) 200 mg bis in die (b.i.d.) or placebo IV infusion for 7 days, or until ICU discharge or death. The primary study outcome is the change in Extravascular Lung Water Index (EVLWi) between day 1 and day 4. Secondary outcome parameters include changes in oxygenation and ventilation parameters, duration of invasive mechanical ventilation, number of ventilator-free days during the 28-day study period, length of ICU stay, and mortality during 28 days after randomization. Additional secondary parameters include safety, tolerability, and pharmacokinetics. DISCUSSION The current study aims to investigate the efficacy and safety of IV imatinib in mechanically ventilated subjects with COVID-19-related ARDS. We hypothesize that imatinib decreases pulmonary edema, as measured by extravascular lung water using a PiCCO catheter. The reduction in pulmonary edema may reverse hypoxemic respiratory failure and hasten recovery. As pulmonary edema is an important contributor to ARDS, we further hypothesize that imatinib reduces disease severity, reflected by a reduction in 28-day mortality, duration of mechanical ventilation, and ICU length of stay. TRIAL STATUS Protocol version and date: V3.1, 16 April 2021. Recruitment started on 09 March 2021. Estimated recruitment period of approximately 40 weeks. TRIAL REGISTRATION ClinicalTrials.gov NCT04794088 . Registered on 11 March 2021.
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Affiliation(s)
- Leila Atmowihardjo
- Dept. of Intensive Care, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Job R. Schippers
- Dept. of Pulmonology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Imke H. Bartelink
- Hospital Pharmacy, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Pierre M. Bet
- Hospital Pharmacy, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Nienke van Rein
- Hospital Pharmacy, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | | | | | | | | | | | - Harm Jan Bogaard
- Dept. of Pulmonology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Leo Heunks
- Dept. of Intensive Care, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Nicole Juffermans
- Dept. of Intensive Care, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Marcus Schultz
- Dept. of Intensive Care, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Pieter R. Tuinman
- Dept. of Intensive Care, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- Dept. of Pulmonology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Jurjan Aman
- Dept. of Pulmonology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
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Zhang R, Chen H, Gao Z, Liang M, Qiu H, Yang Y, Liu L. The Effect of Loop Diuretics on 28-Day Mortality in Patients With Acute Respiratory Distress Syndrome. Front Med (Lausanne) 2021; 8:740675. [PMID: 34621767 PMCID: PMC8490632 DOI: 10.3389/fmed.2021.740675] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/19/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Diuretics have been widely used in critically ill patients while it remains uncertain whether they can reduce mortality in patients with acute respiratory distress syndrome (ARDS). This study aimed to investigate the associations between diuretics and 28-day mortality in patients with ARDS. Methods: This is a secondary analysis of the ARDS Network Fluid and Catheter Treatment Trial (FACTT) of National Heart, Lung, and Blood Institute. Those patients who did not receive renal replacement therapy within the first 48 h after enrollment in the FACTT were included in the analysis. A marginal structural Cox model (MSCM) was used to investigate the associations between diuretics and 28-day mortality after correction of both the baseline and time-varying variables. The latent class analysis (LCA) and subgroup analysis were performed to identify the kind of patients that could be benefited from diuretics. Results: A total of 932 patients were enrolled, i.e., 558 patients in the diuretics group and 374 patients in the no diuretics group within the first 48 h. The 28-day mortality was lower in the diuretics group (15.1 vs. 28.1%, p < 0.001). In MSCM, diuretics use was related to the improved 28-day mortality (HR 0.78; 95% CI 0.62–0.99; p = 0.04). LCA identified three subtypes, and diuretics were associated with reduced mortality in subtype 3, which was characterized by worse renal function and higher central venous pressure (CVP). A subgroup analysis indicated survival advantage among the female patients, sepsis induced ARDS, and those with the ratio of partial pressure of oxygen to the fractional concentration of inspired oxygen (PaO2/FiO2) ≤ 150 mmHg, and mean arterial pressure (MAP) ≥ 65 mmHg. Conclusion: Loop diuretics were associated with the reduced 28-day mortality in the patients with ARDS, after controlling for time-varying confounders. Randomized trials are required to verify the association.
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Affiliation(s)
- Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhiwei Gao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China.,Department of Critical Care Medicine, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, China
| | - Meihao Liang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, China
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Shi R, Lai C, Teboul JL, Dres M, Moretto F, De Vita N, Pham T, Bonny V, Mayaux J, Vaschetto R, Beurton A, Monnet X. COVID-19 ARDS is characterized by higher extravascular lung water than non-COVID-19 ARDS: the PiCCOVID study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:186. [PMID: 34074313 PMCID: PMC8169440 DOI: 10.1186/s13054-021-03594-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/06/2021] [Indexed: 01/08/2023]
Abstract
Background In acute respiratory distress syndrome (ARDS), extravascular lung water index (EVLWi) and pulmonary vascular permeability index (PVPI) measured by transpulmonary thermodilution reflect the degree of lung injury. Whether EVLWi and PVPI are different between non-COVID-19 ARDS and the ARDS due to COVID-19 has never been reported. We aimed at comparing EVLWi, PVPI, respiratory mechanics and hemodynamics in patients with COVID-19 ARDS vs. ARDS of other origin. Methods Between March and October 2020, in an observational study conducted in intensive care units from three university hospitals, 60 patients with COVID-19-related ARDS monitored by transpulmonary thermodilution were compared to the 60 consecutive non-COVID-19 ARDS admitted immediately before the COVID-19 outbreak between December 2018 and February 2020. Results Driving pressure was similar between patients with COVID-19 and non-COVID-19 ARDS, at baseline as well as during the study period. Compared to patients without COVID-19, those with COVID-19 exhibited higher EVLWi, both at the baseline (17 (14–21) vs. 15 (11–19) mL/kg, respectively, p = 0.03) and at the time of its maximal value (24 (18–27) vs. 21 (15–24) mL/kg, respectively, p = 0.01). Similar results were observed for PVPI. In COVID-19 patients, the worst ratio between arterial oxygen partial pressure over oxygen inspired fraction was lower (81 (70–109) vs. 100 (80–124) mmHg, respectively, p = 0.02) and prone positioning and extracorporeal membrane oxygenation (ECMO) were more frequently used than in patients without COVID-19. COVID-19 patients had lower maximal lactate level and maximal norepinephrine dose than patients without COVID-19. Day-60 mortality was similar between groups (57% vs. 65%, respectively, p = 0.45). The maximal value of EVLWi and PVPI remained independently associated with outcome in the whole cohort. Conclusion Compared to ARDS patients without COVID-19, patients with COVID-19 had similar lung mechanics, but higher EVLWi and PVPI values from the beginning of the disease. This was associated with worse oxygenation and with more requirement of prone positioning and ECMO. This is compatible with the specific lung inflammation and severe diffuse alveolar damage related to COVID-19. By contrast, patients with COVID-19 had fewer hemodynamic derangement. Eventually, mortality was similar between groups. Trial registration number and date of registration ClinicalTrials.gov (NCT04337983). Registered 30 March 2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04337983. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03594-6.
