1
|
Cecconi M, Hernandez G, Dunser M, Antonelli M, Baker T, Bakker J, Duranteau J, Einav S, Groeneveld ABJ, Harris T, Jog S, Machado FR, Mer M, Monge García MI, Myatra SN, Perner A, Teboul JL, Vincent JL, De Backer D. Correction to: Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force. Intensive Care Med 2018; 45:136. [PMID: 30547324 DOI: 10.1007/s00134-018-5485-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The original article can be found online.
Collapse
Affiliation(s)
- Maurizio Cecconi
- Humanitas Clinical and Research Center, Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Martin Dunser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Tim Baker
- College of Medicine, Blantyre, Malawi.,Perioperative medicine and intensive care (PMI), Karolinska University Hospital, Stockholm, Sweden
| | - Jan Bakker
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.,Department of Pulmonology and Critical Care, Langone Medical Center-Bellevue Hospital, New York University, New York, NY, USA.,Department of Intensive Care Adults, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.,Division of Pulmonary, Allergy and Critical Care, University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Pulmonary and Critical Care, New York University, 462 First avenue, New York, NY, 10016, USA
| | - Jacques Duranteau
- Laboratoire d'Etude de la Microcirculation, UMR 942, Université Paris 7, Hôpitaux Saint Louis Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service d'Anesthésie-Réanimation Chirurgicale, UMR 942, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Sharon Einav
- Department of Anesthesia , Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - A B Johan Groeneveld
- Institute for Cardiovascular Research ICaR-VU, VU University Medical Center, Amsterdam, The Netherlands
| | - Tim Harris
- Emergency Department, Royal London Hospita, Barts Health NHS Trust, London, UK.,Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sameer Jog
- Deenanath Mangeshkar Hospital and Research center, Pune, India
| | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jean-Louis Teboul
- Hôpitaux universitaires Paris-Sud, Hôpital de Bicêtre, service de réanimation médicale, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.,Inserm UMR S_999, Univ Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, 35 Rue Wayez, 1420, Braine L'Alleud, Belgium
| |
Collapse
|
2
|
Cecconi M, Hernandez G, Dunser M, Antonelli M, Baker T, Bakker J, Duranteau J, Einav S, Groeneveld ABJ, Harris T, Jog S, Machado FR, Mer M, Monge García MI, Myatra SN, Perner A, Teboul JL, Vincent JL, De Backer D. Fluid administration for acute circulatory dysfunction using basic monitoring: narrative review and expert panel recommendations from an ESICM task force. Intensive Care Med 2018; 45:21-32. [DOI: 10.1007/s00134-018-5415-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 10/11/2018] [Indexed: 12/21/2022]
|
3
|
van den Akker JPC, Bakker J, Groeneveld ABJ, den Uil CA. Risk indicators for acute kidney injury in cardiogenic shock. J Crit Care 2018; 50:11-16. [PMID: 30465893 DOI: 10.1016/j.jcrc.2018.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 10/30/2018] [Accepted: 11/09/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE In critical illness, the relation between the macrocirculation, microcirculation and organ dysfunction, such as acute kidney injury (AKI), is complex. This study aimed at identifying predictors for AKI in patients with cardiogenic shock. MATERIALS AND METHODS Thirty-nine adult cardiogenic shock patients, with an admission creatinine <200 μmol l-1, and whose microcirculation was measured within 48 h were enrolled. Patient data were analyzed if AKI stage ≥1 developed according to the Kidney Disease/Improving Outcomes classification within 48 h after admission. Variables with a p < .05 in the univariate analysis were considered for analysis with logistic regression. RESULTS Twenty-four patients (61.5%) developed AKI within 48 h. The group that developed AKI had higher central venous pressures (CVP), lower diastolic arterial blood pressures and mean perfusion pressures, higher maximum ventilator pressures as well as positive end expiratory pressures and were treated with higher dosages of dobutamine. There was no difference of the microcirculation. In the multivariate logistic regression analysis, CVP was the only independent predictor for AKI (OR 1.241; 95% CI 1.030-1.495; p = .023). CONCLUSIONS In this population of patients with cardiogenic shock, CVP was associated with the development of AKI.
Collapse
Affiliation(s)
- Johannes P C van den Akker
- Department of Intensive Care Adults, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands; Division of Pulmonary, Allergy and Critical Care, Columbia University Medical Center, New York, NY, USA; Division of Pulmonary, Critical Care and Sleep Medicine, New York University Langone-Bellevue Hospital, New York, NY, USA; Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A B J Groeneveld
- Department of Intensive Care Adults, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - C A den Uil
- Department of Intensive Care Adults, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015GD, Rotterdam, the Netherlands; Department of Cardiology, Erasmus MC, University Medical Center, s-Gravendijkwal 230, Rotterdam 3015, the Netherlands
| |
Collapse
|
4
|
Groeneveld ABJ, Kindt I, Raijmakers PGHM, Hack CE, Thijs LG. Systemic Coagulation and Fibrinolysis in Patients with or at Risk for the Adult Respiratory Distress Syndrome. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1665431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryThe authors sought to evaluate the pathogenetic and prognostic role of a procoagulant and hypofibrinolytic state in the adult respiratory distress syndrome (ARDS). Twenty-two consecutive patients admitted to the intensive care unit (ICU) for respiratory monitoring (n = 2) or mechanical ventilation (n = 20) were studied, of whom 13 had ARDS and 9 were at risk for the syndrome. Plasma levels of thrombin-anti- thrombin III complexes (TAT), the plasmin-α2-antiplasmin complexes (PAP), tissue-type plasminogen activator (tPA) and plasminogen activator inhibitor type 1 (PAI-1) were measured within 48 h after admission, together with respiratory variables allowing computation of the lung injury score (LIS), and pulmonary microvascular permeability [67Gallium-transferrin pulmonary leak index (PLI)], as measures of pulmonary dysfunction. Blood was also sampled 6-hourly until 2 days after admission. The LIS and PLI were higher in ARDS than at risk patients, in the presence of similar systemic morbidity and mortality. TAT complexes were elevated in a minority of patients of both groups, whereas the PAP, tPA and PAI levels were elevated above normal in the majority of ARDS and at risk patients, but groups did not differ. Neither circulating coagulation nor fibrinolysis variables correlated to either LIS or PLI. Furthermore, the course of haemostatic variables did not relate to outcome. These data indicate that systemic activation of coagulation and impaired fibrinolysis do not play a major role in ARDS development and outcome in patients with acute lung injury.