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Affiliation(s)
- Rui Shi
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Christopher Lai
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Teboul
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Martin Dres
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive Réanimation (Département R3S), Paris, France.,INSERM, UMRS_1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Francesca Moretto
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Nello De Vita
- Università del Piemonte Orientale, Anestesia e Terapia Intensiva, Azienda Ospedaliero Universitaria 'Maggiore Della Carità", Novara, Italy
| | - Tài Pham
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,UVSQ, Univ. Paris-Sud, Inserm, Equipe d'Epidémiologie respiratoire intégrative, CESP, Université Paris-Saclay, 94807, Villejuif, France
| | - Vincent Bonny
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive Réanimation (Département R3S), Paris, France.,INSERM, UMRS_1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Julien Mayaux
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive Réanimation (Département R3S), Paris, France.,INSERM, UMRS_1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Rosanna Vaschetto
- Università del Piemonte Orientale, Anestesia e Terapia Intensiva, Azienda Ospedaliero Universitaria 'Maggiore Della Carità", Novara, Italy
| | - Alexandra Beurton
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Médecine intensive Réanimation (Département R3S), Paris, France.,INSERM, UMRS_1158 Neurophysiologie respiratoire expérimentale et clinique, Sorbonne Université, Paris, France
| | - Xavier Monnet
- AP-HP, Service de médecine intensive-réanimation, Hôpital de Bicêtre, DMU CORREVE, Inserm UMR S_999, FHU SEPSIS, Groupe de recherche clinique CARMAS, Université Paris-Saclay, 78 rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
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Increased extravascular lung water index (EVLWI) reflects rapid non-cardiogenic oedema and mortality in COVID-19 associated ARDS. Sci Rep 2021; 11:11524. [PMID: 34075155 PMCID: PMC8169693 DOI: 10.1038/s41598-021-91043-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/19/2021] [Indexed: 12/23/2022] Open
Abstract
Nearly 5% of patients suffering from COVID-19 develop acute respiratory distress syndrome (ARDS). Extravascular lung water index (EVLWI) is a marker of pulmonary oedema which is associated with mortality in ARDS. In this study, we evaluate whether EVLWI is higher in patients with COVID-19 associated ARDS as compared to COVID-19 negative, ventilated patients with ARDS and whether EVLWI has the potential to monitor disease progression. EVLWI and cardiac function were monitored by transpulmonary thermodilution in 25 patients with COVID-19 ARDS subsequent to intubation and compared to a control group of 49 non-COVID-19 ARDS patients. At intubation, EVLWI was noticeably elevated and significantly higher in COVID-19 patients than in the control group (17 (11–38) vs. 11 (6–26) mL/kg; p < 0.001). High pulmonary vascular permeability index values (2.9 (1.0–5.2) versus 1.9 (1.0–5.2); p = 0.003) suggested a non-cardiogenic pulmonary oedema. By contrast, the cardiac parameters SVI, GEF and GEDVI were comparable in both cohorts. High EVLWI values were associated with viral persistence, prolonged intensive care treatment and in-hospital mortality (23.2 ± 6.7% vs. 30.3 ± 6.0%, p = 0.025). Also, EVLWI showed a significant between-subjects (r = − 0.60; p = 0.001) and within-subjects correlation (r = − 0.27; p = 0.028) to Horowitz index. Compared to non COVID-19 ARDS, COVID-19 results in markedly elevated EVLWI-values in patients with ARDS. High EVLWI reflects a non-cardiogenic pulmonary oedema in COVID-19 ARDS and could serve as parameter to monitor ARDS progression on ICU.
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Virot E, Mathien C, Pointurier V, Poidevin A, Labro G, Pinto L, Jandeaux LM, Mootien J, Kuteifan K. Characterization of pulmonary impairment associated with COVID-19 in patients requiring mechanical ventilation. Rev Bras Ter Intensiva 2021; 33:75-81. [PMID: 33886855 PMCID: PMC8075326 DOI: 10.5935/0103-507x.20210007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/08/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To detect early respiratory and hemodynamic instability to characterize pulmonary impairment in patients with severe COVID-19. Methods We retrospectively analyzed data collected from COVID-19 patients suffering from acute respiratory failure requiring intubation and mechanical ventilation. We used transpulmonary thermodilution assessment with a PiCCO™ device. We collected demographic, respiratory, hemodynamic and echocardiographic data within the first 48 hours after admission. Descriptive statistics were used to summarize the data. Results Fifty-three patients with severe COVID-19 were admitted between March 22nd and April 7th. Twelve of them (22.6%) were monitored with a PiCCO™ device. Upon admission, the global-end diastolic volume indexed was normal (mean 738.8mL ± 209.2) and moderately increased at H48 (879mL ± 179), and the cardiac index was subnormal (2.84 ± 0.65). All patients showed extravascular lung water over 8mL/kg on admission (17.9 ± 8.9). We did not identify any argument for cardiogenic failure. Conclusion In the case of severe COVID-19 pneumonia, hemodynamic and respiratory presentation is consistent with pulmonary edema without evidence of cardiogenic origin, favoring the diagnosis of acute respiratory distress syndrome.
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Affiliation(s)
- Edouard Virot
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Cyrille Mathien
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Valentin Pointurier
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Antoine Poidevin
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Guylaine Labro
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Luis Pinto
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Louise Marie Jandeaux
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Joy Mootien
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France.,Antibiotic Stewardship Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
| | - Khaldoun Kuteifan
- Medical Intensive Care Unit, Hôpital Emile Muller, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace - Alsace - Mulhouse, France
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8
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Huber W, Findeisen M, Lahmer T, Herner A, Rasch S, Mayr U, Hoppmann P, Jaitner J, Okrojek R, Brettner F, Schmid R, Schmidle P. Prediction of outcome in patients with ARDS: A prospective cohort study comparing ARDS-definitions and other ARDS-associated parameters, ratios and scores at intubation and over time. PLoS One 2020; 15:e0232720. [PMID: 32374755 PMCID: PMC7202606 DOI: 10.1371/journal.pone.0232720] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/20/2020] [Indexed: 12/15/2022] Open
Abstract
Background Early recognition of high-risk-patients with acute respiratory distress syndrome (ARDS) might improve their outcome by less protracted allocation to intensified therapy including extracorporeal membrane oxygenation (ECMO). Among numerous predictors and classifications, the American European Consensus Conferenece (AECC)- and Berlin-definitions as well as the oxygenation index (OI) and the Murray-/Lung Injury Score are the most common. Most studies compared the prediction of mortality by these parameters on the day of intubation and/or diagnosis of ARDS. However, only few studies investigated prediction over time, in particular for more than three days. Objective Therefore, our study aimed at characterization of the best predictor and the best day(s) to predict 28-days-mortality within four days after intubation of patients with ARDS. Methods In 100 consecutive patients with ARDS severity according to OI (mean airway pressure*FiO2/paO2), modified Murray-score without radiological points (Murray_mod), AECC- and Berlin-definition, were daily documented for four days after intubation. In the subgroup of 49 patients with transpulmonary thermodilution (TPTD) monitoring (PiCCO), extravascular lung water index (EVLWI) was measured daily. Primary endpoint Prediction of 28-days-mortality (Area under the receiver-operating-characteristic curve (ROC-AUC)); IBM SPSS 26. Results In the totality of patients the best prediction of 28-days-mortality was found on day-1 and day-2 (mean ROC-AUCs for all predictors/scores: 0.632 and 0.620). OI was the best predictor among the ARDS-scores (AUC=0.689 on day-1; 4-day-mean AUC = 0.625). AECC and Murray_mod had 4-day-means AUCs below 0.6. Among the 49 patients with TPTD, EVLWI (4-day-mean AUC=0.696) and OI (4-day-mean AUC=0.695) were the best predictors. AUCs were 0.789 for OI on day-1, and 0.786 for EVLWI on day-2. In binary regression analysis of patients with TPTD, EVLWI (B=-0.105; Wald=7.294; p=0.007) and OI (B=0.124; Wald=7.435; p=0.006) were independently associated with 28-days-mortality. Combining of EVLWI and OI provided ROC-AUCs of 0.801 (day-1) and 0.824 (day-2). Among the totality of patients, the use of TPTD-monitoring „per se“ and a lower SOFA-score were independently associated with a lower 28-days-mortality. Conclusions Prognosis of ARDS-patients can be estblished within two days after intubation. The best predictors were EVLWI and OI and their combination. TPTD-monitoring „per se“ was independently associated with reduced mortality.
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Affiliation(s)
- Wolfgang Huber
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
- * E-mail:
| | - Michael Findeisen
- Klinik für Pneumologie, Gastroenterologie, Internistische Intensiv- und Beatmungsmedizin, München Klinik Harlaching, München, Germany
| | - Tobias Lahmer
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Alexander Herner
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Sebastian Rasch
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Ulrich Mayr
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Petra Hoppmann
- Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Juliane Jaitner
- Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Rainer Okrojek
- Medizinische Klinik und Poliklinik I, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Franz Brettner
- Abteilung Intensivmedizin, Krankenhaus Barmherzige Brüder, München, Germany
| | - Roland Schmid
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
| | - Paul Schmidle
- Medizinische Klinik und Poliklinik II, Klinikum rechts der Isar der Technischen Universität München, München, Germany
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Transpulmonary thermodilution detects rapid and reversible increases in lung water induced by positive end-expiratory pressure in acute respiratory distress syndrome. Ann Intensive Care 2020; 10:28. [PMID: 32124129 PMCID: PMC7052093 DOI: 10.1186/s13613-020-0644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/21/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE It has been suggested that, by recruiting lung regions and enlarging the distribution volume of the cold indicator, increasing the positive end-expiratory pressure (PEEP) may lead to an artefactual overestimation of extravascular lung water (EVLW) by transpulmonary thermodilution (TPTD). METHODS In 60 ARDS patients, we measured EVLW (PiCCO2 device) at a PEEP level set to reach a plateau pressure of 30 cmH2O (HighPEEPstart) and 15 and 45 min after decreasing PEEP to 5 cmH2O (LowPEEP15' and LowPEEP45', respectively). Then, we increased PEEP back to the baseline level (HighPEEPend). Between HighPEEPstart and LowPEEP15', we estimated the degree of lung derecruitment either by measuring changes in the compliance of the respiratory system (Crs) in the whole population, or by measuring the lung derecruited volume in 30 patients. We defined patients with a large derecruitment from the other ones as patients in whom the Crs changes and the measured derecruited volume were larger than the median of these variables observed in the whole population. RESULTS Reducing PEEP from HighPEEPstart (14 ± 2 cmH2O) to LowPEEP15' significantly decreased EVLW from 20 ± 4 to 18 ± 4 mL/kg, central venous pressure (CVP) from 15 ± 4 to 12 ± 4 mmHg, the arterial oxygen tension over inspired oxygen fraction (PaO2/FiO2) ratio from 184 ± 76 to 150 ± 69 mmHg and lung volume by 144 [68-420] mL. The EVLW decrease was similar in "large derecruiters" and the other patients. When PEEP was re-increased to HighPEEPend, CVP, PaO2/FiO2 and EVLW significantly re-increased. At linear mixed effect model, EVLW changes were significantly determined only by changes in PEEP and CVP (p < 0.001 and p = 0.03, respectively, n = 60). When the same analysis was performed by estimating recruitment according to lung volume changes (n = 30), CVP remained significantly associated to the changes in EVLW (p < 0.001). CONCLUSIONS In ARDS patients, changing the PEEP level induced parallel, small and reversible changes in EVLW. These changes were not due to an artefact of the TPTD technique and were likely due to the PEEP-induced changes in CVP, which is the backward pressure of the lung lymphatic drainage. Trial registration ID RCB: 2015-A01654-45. Registered 23 October 2015.