Collapse
Affiliation(s)
- A B J Groeneveld
- The Medical Intensive Care Unit of the Free University Hospital, Amsterdam, The Netherlands
| | - I Kindt
- The Medical Intensive Care Unit of the Free University Hospital, Amsterdam, The Netherlands
| | - P G H M Raijmakers
- The Medical Intensive Care Unit of the Free University Hospital, Amsterdam, The Netherlands
| | - C E Hack
- The Central Laboratory of the Netherlands Red Cross Blood Transfusion Service, and the Institute for Cardiovascular Research at the Free University, Amsterdam, The Netherlands
| | - L G Thijs
- The Medical Intensive Care Unit of the Free University Hospital, Amsterdam, The Netherlands
| |
Collapse
|
5
|
Stads S, Schilder L, Nurmohamed SA, Bosch FH, Purmer IM, den Boer SS, Kleppe CG, Vervloet MG, Beishuizen A, Girbes ARJ, ter Wee PM, Gommers D, Groeneveld ABJ, Oudemans-van Straaten HM. Fluid balance-adjusted creatinine at initiation of continuous venovenous hemofiltration and mortality. A post-hoc analysis of a multicenter randomized controlled trial. PLoS One 2018; 13:e0197301. [PMID: 29874271 PMCID: PMC5991340 DOI: 10.1371/journal.pone.0197301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/27/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with high mortality. The creatinine-based stage of AKI is considered when deciding to start or delay RRT. However, creatinine is not only determined by renal function (excretion), but also by dilution (fluid balance) and creatinine generation (muscle mass). The aim of this study was to explore whether fluid balance-adjusted creatinine at initiation of RRT is related to 28-day mortality independent of other markers of AKI, surrogates of muscle mass and severity of disease. METHODS We performed a post-hoc analysis on data from the multicentre CASH trial comparing citrate to heparin anticoagulation during continuous venovenous hemofiltration (CVVH). To determine whether fluid balance-adjusted creatinine was associated with 28-day mortality, we performed a logistic regression analysis adjusting for confounders of creatinine generation (age, gender, body weight), other markers of AKI (creatinine, urine output) and severity of disease. RESULTS Of the 139 patients, 32 patients were excluded. Of the 107 included patients, 36 died at 28 days (34%). Non-survivors were older, had higher APACHE II and inclusion SOFA scores, lower pH and bicarbonate, lower creatinine and fluid balance-adjusted creatinine at CVVH initiation. In multivariate analysis lower fluid balance-adjusted creatinine (OR 0.996, 95% CI 0.993-0.999, p = 0.019), but not unadjusted creatinine, remained associated with 28-day mortality together with bicarbonate (OR 0.869, 95% CI 0.769-0.982, P = 0.024), while the APACHE II score non-significantly contributed to the model. CONCLUSION In this post-hoc analysis of a multicentre trial, low fluid balance-adjusted creatinine at CVVH initiation was associated with 28-day mortality, independent of other markers of AKI, organ failure, and surrogates of muscle mass, while unadjusted creatinine was not. More tools are needed for better understanding of the complex determinants of "AKI classification", "CVVH initiation" and their relation with mortality, fluid balance is only one.
Collapse
Affiliation(s)
- Susanne Stads
- Department of Intensive care, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Intensive care, Ikazia Hospital, Rotterdam, the Netherlands
| | - Louise Schilder
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - S. Azam Nurmohamed
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Frank H. Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ilse M. Purmer
- Department of Intensive care, Haga hospital, den Haag, the Netherlands
| | - Sylvia S. den Boer
- Department of Intensive care, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Cynthia G. Kleppe
- Department of Intensive care, Noordwest Ziekenhuis groep, Alkmaar, the Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive care, VU University Medical Center, Amsterdam, the Netherlands
- Department of Intensive care, Medical Spectrum, Twente, the Netherlands
| | - Armand R. J. Girbes
- Department of Intensive care, VU University Medical Center, Amsterdam, the Netherlands
| | - Pieter M. ter Wee
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Diederik Gommers
- Department of Intensive care, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | | | | |
Collapse
|
6
|
Raaphorst J, Bossink A, Hack CE, Groeneveld ABJ. Early Inhibition of Activated Fibrinolysis Predicts Microbial Infection, Shock and Mortality in Febrile Medical Patients. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1616084] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryTo evaluate the contribution of an imbalance between coagulation activation and fibinolysis activation and inhibition to morbidity and mortality in sepsis, we determined in medical hospitalized patients at inclusion (day 0) for fever (temperature above 38.0° C axillary or 38.3° C rectally), and daily thereafter for two days, circulating thrombin-antithrombin III (TAT) complexes, plasmin- 2-antiplasmin (PAP) complexes (day 0 only), tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1) and interleukin (IL)-6, the latter as a marker of the inflammatory host response. Study variables were 1) positive microbiological results for specimens from local sites associated with a clinical infection, positive blood cultures (including parasitemia) or both, within 7 days after inclusion, 2) development of shock, i.e. systolic blood pressure <90 mmHg or a reduction of 40 mmHg from baseline within 7 days after inclusion, and 3) death related to febrile illness within 28 days after inclusion. The peak plasma levels of TAT complexes were elevated in 44% and the PAP complexes in all patients. The t-PA and PAI-1 levels were elevated in 74 and 94% of patients, respectively. Values for TAT and PAP did not differ among subgroups, while peak t-PA and IL-6 levels were higher in patients with positive microbiological results, developing shock or ultimately dying than in those without the complications (p <0.005). Peak PAI-1 levels were elevated in patients developing shock and ultimate death versus those with an uncomplicated course (p <0.05). Peak IL-6 related to PAI-1 and t-PA levels, which interrelated. Patients with elevated TAT levels had increased plasma levels of IL-6, PAP, PAI-1 and t-PA versus those with normal TAT (p <0.05). Our data indicate that inhibition of activated fibrinolysis, which may partly depend on both cytokinemia and activation of coagulation, predicts microbial infection, septic shock and mortality of febrile medical patients. This suggests an early pathogenic role of inhibition of activated fibrinolysis in the downhill course of serious microbial infection.
Collapse
|
7
|
Abstract
SummaryThe crosstalk between coagulation and inflammation and the propensity for microthromboembolic disease during sepsis calls for anticoagulant measures to prevent tissue hypoxygenation and to attenuate organ damage and dysfunction. Only one anticoagulant, recombinant human activated protein C (aPC, drotrecogin-α) has a proven survival benefit when used as an adjunctive therapy for human sepsis, partly because of its anti-inflammatory effect. However, heparin (-like compounds) may exert similar beneficial anti-inflammatory actions as aPC, in spite of the relatively narrow therapeutic window for anticoagulation. This narrative review is based on a Medline search of relevant basic and clinical studies published in English and discusses the potential role of heparin in modulating inflammatory responses in the treatment of animal models and human sepsis and its harmful sequelae. In any case, the results of a metaanalysis based on animal data suggest a potentially life-saving effect of heparin (-like compounds) in the treatment of sepsis.Therefore, a prospective randomized clinical trial is called upon to study effects in human sepsis.