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Critical hemodynamic therapy oriented resuscitation helping reduce lung water production and improve survival. Chin Med J (Engl) 2019; 132:1139-1146. [PMID: 30882456 PMCID: PMC6511433 DOI: 10.1097/cm9.0000000000000205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Increased extravascular lung water (EVLW) in shock is common in the critically ill patients. This study aimed to explore the effect of cardiac output (CO) on EVLW and its relevant influence on prognosis. METHODS The hemodynamic data of 428 patients with pulse-indicated continuous CO catheterization from Department of Critical Care Medicine, Peking Union Medical College Hospital were retrospectively collected and analyzed. The patients were assigned to acute respiratory distress syndrome group, cardiogenic shock group, septic shock group, and combined shock (cardiogenic and septic) group according to their symptoms. Information on 28-day mortality and renal function was also collected. RESULTS The CO and EVLW index (EVLWI) in the cardiogenic and combined shock groups were lower than those in the other groups (acute respiratory distress syndrome group vs. cardiogenic shock group vs. septic shock group vs. combined shock group: CO, 5.1 [4.0, 6.2] vs. 4.7 [4.0, 5.7] vs. 5.5 [4.3, 6.7] vs. 4.6 [3.5, 5.7] at 0 to 24 h, P = 0.009; 4.6 [3.8, 5.6] vs. 4.8 [4.1, 5.7] vs. 5.3 [4.4, 6.5] vs. 4.5 [3.8, 5.3] at 24 to 48 h, P = 0.048; 4.5 [4.1, 5.4] vs. 4.8 [3.8, 5.5] vs. 5.3 [4.0, 6.4] vs. 4.0 [3.2, 5.4] at 48 to 72 h, P = 0.006; EVLWI, 11.4 [8.7, 19.1] vs. 7.9 [6.6, 10.0] vs. 8.8 [7.4, 11.0] vs. 8.2 [6.7, 11.3] at 0 to 24 h, P < 0.001; 11.8 [7.7, 17.2] vs. 7.8 [6.3, 10.2] vs. 8.7 [6.6, 12.2] vs. 8.0 [6.6, 11.1] at 24 to 48 h, P < 0.001; and 11.3 [7.7, 18.7] vs. 7.5 [6.3, 10.0] vs. 8.8 [6.3, 12.2] vs. 8.4 [6.4, 11.2] at 48 to 72 h, P < 0.001. The trend of the EVLWI in the septic shock group was higher than that in the cardiogenic shock group (P < 0.05). Moreover, there existed some difference in the pulmonary vascular permeability index among the cardiogenic shock group, the septic shock group, and the combined shock group, without statistical significance (P > 0.05). In addition, there was no significant difference in tissue perfusion or renal function among the four groups during the observation period (P > 0.05). However, the cardiogenic shock group had a higher 28-day survival rate than the other three groups [log rank (Mantel-Cox) = 31.169, P < 0.001]. CONCLUSION Tissue-aimed lower CO could reduce the EVLWI and achieve a better prognosis.
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Transpulmonary thermodilution before and during veno-venous extra-corporeal membrane oxygenation ECMO: an observational study on a potential loss of indicator into the extra-corporeal circuit. J Clin Monit Comput 2019; 34:923-936. [DOI: 10.1007/s10877-019-00398-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 10/07/2019] [Indexed: 01/19/2023]
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12
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Araos J, Alegria L, Garcia P, Cruces P, Soto D, Erranz B, Amthauer M, Salomon T, Medina T, Rodriguez F, Ayala P, Borzone GR, Meneses M, Damiani F, Retamal J, Cornejo R, Bugedo G, Bruhn A. Near-Apneic Ventilation Decreases Lung Injury and Fibroproliferation in an Acute Respiratory Distress Syndrome Model with Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2019; 199:603-612. [DOI: 10.1164/rccm.201805-0869oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
| | | | | | - Pablo Cruces
- Center of Acute Respiratory Critical Illness, Santiago, Chile
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andrés Bello, Santiago, Chile
| | | | - Benjamín Erranz
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana–Universidad del Desarrollo, Santiago, Chile
| | | | - Tatiana Salomon
- Unidad de Pacientes Críticos Pediátrica, Clínica Alemana, Santiago, Chile
| | - Tania Medina
- Escuela de Enfermería, Facultad de Medicina, Universidad Finis Terrae, Santiago, Chile
| | | | - Pedro Ayala
- Departamento de Enfermedades Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gisella R. Borzone
- Departamento de Enfermedades Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Manuel Meneses
- Departamento de Anatomía Patológica, Instituto Nacional del Tórax, Santiago, Chile
| | - Felipe Damiani
- Departamento de Medicina Intensiva
- Escuela de Kinesiología, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile; and
| | - Jaime Retamal
- Departamento de Medicina Intensiva
- Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Rodrigo Cornejo
- Center of Acute Respiratory Critical Illness, Santiago, Chile
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva
- Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva
- Center of Acute Respiratory Critical Illness, Santiago, Chile
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Tagami T, Ong MEH. Extravascular lung water measurements in acute respiratory distress syndrome: why, how, and when? Curr Opin Crit Care 2018; 24:209-215. [PMID: 29608455 PMCID: PMC6037282 DOI: 10.1097/mcc.0000000000000503] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Increase in pulmonary vascular permeability accompanied with accumulation of excess extravascular lung water (EVLW) is the hallmark of acute respiratory distress syndrome (ARDS). Currently, EVLW and pulmonary vascular permeability index (PVPI) can be quantitatively measured using the transpulmonary thermodilution (TPTD) technique. We will clarify why, how, and when EVLW and PVPI measurements should be performed. RECENT FINDINGS Although the Berlin criteria of ARDS are simple and widely used, several criticisms of them have been published. The last 2 decades have witnessed the introduction and evolution of the TPTD technique for measuring EVLW and PVPI. Several publications have recommended to evaluate EVLW and the PVPI during the treatment of critically ill patients. Accurate and objective diagnoses can be made for ARDS patients using EVLW and PVPI. EVLW more than 10 ml/kg is a reasonable criterion for pulmonary edema, and EVLW more than 15 ml/kg for a severe condition. In addition to EVLW more than 10 mL/kg, PVPI more than three suggests increased vascular permeability (i.e., ARDS), and PVPI less than 2 represent normal vascular permeability (i.e., cardiogenic pulmonary edema). SUMMARY EVLW and PVPI measurement will open the door to future ARDS clinical practice and research, and have potential to be included in the future ARDS definition.
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Affiliation(s)
- Takashi Tagami
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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15
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Quantitative computed tomography in comparison with transpulmonary thermodilution for the estimation of pulmonary fluid status: a clinical study in critically ill patients. J Clin Monit Comput 2018; 33:5-12. [PMID: 29680878 DOI: 10.1007/s10877-018-0144-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/16/2018] [Indexed: 01/09/2023]
Abstract
Extravascular lung water (index) (EVLW(I)) can be estimated using transpulmonary thermodilution (TPTD). Computed tomography (CT) with quantitative analysis of lung tissue density has been proposed to quantify pulmonary edema. We compared variables of pulmonary fluid status assessed using quantitative CT and TPTD in critically ill patients. In 21 intensive care unit patients, we performed TPTD measurements directly before and after chest CT. Based on the density data of segmented CT images we calculated the tissue volume (TV), tissue volume index (TVI), and the mean weighted index of voxel aqueous density (VMWaq). CT-derived TV, TVI, and VMWaq did not predict TPTD-derived EVLWI values ≥ 14 mL/kg. There was a significant moderate positive correlation between VMWaq and mean EVLWI (EVLWI before and after CT) (r = 0.45, p = 0.042) and EVLWI after CT (r = 0.49, p = 0.025) but not EVLWI before CT (r = 0.38, p = 0.086). There was no significant correlation between TV and EVLW before CT, EVLW after CT, or mean EVLW. There was no significant correlation between TVI and EVLWI before CT, EVLWI after CT, or mean EVLWI. CT-derived variables did not predict elevated TPTD-derived EVLWI values. In unselected critically ill patients, variables of pulmonary fluid status assessed using quantitative CT cannot be used to predict EVLWI.
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16
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Sakka SG, Tagami T, Kirov M, Perel A. Letter to: acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2018; 10:E221-E223. [PMID: 29708169 DOI: 10.21037/jtd.2018.02.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Samir G Sakka
- Department of Anesthesiology and Operative Intensive Care Medicine, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Mikhail Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Azriel Perel
- Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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Protective effects of continuous positive airway pressure on a nonventilated lung during one-lung ventilation: A prospective laboratory study in rats. Eur J Anaesthesiol 2018; 33:776-83. [PMID: 27139568 DOI: 10.1097/eja.0000000000000460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of one-lung ventilation (OLV) to facilitate intrathoracic surgery is a cause of lung injury. OBJECTIVE We hypothesised that application of continuous positive airway pressure (CPAP) to a nonventilated lung during OLV would prevent alveolar hypoxia and blood flow shift from the nonventilated to the ventilated lung, thereby attenuating lung injury. DESIGN Controlled animal study. SETTINGS University laboratory. STUDY PARTICIPANTS Adult male Sprague-Dawley rats (n = 4 to 8 per group, depending on experiments). INTERVENTIONS Rats were alternately assigned to one of two ventilation protocol groups: control and CPAP groups. Rats received 240 min of OLV followed by 240 min of two-lung reventilation (re-TLV). The nonventilated lungs of rats in the control group were collapsed during OLV whereas rats in the CPAP group received CPAP (5 cmH2O with 100% oxygen) to the nonventilated lungs. MAIN OUTCOME MEASURES Pulmonary blood flow during OLV was measured by quantification of lung radioactivity after intravenous infusion of indium-labelled macroaggregated albumin. Inflammatory cytokines in the lungs after 240 min of OLV, and after the subsequent 240 min of re-TLV were measured. Additionally, we measured lung wet-to-dry weight ratios after re-TLV. We also measured lung malondialdehyde levels after re-TLV as an indicator of reactive oxygen species produced by reoxygenation. RESULTS Application of CPAP attenuated the pulmonary blood flow shift from the nonventilated to the ventilated lung. CPAP decreased the levels of IL-6, CXC chemokine ligand-1 and CC chemokine ligand-2 in both lungs after 240 min of OLV. CPAP also decreased CXC chemokine ligand-1 in the nonventilated lung and CC chemokine ligand-2 in both lungs after re-TLV. Moreover, wet-to-dry weight ratios of both lungs were decreased by application of CPAP. However, lung malondialdehyde concentrations were not affected by CPAP. CONCLUSIONS CPAP applied to the nonventilated lung during OLV suppresses blood flow shift and decreases inflammatory cytokines and water content in both lungs. Application of CPAP may attenuate lung injury during and after OLV.
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Assaad S, Shelley B, Perrino A. Transpulmonary Thermodilution: Its Role in Assessment of Lung Water and Pulmonary Edema. J Cardiothorac Vasc Anesth 2017; 31:1471-1480. [DOI: 10.1053/j.jvca.2017.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Indexed: 11/11/2022]
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Endo Y, Tamura J, Ishizuka T, Itami T, Hanazono K, Miyoshi K, Sano T, Yamashita K, Muir WW. Stroke volume variation (SVV) and pulse pressure variation (PPV) as indicators of fluid responsiveness in sevoflurane anesthetized mechanically ventilated euvolemic dogs. J Vet Med Sci 2017; 79:1437-1445. [PMID: 28690287 PMCID: PMC5573834 DOI: 10.1292/jvms.16-0287] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Changes in stroke volume variation (SVV) and pulse pressure variation (PPV) in response to fluid infusion were experimentally evaluated during vecuronium infusion and sevoflurane anesthesia in 5 adult, mechanically ventilated, euvolemic, beagle dogs. Sequential increases in central venous pressure (CVP; 3-7[baseline], 8-12, 13-17, 18-22 and 23-27 mmHg) were produced by infusing lactated Ringer's solution and 6% hydroxyethyl starch solution. Heart rate (beats/min), right atrial pressure (RAP, mmHg), pulmonary arterial pressure (PAP, mmHg), pulmonary capillary wedge pressure (PCWP, mmHg), transpulmonary thermodilution cardiac output (TPTDCO, l/min), stroke volume (SV, ml/beat), arterial blood pressure (ABP, mmHg), extravascular lung water (EVLW, ml), pulmonary vascular permeability index (PVPI, calculated), SVV (%), PPV (%) and systemic vascular resistance (SVR, dynes/sec/cm5) were determined at each predetermined CVP range. Heart rate (P=0.019), RAP (P<0.001), PAP (P<0.001), PCWP (P<0.001), TPTDCO (P=0.009) and SV (P=0.04) increased and SVR (P<0.001), SVV (P<0.001) and PPV (P<0.001) decreased associated with each stepwise increase in CVP. Arterial blood pressure, EVLW, PVPI and the arterial partial pressures of oxygen and carbon dioxide did not change. The changes in SVV and PPV directly reflected the fluid load and the minimum threshold values for detecting fluid responsiveness were SVV ≥11% and PPV ≥7% in dogs.