Collapse
|
8
|
Spoelstra–de Man AME, Smorenberg A, Groeneveld ABJ. Different effects of fluid loading with saline, gelatine, hydroxyethyl starch or albumin solutions on acid-base status in the critically ill. PLoS One 2017; 12:e0174507. [PMID: 28380062 PMCID: PMC5381890 DOI: 10.1371/journal.pone.0174507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 03/01/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction Fluid administration in critically ill patients may affect acid-base balance. However, the effect of the fluid type used for resuscitation on acid-base balance remains controversial. Methods We studied the effect of fluid resuscitation of normal saline and the colloids gelatine 4%, hydroxyethyl starch (HES) 6%, and albumin 5% on acid-base balance in 115 clinically hypovolemic critically ill patients during a 90 minute filling pressure-guided fluid challenge by a post-hoc analysis of a prospective randomized clinical trial. Results About 1700 mL was infused per patient in the saline and 1500 mL in each of the colloid groups (P<0.001). Overall, fluid loading slightly decreased pH (P<0.001) and there was no intergroup difference. This mildly metabolic acidifying effect was caused by a small increase in chloride concentration and decrease in strong ion difference in the saline- and HES-, and an increase in (uncorrected) anion gap in gelatine- and albumin-loaded patients, independent of lactate concentrations. Conclusion In clinically hypovolemic, critically ill patients, fluid resuscitation by only 1500–1700 mL of normal saline, gelatine, HES or albumin, resulted in a small decrease in pH, irrespective of the type of fluid used. Therefore, a progressive metabolic acidosis, even with increased anion gap, should not be erroneously attributed to insufficient fluid resuscitation. Trial registration ISRCTN Registry ISRCTN19023197
Collapse
Affiliation(s)
| | - Annemieke Smorenberg
- Department of Internal Medicine, Ziekenhuis Amstelland, Amstelveen, The Netherlands
- * E-mail:
| | | |
Collapse
|
9
|
van der Geest PJ, Mohseni M, Nieboer D, Duran S, Groeneveld ABJ. Procalcitonin to guide taking blood cultures in the intensive care unit; a cluster-randomized controlled trial. Clin Microbiol Infect 2016; 23:86-91. [PMID: 27746396 DOI: 10.1016/j.cmi.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 10/02/2016] [Accepted: 10/03/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVES We aimed to study the safety and efficacy of procalcitonin in guiding blood cultures taking in critically ill patients with suspected infection. METHODS We performed a cluster-randomized, multi-centre, single-blinded, cross-over trial. Patients suspected of infection in whom taking blood for culture was indicated were included. The participating intensive care units were stratified and randomized by treatment regimen into a control group and a procalcitonin-guided group. All patients included in this trial followed the regimen that was allocated to the intensive care unit for that period. In both groups, blood was drawn at the same moment for a procalcitonin measurement and blood cultures. In the procalcitonin-guided group, blood cultures were sent to the department of medical microbiology when the procalcitonin was >0.25 ng/mL. The main outcome was safety, expressed as mortality at day 28 and day 90. RESULTS The control group included 288 patients and the procalcitonin-guided group included 276 patients. The 28- and 90-day mortality rates in the procalcitonin-guided group were 29% (80/276) and 38% (105/276), respectively. The mortality rates in the control group were 32% (92/288) at day 28 and 40% (115/288) at day 90. The intention-to-treat analysis showed hazard ratios of 0.85 (95% CI 0.62-1.17) and 0.89 (95% CI 0.67-1.17) for 28-day and 90-day mortality, respectively. The results were deemed non-inferior because the upper limit of the 95% CI was below the margin of 1.20. CONCLUSION Applying procalcitonin to guide blood cultures in critically ill patients with suspected infection seems to be safe, but the benefits may be limited. TRIAL REGISTRATION ClinicalTrials.gov identifier: ID NCT01847079. Registered on 24 April 2013, retrospectively registered.
Collapse
Affiliation(s)
- P J van der Geest
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - M Mohseni
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - D Nieboer
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - S Duran
- Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - A B J Groeneveld
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
10
|
van der Geest PJ, Hunfeld NGM, Ladage SE, Groeneveld ABJ. Micafungin versus anidulafungin in critically ill patients with invasive candidiasis: a retrospective study. BMC Infect Dis 2016; 16:490. [PMID: 27634140 PMCID: PMC5025542 DOI: 10.1186/s12879-016-1825-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 09/09/2016] [Indexed: 11/25/2022] Open
Abstract
Background In critically ill patients the incidence of invasive fungal infections caused by Candida spp. has increased remarkably. Echinocandins are recommended as initial treatment for invasive fungal infections. The safety and efficacy of micafungin compared to caspofungin is similar, but no comparison is made between anidulafungin and micafungin concerning safety and efficacy. We therefore performed a retrospective study to assess these aspects in critically ill patients with invasive candidiasis. Methods All patients in the intensive care unit (ICU) with invasive candidiasis, who were only treated with anidulafungin or micafungin, between January 2012 and December 2014 were retrospectively included. Baseline demographic characteristics, infection characteristics and patient courses were assessed. Results A total of 63 patients received either anidulafungin (n = 30) or micafungin (n = 33) at the discretion of the attending intensivist. Baseline characteristics were comparable between the two groups, suggesting similar risk for developing invasive candidiasis. Patients with invasive candidiasis and liver failure were more often treated with anidulafungin than micafungin. Response rates were similar for both groups. No difference was observed in 28-day mortality, but 90-day mortality was higher in patients on anidulafungin. Multivariable cox regression analysis showed that age and serum bilirubin were the best parameters for the prediction of 90-day mortality, whereas APACHE II, Candida score and antifungal therapy did not contribute (P > 0.05). None of the patients developed impaired liver function related to antifungal use and no differences were seen in prothrombin time, serum transaminases and bilirubin levels between the groups, after exclusion of patients with liver injury or failure. Conclusion Micafungin can be safely and effectively used in critically ill patients with invasive candidiasis. The observed increased 90-day mortality with anidulafungin can be explained by intensivists unnecessarily avoiding micafungin in patients with liver injury and failure.
Collapse
Affiliation(s)
- Patrick J van der Geest
- Department of Intensive Care Medicine, Erasmus University Medical Center, 's Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| | - Nicole G M Hunfeld
- Department of Intensive Care Medicine, Erasmus University Medical Center, 's Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.,Department of Pharmacy, Erasmus University Medical Center, 's Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands
| | - Sophie E Ladage
- Department of Intensive Care Medicine, Erasmus University Medical Center, 's Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care Medicine, Erasmus University Medical Center, 's Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| |
Collapse
|
11
|
Egal M, de Geus HRH, Groeneveld ABJ. Neutrophil Gelatinase-Associated Lipocalin as a Diagnostic Marker for Acute Kidney Injury in Oliguric Critically Ill Patients: A Post-Hoc Analysis. Nephron Clin Pract 2016; 134:81-88. [PMID: 27505067 DOI: 10.1159/000447602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 06/10/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Oliguria occurs frequently in critically ill patients, challenging clinicians to distinguish functional adaptation from serum-creatinine-defined acute kidney injury (AKIsCr). We investigated neutrophil gelatinase-associated lipocalin (NGAL)'s ability to differentiate between these 2 conditions. METHODS This is a post-hoc analysis of a prospective cohort of adult critically ill patients. Patients without oliguria within the first 6 h of admission were excluded. Plasma and urinary NGAL were measured at 4 h after admission. AKIsCr was defined using the AKI network criteria with pre-admission serum creatinine or lowest serum creatinine value during the admission as the baseline value. Hazard ratios for AKIsCr occurrence within 72 h were calculated using Cox regression and adjusted for risk factors such as sepsis, pre-admission serum creatinine, and urinary output. Positive predictive values (PPV) and negative predictive values (NPV) were calculated for the optimal cutoffs for NGAL. RESULTS Oliguria occurred in 176 patients, and 61 (35%) patients developed AKIsCr. NGAL was a predictor for AKIsCr in univariate and multivariate analysis. When NGAL was added to a multivariate model including sepsis, pre-admission serum creatinine and lowest hourly urine output, it outperformed the latter model (plasma p = 0.001; urinary p = 0.048). Cutoff values for AKIsCr were 280 ng/ml for plasma (PPV 80%; NPV 79%), and 250 ng/ml for urinary NGAL (PPV 58%; NPV 78%). CONCLUSIONS NGAL can be used to distinguish oliguria due to the functional adaptation from AKIsCr, directing resources to patients more likely to develop AKIsCr.