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Affiliation(s)
- Yusuke Endo
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Jun Tamura
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Tomohito Ishizuka
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Takaharu Itami
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Kiwamu Hanazono
- Veterinary Teaching Hospital, Graduate School of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido 060-0818, Japan
| | - Kenjiro Miyoshi
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Tadashi Sano
- Department of Veterinary Nursing Science, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - Kazuto Yamashita
- Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, Ebetsu, Hokkaido 069-8591, Japan
| | - William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, Tennessee 37752, U.S.A
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Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28625165 PMCID: PMC5474867 DOI: 10.1186/s13054-017-1739-5] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background For complex patients in the intensive care unit or in the operating room, many questions regarding their haemodynamic management cannot be answered with simple clinical examination. In particular, arterial pressure allows only a rough estimation of cardiac output. Transpulmonary thermodilution is a technique that provides a full haemodynamic assessment through cardiac output and other indices. Main body Through the analysis of the thermodilution curve recorded at the tip of an arterial catheter after the injection of a cold bolus in the venous circulation, transpulmonary thermodilution intermittently measures cardiac output. This measure allows the calibration of pulse contour analysis. This provides continuous and real time monitoring of cardiac output, which is not possible with the pulmonary artery catheter. Transpulmonary thermodilution provides several variables beyond cardiac output. It estimates the end-diastolic volume of the four cardiac cavities, which is a marker of cardiac preload. It provides an estimation of the systolic function of the combined ventricles. It is more direct than the pulmonary artery catheter, but does not allow the distinct estimation of right and left cardiac function. It is easier and faster to perform than echocardiography, but does not provide a full evaluation of the cardiac structure and function. Transpulmonary thermodilution has the unique advantage of being able to estimate at the bedside extravascular lung water, which quantifies the volume of pulmonary oedema, and pulmonary vascular permeability, which quantifies the degree of a pulmonary capillary leak. Both indices are helpful for guiding fluid strategy, especially in case of acute respiratory distress syndrome. Conclusions Transpulmonary thermodilution provides a full cardiovascular evaluation that allows one to answer many questions regarding haemodynamic management. It belongs to the category of “advanced” devices that are indicated for the most critically ill and/or complex patients.
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Affiliation(s)
- Xavier Monnet
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France. .,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France. .,Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, F-94270, Le Kremlin-Bicêtre, France.
| | - Jean-Louis Teboul
- Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Medical Intensive Care Unit, Le Kremlin-Bicêtre, F-94270, France.,Université Paris-Sud, Faculté de médecine Paris-Sud, Inserm UMR S_999, Le Kremlin-Bicêtre, F-94270, France
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Honore PM, Spapen HD. Passive leg raising test with minimally invasive monitoring: the way forward for guiding septic shock resuscitation? J Intensive Care 2017; 5:36. [PMID: 28616241 PMCID: PMC5465672 DOI: 10.1186/s40560-017-0232-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 06/02/2017] [Indexed: 12/21/2022] Open
Abstract
Background Swift and adequate fluid loading is a cornerstone of septic shock therapy. Yet, careful assessment of volume responsiveness and volume amount during the resuscitation process is a prerequisite. Both overzealous initial fluid administration and late fluid overload are harmful and may be associated with increased mortality. Main body Static (i.e., central venous or pulmonary artery occlusion) pressure readings are erroneous for monitoring fluid resuscitation and should be abandoned. Dynamic measurements (i.e., stroke volume and pulse pressure variation) better predict fluid responsiveness than static filling pressures but the conditions necessary for these parameters to correctly evaluate preload dependency are frequently not met. The passive leg raising maneuver as a means to alter biventricular preload in combination with real-time measurement of cardiac output changes is an easy-to-use, fast, relatively unbiased, and accurate bedside test to guide fluid management and to avoid fluid overload during early septic shock treatment. Moreover, PLR may also be particularly useful to assist various treatments that trigger fluid removal during the “de-resuscitation” phase of septic shock. Conclusions The passive leg raising maneuver in combination with real-time measurement of cardiac output changes is an easy-to-use, fast, relatively unbiased, and accurate bedside test to guide fluid management during septic shock.
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Affiliation(s)
- Patrick M Honore
- Intensive Care Medicine, ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 101, Laarbeeklaan, 1090 Jette, Brussels Belgium
| | - Herbert D Spapen
- Intensive Care Medicine, ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 101, Laarbeeklaan, 1090 Jette, Brussels Belgium
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Single-Site Low-Flow Veno-Venous Extracorporeal Lung Support Does Not Influence Hemodynamic Monitoring by Transpulmonary Thermodilution. ASAIO J 2016; 62:454-7. [DOI: 10.1097/mat.0000000000000379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care 2015; 5:38. [PMID: 26546321 PMCID: PMC4636545 DOI: 10.1186/s13613-015-0081-9] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 10/27/2015] [Indexed: 12/16/2022] Open
Abstract
Extravascular lung water (EVLW) is the amount of fluid that is accumulated in the interstitial and alveolar spaces. In lung oedema, EVLW increases either because of increased lung permeability or because of increased hydrostatic pressure in the pulmonary capillaries, or both. Increased EVLW is always potentially life-threatening, mainly because it impairs gas exchange and reduces lung compliance. The only technique that provides an easy measurement of EVLW at the bedside is transpulmonary thermodilution. The validation of EVLW measurements by thermodilution was based on studies showing reasonable correlations with gravimetry or thermo-dye dilution in experimental and clinical studies. EVLW should be indexed to predicted body weight. This indexation reduces the proportion of ARDS patients for whom EVLW is in the normal range. Compared to non-indexed EVLW, indexed EVLW (EVLWI) is better correlated with the lung injury score and the oxygenation and it is a better predictor of mortality of patients with acute lung injury or acute respiratory distress syndrome (ARDS). Transpulmonary thermodilution also provides the pulmonary vascular permeability index (PVPI), which is an indirect reflection of the integrity of the alveolocapillary barrier. As clinical applications, EVLWI and PVPI may be useful to guide fluid management of patients at risk of fluid overload, as during septic shock and ARDS. High EVLWI and PVPI values predict mortality in several categories of critically ill patients, especially during ARDS. Thus, fluid administration should be limited when EVLWI is already high. Whatever the value of EVLWI, PVPI may indicate that fluid administration is particularly at risk of aggravating lung oedema. In the acute phase of haemodynamic resuscitation during septic shock and ARDS, high EVLWI and PVPI values may warn of the risk of fluid overload and prevent excessive volume expansion. At the post-resuscitation phase, they may prompt initiation of fluid removal thereby achieving a negative fluid balance.