Collapse
Affiliation(s)
- Mohamud Egal
- Department of Intensive Care, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | | | | |
Collapse
|
12
|
van der Geest PJ, Mohseni M, Linssen J, Duran S, de Jonge R, Groeneveld ABJ. The intensive care infection score - a novel marker for the prediction of infection and its severity. Crit Care 2016; 20:180. [PMID: 27384242 PMCID: PMC4936267 DOI: 10.1186/s13054-016-1366-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/01/2016] [Indexed: 12/16/2022]
Abstract
Background The prediction of infection and its severity remains difficult in the critically ill. A novel, simple biomarker derived from five blood-cell derived parameters that characterize the innate immune response in routine blood samples, the intensive care infection score (ICIS), could be helpful in this respect. We therefore compared the predictive value of the ICIS with that of the white blood cell count (WBC), C-reactive protein (CRP) and procalcitonin (PCT) for infection and its severity in critically ill patients. Methods We performed a multicenter, cluster-randomized, crossover study in critically ill patients between January 2013 and September 2014. Patients with a suspected infection for which blood cultures were taken by the attending intensivist were included. Blood was taken at the same time for WBC, ICIS, CRP and PCT measurements in the control study periods. Results of imaging and cultures were collected. Patients were divided into groups of increasing likelihood of infection and invasiveness: group 1 without infection or with possible infection irrespective of cultures, group 2 with probable or microbiologically proven local infection without blood stream infection (BSI) and group 3 with BSI irrespective of local infection. Septic shock was assessed. Results In total, 301 patients were enrolled. CRP, PCT and ICIS were higher in groups 2 and 3 than group 1. The area under the receiver operating characteristic curve (AUROC) for the prediction of infection was 0.70 for CRP, 0.71 for PCT and 0.73 for ICIS (P < 0.001). For the prediction of septic shock the AUROC was 0.73 for CRP, 0.85 for PCT and 0.76 for ICIS. These AUROC did not differ from each other. Conclusion The data suggest that the ICIS is potentially useful for the prediction of infection and its severity in critically ill patients, non-inferiorly to CRP and PCT. In contrast to CRP and PCT, the ICIS can be determined routinely without extra blood sampling and lower costs, yielding results within 15 minutes. Trial registration ClinicalTrials.gov identifier: ID NCT01847079. Registered on 24 April 2013.
Collapse
Affiliation(s)
- Patrick J van der Geest
- Department of Intensive Care Medicine of the Erasmus Medical Center, 's Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands.
| | - Mostafa Mohseni
- Department of Intensive Care Medicine of the Erasmus Medical Center, 's Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
| | - Jo Linssen
- Faculty of Health Science, University of Medicine, Institute of Immunology, University Witten/Herdecke, Witten, Germany
| | - Servet Duran
- Department of Intensive Care Medicine of the Maasstad Hospital, Rotterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry of the Erasmus Medical Center, Rotterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care Medicine of the Erasmus Medical Center, 's Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
| |
Collapse
|
13
|
Egal M, Erler NS, de Geus HRH, van Bommel J, Groeneveld ABJ. Targeting Oliguria Reversal in Goal-Directed Hemodynamic Management Does Not Reduce Renal Dysfunction in Perioperative and Critically Ill Patients: A Systematic Review and Meta-Analysis. Anesth Analg 2016; 122:173-85. [PMID: 26505575 DOI: 10.1213/ane.0000000000001027] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We investigated whether resuscitation protocols to achieve and maintain urine output above a predefined threshold-including oliguria reversal as a target--prevent acute renal failure (ARF). METHODS We performed a systematic review and meta-analysis using studies found by searching MEDLINE, EMBASE, and references in relevant reviews and articles. We included all studies that compared "conventional fluid management" (CFM) with "goal-directed therapy" (GDT) using cardiac output, urine output, or oxygen delivery parameters and reported the occurrence of ARF in critically ill or surgical patients. We divided studies into groups with and without oliguria reversal as a target for hemodynamic optimization. We calculated the combined odds ratio (OR) and 95% confidence intervals (CIs) using random-effects meta-analysis. RESULTS We based our analyses on 28 studies. In the overall analysis, GDT resulted in less ARF than CFM (OR, 0.58; 95% CI, 0.44-0.76; P < 0.001; I = 34.3%; n = 28). GDT without oliguria reversal as a target resulted in less ARF (OR, 0.45; 95% CI, 0.34-0.61; P < 0.001; I = 7.1%; n = 7) when compared with CFM with oliguria reversal as a target. The studies comparing GDT with CFM in which the reversal of oliguria was targeted in both or in neither group did not provide enough evidence to conclude a superiority of GDT (targeting oliguria reversal in both protocols: OR, 0.63; 95% CI, 0.36-1.10; P = 0.09; I = 48.6%; n = 9, and in neither protocol: OR, 0.66; 95% CI, 0.37-1.16; P = 0.14; I = 20.2%; n = 12). CONCLUSIONS Current literature favors targeting circulatory optimization by GDT without targeting oliguria reversal to prevent ARF. Future studies are needed to investigate the hypothesis that targeting oliguria reversal does not prevent ARF in critically ill and surgical patients.
Collapse
Affiliation(s)
- Mohamud Egal
- From the Departments of *Intensive Care, †Biostatistics, and ‡Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | |
Collapse
|
14
|
Hoeboer SH, Groeneveld ABJ, van der Heijden M, Oudemans-van Straaten HM. Serial inflammatory biomarkers of the severity, course and outcome of late onset acute respiratory distress syndrome in critically ill patients with or at risk for the syndrome after new-onset fever. Biomark Med 2016; 9:605-16. [PMID: 26079964 DOI: 10.2217/bmm.15.15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
AIM Accurate biomarkers of the acute respiratory distress syndrome (ARDS) may help risk stratification and management. We assessed the relation between several biomarkers and the severity, course and outcome of late onset ARDS in 101 consecutive critically ill patients with new onset fever. MATERIALS AND METHODS On study days 0, 1, 2 and 7 we measured angiopoietin-2 (ANG2), pentraxin-3 (PTX3), interleukin-6 (IL-6), procalcitonin (PCT) and midregional proadrenomedullin (proADM). ARDS was defined by the Berlin definition and by the lung injury score (LIS). RESULTS At baseline, 48% had ARDS according to the Berlin definition and 86% according to the LIS. Baseline markers poorly predicted maximum Berlin categories attained within 7 days, whereas ANG2 best predicted maximum LIS. Depending on the ARDS definition, the day-by-day area under the receiver operating characteristic curves suggested greatest monitoring value for IL-6 and PCT, followed by ANG2. ANG2 and proADM predicted outcome, independently of disease severity. CONCLUSION Whereas IL-6 and PCT had some disease monitoring value, ANG2 was the only biomarker capable of both predicting the severity, monitoring the course and predicting the outcome of late onset ARDS in febrile critically ill patients, irrespective of underlying risk factor, thereby yielding the most specific ARDS biomarker among those studied.
Collapse
Affiliation(s)
- Sandra H Hoeboer
- Department of intensive care of Erasmus Medical Centre Rotterdam, s-Gravendijkwal 230; 3015 CE Rotterdam, The Netherlands.,Department of intensive care of VU University Medical Centre Amsterdam, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of intensive care of Erasmus Medical Centre Rotterdam, s-Gravendijkwal 230; 3015 CE Rotterdam, The Netherlands
| | - Melanie van der Heijden
- Department of intensive care of Erasmus Medical Centre Rotterdam, s-Gravendijkwal 230; 3015 CE Rotterdam, The Netherlands.,Department of physiology of VU University Medical Centre Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Heleen M Oudemans-van Straaten
- Department of intensive care of VU University Medical Centre Amsterdam, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| |
Collapse
|
15
|
Heijnen BGADH, Spoelstra-de Man AME, Groeneveld ABJ. Low Transmission of Airway Pressures to the Abdomen in Mechanically Ventilated Patients With or Without Acute Respiratory Failure and Intra-Abdominal Hypertension. J Intensive Care Med 2016; 32:218-222. [PMID: 26732769 DOI: 10.1177/0885066615625180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Intra-abdominal pressure, measured at end expiration, may depend on ventilator settings and transmission of intrathoracic pressure. We determined the transmission of positive intrathoracic pressure during mechanical ventilation at inspiration and expiration into the abdominal compartment. METHODS AND RESULTS We included 9 patients after uncomplicated cardiac surgery and 9 with acute respiratory failure. Intravesical pressures were measured thrice (reproducibility of 1.8%) and averaged, at the end of each inspiratory and expiratory hold maneuvers of 5 seconds. Transmission, the change in intra-abdominal over intrathoracic pressures from end inspiration to end expiration, was about 8%. End-expiratory intra-abdominal pressure was lower than "total" intra-abdominal pressure over the entire respiratory cycle by 0.34 cm H2O. It was 0.73 cm H2O higher than "true" intra-abdominal pressure over the entire respiratory cycle, taking transmission into account. The percentage error was 3% for total and 10% for true pressure. Results did not differ among patients with or without acute respiratory failure and decreased respiratory compliance or between those with (≥12 mm Hg, n = 5) or without intra-abdominal hypertension. CONCLUSIONS Transmitted airway pressure only slightly affects intra-abdominal pressure in mechanically ventilated patients, irrespective of respiratory compliance and baseline intra-abdominal pressure values. End-expiratory measurements referenced against atmospheric pressure may suffice for clinical practice.
Collapse
Affiliation(s)
- Bram G A D H Heijnen
- 1 Department of Intensive Care, St Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | | | | |
Collapse
|
16
|
van der Geest PJ, Rijnders BJA, Vonk AG, Groeneveld ABJ. Echinocandin to fluconazole step-down therapy in critically ill patients with invasive, susceptible Candida albicans infections. Mycoses 2015; 59:179-85. [PMID: 26707572 DOI: 10.1111/myc.12450] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/24/2015] [Accepted: 11/22/2015] [Indexed: 01/24/2023]
Abstract
Invasive Candida spp. infections are increasingly diagnosed in critically ill patients. For initial treatment, an echinocandin is recommended with a possible step-down to fluconazole when the patients' condition is improving and the isolate appears susceptible, but there are no data to support such policy. We studied the safety and efficacy of step-down therapy in critically ill patients with culture proven deep seated or bloodstream infections by C. albicans susceptible to fluconazole. All patients admitted into the intensive care unit from January 2010 to December 2014, who had a culture proven invasive C. albicans infection and received initial treatment with an echinocandin for at least 4 days were included. Data on patient characteristics, treatment and vital outcomes were assessed. Of the 56 patients, 32 received step-down fluconazole therapy, at median day 5, whereas the echinocandin was continued in the other 24. No differences where seen in baseline characteristics or risk factors for invasive C. albicans infection between the two groups. Response rates were similar and no difference where seen in 28-day or 90-day mortality between the groups. Step-down therapy to fluconazole may be safe and effective in critically ill patients with invasive infections by C. albicans, susceptible to fluconazole, who have clinically improved as early as 4 days after start of treatment with an echinocandin.
Collapse
Affiliation(s)
| | - Bart J A Rijnders
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alieke G Vonk
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
17
|
Alders DJC, Groeneveld ABJ, Binsl TW, van Beek JHGM. Progressively heterogeneous mismatch of regional oxygen delivery to consumption during graded coronary stenosis in pig left ventricle. Am J Physiol Heart Circ Physiol 2015; 309:H1708-19. [DOI: 10.1152/ajpheart.00657.2014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/18/2015] [Indexed: 11/22/2022]
Abstract
In normal hearts, myocardial perfusion is fairly well matched to regional metabolic demand, although both are distributed heterogeneously. Nonuniform regional metabolic vulnerability during coronary stenosis would help to explain nonuniform necrosis during myocardial infarction. In the present study, we investigated whether metabolism-perfusion correlation diminishes during coronary stenosis, indicating increasing mismatch of regional oxygen supply to demand. Thirty anesthetized male pigs were studied: controls without coronary stenosis ( n = 11); group I, left anterior descending (LAD) coronary stenosis leading to coronary perfusion pressure reduction to 70 mmHg ( n = 6); group II, stenosis with perfusion pressure of about 35 mmHg ( n = 6); and group III, stenosis with perfusion pressure of 45 mmHg combined with adenosine infusion ( n = 7). [2-13C]- and [1,2-13C]acetate infusion was used to calculate regional O2 consumption from glutamate NMR spectra measured for multiple tissue samples of about 100 mg dry mass in the LAD region. Blood flow was measured with microspheres in the same regions. In control hearts without stenosis, regional oxygen extraction did not correlate with basal blood flow. Average myocardial O2 delivery and consumption decreased during coronary stenosis, but vasodilation with adenosine counteracted this. Regional oxygen extraction was on average decreased during stenosis, suggesting adaptation of metabolism to lower oxygen supply after half an hour of ischemia. Whereas regional O2 delivery correlated with O2 consumption in controls, this relation was progressively lost with graded coronary hypotension but partially reestablished by adenosine infusion. Therefore, coronary stenosis leads to heterogeneous metabolic stress indicated by decreasing regional O2 supply to demand matching in myocardium during partial coronary obstruction.