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Affiliation(s)
- Mathieu Jozwiak
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Jean-Louis Teboul
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
| | - Xavier Monnet
- Faculté de Médecine, Université Paris-Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France. .,AP-HP, Service de réanimation médicale, Hôpital de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. .,Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Low-dose corticosteroid treatment and mortality in refractory abdominal septic shock after emergency laparotomy. Ann Intensive Care 2015; 5:32. [PMID: 26514125 PMCID: PMC4626466 DOI: 10.1186/s13613-015-0074-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/19/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The role of low-dose corticosteroid as an adjunctive treatment for abdominal septic shock remains controversial. METHODS We identified refractory septic shock patients who required noradrenaline and at least one of other vasopressor/inotropic (dopamine, dobutamine or vasopressin) following emergency open laparotomy for perforation of the lower intestinal tract between July 2010 and March 2013 using the Japanese Diagnosis Procedure Combination inpatient database. In-hospital mortality was compared between the low-dose corticosteroid and control groups. RESULTS There were 2164 eligible patients (155 in the corticosteroid group, 2009 in the control group). We observed no significant difference between the groups in terms of in-hospital mortality in the unadjusted analysis [corticosteroid vs. control groups, 19.4 and 25.1 %, respectively; difference, -5.7 %; 95 % confidence interval (CI), -12.8 to 1.3]; however, a significant difference in in-hospital mortality was evident in the propensity score-weighted analysis (17.6 and 25.0 %, respectively; difference, -7.4 %; 95 % CI -9.9 to -5.0). An instrumental variable analysis with the hospital low-dose corticosteroid prescription proportion showed that receipt of low-dose corticosteroid was significantly associated with reduction in in-hospital mortality (differences, -13.5 %; 95 % CI -24.6 to -2.3). CONCLUSIONS Low-dose corticosteroid administration may be associated with reduced in-hospital mortality in patients with refractory septic shock following emergency laparotomy for lower intestinal perforation.
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Affiliation(s)
- Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8555, Japan. .,Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, 206-8512, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8555, Japan.
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8555, Japan.
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Ursulet L, Roussiaux A, Belcour D, Ferdynus C, Gauzere BA, Vandroux D, Jabot J. Right over left ventricular end-diastolic area relevance to predict hemodynamic intolerance of high-frequency oscillatory ventilation in patients with severe ARDS. Ann Intensive Care 2015; 5:25. [PMID: 26380993 PMCID: PMC4573736 DOI: 10.1186/s13613-015-0068-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/08/2015] [Indexed: 01/19/2023] Open
Abstract
Background High-frequency oscillatory ventilation (HFOV) does not improve the prognosis of ARDS patients despite an improvement in oxygenation. This paradox may partly be explained by HFOV hemodynamic side-effects on right ventricular function. Our goal was to study the link between HFOV and hemodynamic effects and to test if the pre-HFOV right over left ventricular end-diastolic area (RVEDA/LVEDA) ratio, as a simple parameter of afterload-related RV dysfunction, could be used to predict HFOV hemodynamic intolerance in patients with severe ARDS. Methods Twenty-four patients were studied just before and within 3 h of HFOV using transthoracic echocardiography and transpulmonary thermodilution. Results Before HFOV, the mean PaO2/FiO2 ratio was 89 ± 23. The number of patients with a RVEDA/LVEDA ratio >0.6 significantly increased after HFOV [11 (46 %) vs. 17 (71 %)]. Although HFOV did not significantly decrease the arterial pressure (systolic, diastolic, mean and pulse pressure), it significantly decreased the cardiac index (CI) by 13 ± 18 % and significantly increased the RVEDA/LVEDA ratio by 14 ± 11 %. A significant correlation was observed between pre-HFOV RVEDA/LVEDA ratio and CI diminution after HFOV (r = 0.78; p < 0.0001). A RVEDA/LVEDA ratio superior to 0.6 resulted in a CI decrease >15 % during HFOV with a sensitivity of 80 % (95 % confidence interval 44–98 %) and a specificity of 79 % (confidence interval 49–95 %). Conclusion The RVEDA/LVEDA ratio measured just before HFOV predicts the hemodynamic intolerance of this technique in patients with severe ARDS. A high ratio under CMV raises questions about the use of HFOV in such patients. Trial registration: ClinicalTrials.gov: NCT01167621
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Affiliation(s)
- Lionel Ursulet
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Arnaud Roussiaux
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Dominique Belcour
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Cyril Ferdynus
- Methodological Support and Biostatistics Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Bernard-Alex Gauzere
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - David Vandroux
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
| | - Julien Jabot
- Medical Surgical Intensive Care Unit, Saint Denis University Hospital, Saint Denis, Reunion Island, France.
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Supplemental dose of antithrombin use in disseminated intravascular coagulation patients after abdominal sepsis. Thromb Haemost 2015; 114:537-45. [PMID: 25948492 DOI: 10.1160/th15-01-0053] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/25/2015] [Indexed: 11/05/2022]
Abstract
The effectiveness of supplemental dose antithrombin administration (1,500 to 3,000 IU/ day) for patients with sepsis-associated disseminated intravascular coagulation (DIC), especially sepsis due to abdominal origin, remains uncertain. This was a retrospective cohort study of patients with mechanically ventilated septic shock and DIC after emergency surgery for perforation of the lower intestinal tract using a nationwide administrative database, Japanese Diagnosis Procedure Combination inpatient database. A total of 2,164 patients treated at 612 hospitals during the 33-month study period between 2010 and 2013 were divided into an antithrombin group (n=1,021) and a control group (n=1,143), from which 518 propensity score-matched pairs were generated. Although there was no significant 28-day mortality difference between the two groups in the unmatched groups (control vs antithrombin: 25.7 vs 22.9 %; difference, 2.8 %; 95 % confidence interval [CI], -0.8-6.4), a significant difference existed between the two groups in propensity-score weighted groups (26.3 vs 21.7 %; difference, 4.6 %; 95 % CI, 2.0-7.1) and propensity-score matched groups (27.6 vs 19.9 %; difference, 7.7 %; 95 % CI, 2.5-12.9). Logistic regression analyses showed a significant association between antithrombin use and lower 28-day mortality in propensity-matched groups (odds ratio, 0.65; 95 % CI, 0.49-0.87). Analysis using the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 6.5 % (95 % CI, 0.05-13.0) reduction in 28-day mortality. Supplemental dose of antithrombin administration may be associated with reduced 28-day mortality in sepsis-associated DIC patients after emergency laparotomy for intestinal perforation.