Collapse
Affiliation(s)
- David J. C. Alders
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Johannes H. G. M. van Beek
- Center for Integrative Bioinformatics and
- Section Functional Genomics, Department of Clinical Genetics, VU University Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
18
|
Schilder L, Nurmohamed SA, ter Wee PM, Paauw NJ, Girbes ARJ, Beishuizen A, Beelen RHJ, Groeneveld ABJ. Putative novel mediators of acute kidney injury in critically ill patients: handling by continuous venovenous hemofiltration and effect of anticoagulation modalities. BMC Nephrol 2015; 16:178. [PMID: 26519056 PMCID: PMC4628303 DOI: 10.1186/s12882-015-0167-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/14/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Novel putative mediators of acute kidney injury (AKI) include immune-cell derived tumour necrosis factor-like weak inducer of apoptosis (TWEAK), angiopoietin-2 (Ang-2) and protein pentraxin-3 (PTX3). The effect of continuous venovenous hemofiltration (CVVH) and different anticoagulation regimens on plasma levels were studied. METHODS At 0, 10, 60, 180 and 720 min of CVVH, samples were collected from pre- and postfilter blood and ultrafiltrate. No anticoagulation (n = 13), unfractionated heparin (n = 8) or trisodium citrate (n = 21) were compared. RESULTS Concentrations of TWEAK, Ang-2 and PTX3 were hardly affected by CVVH since the mediators were not (TWEAK, PTX3) or hardly (Ang-2) detectable in ultrafiltrate, indicating negligible clearance by the filter in spite of molecular sizes (TWEAK, PTX3) at or below the cutoff of the membrane. Heparin use, however, was associated with an increase in in- and outlet plasma TWEAK. CONCLUSION Novel AKI mediators are not cleared nor produced by CVVH. However, heparin anticoagulation increased TWEAK levels in patient's plasma whereas citrate did not, favouring the latter as anticoagulant in CVVH for AKI.
Collapse
Affiliation(s)
- Louise Schilder
- Department of Nephrology, VU University medical center, De Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - S Azam Nurmohamed
- Department of Nephrology, VU University medical center, De Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - Pieter M ter Wee
- Department of Nephrology, VU University medical center, De Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - Nanne J Paauw
- Department of Molecular Cell Biology and Immunology, Netherlands, The Netherlands.
| | - Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
| | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Robert H J Beelen
- Department of Molecular Cell Biology and Immunology, Netherlands, The Netherlands.
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| |
Collapse
|
19
|
Cherpanath TGV, Smeding L, Hirsch A, Lagrand WK, Schultz MJ, Groeneveld ABJ. Low tidal volume ventilation ameliorates left ventricular dysfunction in mechanically ventilated rats following LPS-induced lung injury. BMC Anesthesiol 2015; 15:140. [PMID: 26446079 PMCID: PMC4597388 DOI: 10.1186/s12871-015-0123-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 10/03/2015] [Indexed: 01/06/2023] Open
Abstract
Background High tidal volume ventilation has shown to cause ventilator-induced lung injury (VILI), possibly contributing to concomitant extrapulmonary organ dysfunction. The present study examined whether left ventricular (LV) function is dependent on tidal volume size and whether this effect is augmented during lipopolysaccharide(LPS)-induced lung injury. Methods Twenty male Wistar rats were sedated, paralyzed and then randomized in four groups receiving mechanical ventilation with tidal volumes of 6 ml/kg or 19 ml/kg with or without intrapulmonary administration of LPS. A conductance catheter was placed in the left ventricle to generate pressure-volume loops, which were also obtained within a few seconds of vena cava occlusion to obtain relatively load-independent LV systolic and diastolic function parameters. The end-systolic elastance / effective arterial elastance (Ees/Ea) ratio was used as the primary parameter of LV systolic function with the end-diastolic elastance (Eed) as primary LV diastolic function. Results Ees/Ea decreased over time in rats receiving LPS (p = 0.045) and high tidal volume ventilation (p = 0.007), with a lower Ees/Ea in the rats with high tidal volume ventilation plus LPS compared to the other groups (p < 0.001). Eed increased over time in all groups except for the rats receiving low tidal volume ventilation without LPS (p = 0.223). A significant interaction (p < 0.001) was found between tidal ventilation and LPS for Ees/Ea and Eed, and all rats receiving high tidal volume ventilation plus LPS died before the end of the experiment. Conclusions Low tidal volume ventilation ameliorated LV systolic and diastolic dysfunction while preventing death following LPS-induced lung injury in mechanically ventilated rats. Our data advocates the use of low tidal volumes, not only to avoid VILI, but to avert ventilator-induced myocardial dysfunction as well.
Collapse
Affiliation(s)
- Thomas G V Cherpanath
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Lonneke Smeding
- Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Alexander Hirsch
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Wim K Lagrand
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - A B Johan Groeneveld
- Department of Intensive Care Medicine, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
| |
Collapse
|
20
|
de Jong MFC, Molenaar N, Beishuizen A, Groeneveld ABJ. Erratum to: Diminished adrenal sensitivity to endogenous and exogenous adrenocorticotropic hormone in critical illness: a prospective cohort study. Crit Care 2015; 19:313. [PMID: 26336862 PMCID: PMC4558768 DOI: 10.1186/s13054-015-1015-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Margriet F C de Jong
- Department of Nephrology, VU University Medical Centre, De Boelelaan 1117, Amsterdam, 1081HV, The Netherlands.
| | - Nienke Molenaar
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care, Medical Spectrum Twente, Enschede, The Netherlands.,Department of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
21
|
Molenaar N, Groeneveld ABJ, de Jong MFC. Three calculations of free cortisol versus measured values in the critically ill. Clin Biochem 2015; 48:1053-8. [PMID: 26169244 DOI: 10.1016/j.clinbiochem.2015.07.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/03/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate the agreement between the calculated free cortisol levels according to widely applied Coolens and adjusted Södergård equations with measured levels in the critically ill. DESIGN AND METHODS A prospective study in a mixed intensive care unit. We consecutively included 103 patients with treatment-insensitive hypotension in whom an adrenocorticotropic hormone (ACTH) test (250μg) was performed. Serum total and free cortisol (equilibrium dialysis), corticosteroid-binding globulin and albumin were assessed. Free cortisol was estimated by the Coolens method (C) and two adjusted Södergård (S1 and S2) equations. Bland Altman plots were made. RESULTS The bias for absolute (t=0, 30 and 60min after ACTH injection) cortisol levels was 38, -24, 41nmol/L when the C, S1 and S2 equations were used, with 95% limits of agreement between -65-142, -182-135, and -57-139nmol/L and percentage errors of 66, 85, and 64%, respectively. Bias for delta (peak-baseline) cortisol was 14, -31 and 16nmol/L, with 95% limits of agreement between -80-108, -157-95, and -74-105nmol/L, and percentage errors of 107, 114, and 100% for C, S1 and S2 equations, respectively. CONCLUSIONS Calculated free cortisol levels have too high bias and imprecision to allow for acceptable use in the critically ill.
Collapse
Affiliation(s)
- Nienke Molenaar
- Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Margriet F C de Jong
- Department of Nephrology, University Medical Center Groningen, 9700 RB Groningen, The Netherlands.
| |
Collapse
|
22
|
Streefkerk JO, Beishuizen A, Groeneveld ABJ. Gastric feeding intolerance is not caused by mucosal ischemia measured by intragastric air tonometry in the critically ill. Clin Nutr 2015; 35:731-4. [PMID: 26082336 DOI: 10.1016/j.clnu.2015.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/09/2015] [Accepted: 05/22/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Gastric mucosal ischemia may be a risk factor for gastrointestinal intolerance to early feeding in the critically ill. AIMS To study intragastric PCO2 air tonometry and gastric residual volumes (GRV) before and after the start of gastric feeding. METHODS This is a two-center study in intensive care units of a university and teaching hospital. Twenty-nine critically ill, consecutive and consenting patients scheduled to start gastric feeding were studied after insertion of a gastric tonometry catheter and prior to and after start of gastric feeding (500 ml over 1 h), when clinically indicated. RESULTS Blood gasometry and intragastric tonometry were performed prior to and 2 h after gastric feeding. The intragastric to arterial PCO2 gap (normal <8 mm Hg) was elevated in 41% of patients prior to feeding and measured (mean ± standard deviation) 13 ± 20 and 16 ± 23 mm Hg in patients with normal (<100 ml, 42 ± 34 ml, n = 19) and elevated GRV (250 ± 141 ml, n = 10, P = 0.75), respectively. After feeding, the gradient did not increase and measured 27 ± 25 and 23 ± 34 mm Hg, respectively (P = 0.80). CONCLUSION Gastric mucosal ischemia is not a major risk factor for intolerance to early gastric feeding in the critically ill.
Collapse
Affiliation(s)
- Jörn O Streefkerk
- Department of Intensive Care Medisch Centrum Haaglanden and Bronovo Ziekenhuis, Den Haag, Rotterdam, The Netherlands
| | | | | |
Collapse
|
23
|
Affiliation(s)
- A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, 230 Gravendijkwal, 3015 CE, Rotterdam, The Netherlands.
| | | | - Mahlon M Wilkes
- Hygeia Associates, 17988 Brewer Road, Grass Valley, CA, 95949, USA.
| |
Collapse
|
24
|
Jakob SM, Groeneveld ABJ, Teboul JL. Venous-arterial CO2 to arterial-venous O2 difference ratio as a resuscitation target in shock states? Intensive Care Med 2015; 41:936-8. [PMID: 25851389 DOI: 10.1007/s00134-015-3778-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital (Inselspital), University of Bern, Bern, Switzerland,
| | | | | |
Collapse
|
25
|
Hoeboer SH, Oudemans-van Straaten HM, Groeneveld ABJ. Albumin rather than C-reactive protein may be valuable in predicting and monitoring the severity and course of acute respiratory distress syndrome in critically ill patients with or at risk for the syndrome after new onset fever. BMC Pulm Med 2015; 15:22. [PMID: 25888398 PMCID: PMC4381515 DOI: 10.1186/s12890-015-0015-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/19/2015] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND We studied the value of routine biochemical variables albumin, C-reactive protein (CRP) and lactate dehydrogenase (LDH) to improve prediction and monitoring of acute respiratory distress syndrome (ARDS) severity in the intensive care unit. METHODS In 101 critically ill patients, with or at risk for ARDS after new onset fever, data were collected on days (D) 0, 1, 2, and 7 after inclusion. ARDS was defined by the Berlin definition and lung injury score (LIS). RESULTS At baseline, 48 patients had mild to severe ARDS according to Berlin and 87 according to LIS (Rs = 0.54, P < 0.001). Low baseline albumin levels were moderately associated with maximum Berlin and LIS categories within 7 days; an elevated CRP level was moderately associated with maximum Berlin categories only. The day-by-day Berlin and LIS categories were inversely associated with albumin levels (P = 0.01, P < 0.001) and directly with CRP levels (P = 0.02, P = 0.04, respectively). Low albumin levels had monitoring value for ARDS severity on all study days (area under the receiver operating characteristic curve, AUROC, 0.62-0.82, P < 0.001-0.03), whereas supranormal CRP levels performed less . When the Berlin or LIS category increased, albumin levels decreased ≥1 g/L (AUROC 0.72-0.77, P = 0.001) and CRP increased ≥104 mg/L (only significant for Berlin, AUROC 0.69, P = 0.04). When the LIS decreased, albumin levels increased ≥1 g/L (AUROC 0.68, P = 0.02). LDH was higher in 28-day non-survivors than survivors (P = 0.007). CONCLUSIONS Overall, albumin may be of greater value than CRP in predicting and monitoring the severity and course of ARDS in critically patients with or at risk for the syndrome after new onset fever. Albumin levels below 20 g/L as well as a decline over a week are associated with ARDS of increasing severity, irrespective of its definition. LDH levels predicted 28-day mortality.
Collapse
Affiliation(s)
- Sandra H Hoeboer
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| |
Collapse
|
26
|
Hoeboer SH, van der Geest PJ, Nieboer D, Groeneveld ABJ. The diagnostic accuracy of procalcitonin for bacteraemia: a systematic review and meta-analysis. Clin Microbiol Infect 2015; 21:474-81. [PMID: 25726038 DOI: 10.1016/j.cmi.2014.12.026] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 11/29/2014] [Accepted: 12/20/2014] [Indexed: 01/07/2023]
Abstract
The diagnostic use of procalcitonin for bacterial infections remains a matter of debate. Most studies have used ambiguous outcome measures such as sepsis instead of infection. We performed a systematic review and meta-analysis to investigate the diagnostic accuracy of procalcitonin for bacteraemia, a proven bloodstream infection. We searched all major databases from inception to June 2014 for original, English language, research articles that studied the diagnostic accuracy between procalcitonin and positive blood cultures in adult patients. We calculated the area under the summary receiver-operating characteristic (SROC) curves and pooled sensitivities and specificities. To minimize potential heterogeneity we performed subgroup analyses. In total, 58 of 1567 eligible studies were included in the meta-analysis and provided a total of 16,514 patients, of whom 3420 suffered from bacteraemia. In the overall analysis the area under the SROC curve was 0.79. The optimal and most widely used procalcitonin cut-off value was 0.5 ng/mL with a corresponding sensitivity of 76% and specificity of 69%. In subgroup analyses the lowest area under the SROC curve was found in immunocompromised/neutropenic patients (0.71), the highest area under the SROC curve was found in intensive-care patients (0.88), sensitivities ranging from 66 to 89% and specificities from 55 78%. In spite of study heterogeneity, procalcitonin had a fair diagnostic accuracy for bacteraemia in adult patients suspected of infection or sepsis. In particular low procalcitonin levels can be used to rule out the presence of bacteraemia. Further research is needed on the safety and efficacy of procalcitonin as a single diagnostic tool to avoid taking blood cultures.