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Affiliation(s)
- Takashi Tagami
- Takashi Tagami, MD, PhD, Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan, E-mail:
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Intravenous Immunoglobulin and Mortality in Pneumonia Patients With Septic Shock: An Observational Nationwide Study. Clin Infect Dis 2015; 61:385-92. [DOI: 10.1093/cid/civ307] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/21/2015] [Indexed: 12/22/2022] Open
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Tagami T, Matsui H, Fushimi K, Yasunaga H. Intravenous immunoglobulin use in septic shock patients after emergency laparotomy. J Infect 2015; 71:158-66. [PMID: 25869539 DOI: 10.1016/j.jinf.2015.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/18/2015] [Accepted: 04/03/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The role of intravenous immunoglobulin (IVIG) as an adjunctive treatment for abdominal sepsis remains controversial. METHODS Mechanically ventilated septic shock patients following emergency laparotomy for perforation of the lower intestinal tract were identified in the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2013. The effect of IVIG use on 28-day mortality was evaluated using propensity score and instrumental variable analyses. RESULTS Eligible patients (n = 4919) treated at 845 hospitals were divided into IVIG (n = 2085) and control (n = 2834) groups. Propensity score matching created a matched cohort of 1081pairs with and without IVIG treatment. Although significant mortality differences existed between the IVIG and control groups in the unmatched analysis (20.6% vs. 18.3%; difference, 2.3%; 95% confidence interval [CI], 0.07-4.5), there were no significant differences in the propensity score-matched analysis (20.4% vs. 19.3%; difference, 1.1%; 95% CI, -2.3-4.5). Analysis employing the pattern of hospital IVIG use as an instrumental variable showed that IVIG use was not associated with reduced mortality (difference -2.5; 95% CI, -6.5-1.6). CONCLUSIONS There may be no significant association between IVIG use and mortality in mechanically ventilated septic shock patients after emergency laparotomy.
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Affiliation(s)
- Takashi Tagami
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan; Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan.
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University, Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8555, Japan.
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Tagami T, Tosa R, Omura M, Fukushima H, Kaneko T, Endo T, Rinka H, Murai A, Yamaguchi J, Yoshikawa K, Saito N, Uzu H, Kase Y, Takatori M, Izumino H, Nakamura T, Seo R, Kitazawa Y, Sugita M, Takahashi H, Kuroki Y, Irahara T, Kanemura T, Yokota H, Kushimoto S. Effect of a selective neutrophil elastase inhibitor on mortality and ventilator-free days in patients with increased extravascular lung water: a post hoc analysis of the PiCCO Pulmonary Edema Study. J Intensive Care 2014; 2:67. [PMID: 25705423 PMCID: PMC4336272 DOI: 10.1186/s40560-014-0067-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neutrophil elastase plays an important role in the development and progression of acute respiratory distress syndrome (ARDS). Although the selective elastase inhibitor, sivelestat, is widely used in Japan for treating ARDS patients, its effectiveness remains controversial. The aim of the current study was to investigate the effects of sivelestat in ARDS patients with evidence of increased extravascular lung water by re-analyzing a large multicenter study database. METHODS A post hoc analysis of the PiCCO Pulmonary Edema Study was conducted. This multicenter prospective cohort study included 23 institutions in Japan. Adult mechanically ventilated ARDS patients with an extravascular lung water index of >10 mL/kg were included and propensity score analyses were performed. The endpoints were 28-day mortality and ventilator-free days (VFDs). RESULTS Patients were categorized into sivelestat (n = 87) and control (n = 77) groups, from which 329 inverse probability-weighted group patients (162 vs. 167) were generated. The overall 28-day mortality was 31.1% (51/164). There was no significant difference in 28-day mortality between the study groups (sivelestat vs. control; unmatched: 29.9% vs. 32.5%; difference, -2.6%, 95% confidence interval (CI), -16.8 to 14.2; inverse probability-weighted: 24.7% vs. 29.5%, difference, -4.8%, 95% CI, -14.4 to 9.6). Although administration of sivelestat did not alter the number of ventilator-free days (VFDs) in the unmatched (9.6 vs. 9.7 days; difference, 0.1, 95% CI, -3.0 to 3.1), the inverse probability-weighted analysis identified significantly more VFDs in the sivelestat group than in the control group (10.7 vs. 8.4 days, difference, -2.3, 95% CI, -4.4 to -0.2). CONCLUSIONS Although sivelestat did not significantly affect 28-day mortality, this treatment may have the potential to increase VFDs in ARDS patients with increased extravascular lung water. Prospective randomized controlled studies are required to confirm the results of the current study.
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Affiliation(s)
- Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603 Japan ; Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryoichi Tosa
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima, Japan
| | - Mariko Omura
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Fukushima, Japan
| | - Hidetada Fukushima
- Department of Emergency and Critical Care Medicine, Nara Medical University, Nara, Japan
| | - Tadashi Kaneko
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Tomoyuki Endo
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Miyagi, Japan
| | - Hiroshi Rinka
- Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Akira Murai
- Department of Emergency and Critical Care Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuhide Yoshikawa
- Shock Trauma and Emergency Medical Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Nobuyuki Saito
- Department of Emergency and Critical Care Medicine, Nippon Medical School Chiba Hokusou Hospital, Chiba, Japan
| | - Hideaki Uzu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Yoichi Kase
- Critical Care Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Takatori
- Department of Anesthesia and Intensive Care, Hiroshima City Hospital, Hiroshima, Japan
| | - Hiroo Izumino
- Advanced Emergency and Critical Care Center, Kansai Medical University Takii Hospital, Osaka, Japan
| | | | - Ryutarou Seo
- Intensive Care Unit, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Yasuhide Kitazawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University, Osaka, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Hiroyuki Takahashi
- Department of Intensive Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Yuichi Kuroki
- Department of Emergency and Critical Care Medicine, Social Insurance Chukyo Hospital, Aichi, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Takashi Kanemura
- Emergency and Critical Care Medicine, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603 Japan
| | - Shigeki Kushimoto
- Division of Emergency Medicine, Tohoku University Graduate School of Medicine, Miyagi, Japan
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