Collapse
Affiliation(s)
- S H Hoeboer
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - P J van der Geest
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - D Nieboer
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - A B J Groeneveld
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
27
|
Hoeboer SH, Groeneveld ABJ, Engels N, van Genderen M, Wijnhoven BPL, van Bommel J. Rising C-reactive protein and procalcitonin levels precede early complications after esophagectomy. J Gastrointest Surg 2015; 19:613-24. [PMID: 25663633 PMCID: PMC4361731 DOI: 10.1007/s11605-015-2745-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 01/05/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Elective esophagectomy with gastric tube reconstruction carries a high risk for complications. Early and accurate diagnosis could improve patient management. Increased C-reactive protein (CRP) levels may be associated with any, surgical or infectious, complication and procalcitonin (PCT) specifically with infectious complications. METHODS We measured CRP and PCT on post-operative days 0, 1, 2, and 3 in 45 consecutive patients. Complications were recorded up to 10 days post-esophagectomy. RESULTS Twenty-eight patients developed a post-operative complication (5 surgical, 14 infectious, 9 combined surgical/infectious, including anastomotic leakage), presenting on day 3 or later. Elevated days 2 and 3 and a rise in CRP preceded the diagnosis of general or combined surgical/infectious complications (minimum area under the receiver operating characteristics curve (AUROC) 0.75, P = 0.006). Elevated day 3 PCT preceded combined complications (AUROC 0.86, P < 0.001). High day 1 and 3 PCT levels preceded anastomotic leakage (minimum AUROC 0.76, P = 0.005), as did the day 3 CRP levels and their increases (minimum AUROC 0.78, P = 0.002). CONCLUSIONS This small study suggests that high or increasing CRP levels may precede the clinical diagnosis of general or surgical/infectious complications after esophagectomy. Elevated PCT levels may more specifically and timely precede combined surgical/infectious complications mainly associated with anastomotic leakage.
Collapse
Affiliation(s)
- Sandra H. Hoeboer
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - A. B. Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Noel Engels
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Michel van Genderen
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | | | - Jasper van Bommel
- Department of Intensive Care, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| |
Collapse
|
28
|
de Waard MC, Banwarie RP, Jewbali LSD, Struijs A, Girbes ARJ, Groeneveld ABJ. Intravascular versus surface cooling speed and stability after cardiopulmonary resuscitation. Emerg Med J 2014; 32:775-80. [PMID: 25527471 DOI: 10.1136/emermed-2014-203811] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 11/28/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVE Mild therapeutic hypothermia (MTH) is used to limit neurological injury and improve survival after cardiac arrest (CA) and cardiopulmonary resuscitation, but the optimal mode of cooling is controversial. We therefore compared the effectiveness of MTH using invasive intravascular or non-invasive surface cooling with temperature feedback control. METHODS This retrospective study in post-CA patients studied the effects of intravascular cooling (CoolGard, Zoll, n=97), applied on the intensive care unit (ICU) in one university hospital compared with those of surface cooling (Medi-Therm, Gaymar, n=76) applied in another university hospital. RESULTS Time to reach target temperature and cooling speeds did not differ between groups. During the maintenance phase, mean core temperature was 33.1°C (range 32.7-33.7°C) versus 32.5°C (range 31.7-33.4°C) at targets of 33.0 and 32.5°C in intravascularly versus surface cooled patients, respectively. The variation coefficient for temperature during maintenance was higher in the surface than the intravascular cooling group (mean 0.85% vs 0.35%, p<0.0001). ICU survival was 60% and 50% in the intravascularly and surface cooled groups, respectively (NS). Lower age (OR 0.95; 95% CI 0.93 to 0.98; p<0.0001), ventricular fibrillation/ventricular tachycardia as presenting rhythm (OR 7.6; 95% CI 1.8 to 8.9; p<0.0001) and lower mean temperature during the maintenance phase (OR 0.52; 95% CI 0.25 to 1.08; p=0.081) might be independent determinants of ICU survival, while cooling technique and temperature variability did not contribute. CONCLUSIONS In post-CA patients, intravascular cooling systems result in equal cooling speed, but less variation in temperature during the maintenance phase, as surface cooling. This may not affect the outcome.
Collapse
Affiliation(s)
- M C de Waard
- Department of Intensive Care, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - R P Banwarie
- Department of Intensive Care, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L S D Jewbali
- Department of Intensive Care, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A Struijs
- Department of Intensive Care, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A R J Girbes
- Department of Intensive Care, Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - A B J Groeneveld
- Department of Intensive Care, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
29
|
de Haan K, Groeneveld ABJ, de Geus HRH, Egal M, Struijs A. Vitamin D deficiency as a risk factor for infection, sepsis and mortality in the critically ill: systematic review and meta-analysis. Crit Care 2014; 18:660. [PMID: 25475621 PMCID: PMC4277653 DOI: 10.1186/s13054-014-0660-4] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 11/12/2014] [Indexed: 12/24/2022]
Abstract
Introduction In Europe, vitamin D deficiency is highly prevalent varying between 40% and 60% in the healthy general adult population. The consequences of vitamin D deficiency for sepsis and outcome in critically ill patients remain controversial. We therefore systematically reviewed observational cohort studies on vitamin D deficiency in the intensive care unit. Methods Fourteen observational reports published from January 2000 to March 2014, retrieved from Pubmed and Embase, involving 9,715 critically ill patients and serum 25-hydroxyvitamin D3 (25 (OH)-D) concentrations, were meta-analysed. Results Levels of 25 (OH)-D less than 50 nmol/L were associated with increased rates of infection (risk ratio (RR) 1.49, 95% (confidence interval (CI) 1.12 to 1.99), P = 0.007), sepsis (RR 1.46, 95% (CI 1.27 to 1.68), P <0.001), 30-day mortality (RR 1.42, 95% (CI 1.00 to 2.02), P = 0.05), and in-hospital mortality (RR 1.79, 95% (CI 1.49 to 2.16), P <0.001). In a subgroup analysis of adjusted data including vitamin D deficiency as a risk factor for 30-day mortality the pooled RR was 1.76 (95% CI 1.37 to 2.26, P <0.001). Conclusions This meta-analysis suggests that vitamin D deficiency increases susceptibility for severe infections and mortality of the critically ill. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0660-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kim de Haan
- Department of Intensive Care, Erasmus Medical Centre, Mailbox 2040, H603a, 3000CA, Rotterdam, The Netherlands.
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, Mailbox 2040, H603, 3000CA, Rotterdam, The Netherlands.
| | - Hilde R H de Geus
- Department of Intensive Care, Erasmus Medical Centre, Mailbox 2040, H619, 3000CA, Rotterdam, The Netherlands.
| | - Mohamud Egal
- Department of Intensive Care, Erasmus Medical Centre, Mailbox 2040, H619, 3000CA, Rotterdam, The Netherlands.
| | - Ard Struijs
- Department of Intensive Care, Erasmus Medical Centre, Mailbox 2040, H603a, 3000CA, Rotterdam, The Netherlands.
| |
Collapse
|
30
|
Schilder L, Nurmohamed SA, Bosch FH, Purmer IM, den Boer SS, Kleppe CG, Vervloet MG, Beishuizen A, Girbes ARJ, Ter Wee PM, Groeneveld ABJ. Citrate anticoagulation versus systemic heparinisation in continuous venovenous hemofiltration in critically ill patients with acute kidney injury: a multi-center randomized clinical trial. Crit Care 2014; 18:472. [PMID: 25128022 PMCID: PMC4161888 DOI: 10.1186/s13054-014-0472-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 07/23/2014] [Indexed: 11/17/2022]
Abstract
Introduction Because of ongoing controversy, renal and vital outcomes are compared between systemically administered unfractionated heparin and regional anticoagulation with citrate-buffered replacement solution in predilution mode, during continuous venovenous hemofiltration (CVVH) in critically ill patients with acute kidney injury (AKI). Methods In this multi-center randomized controlled trial, patients admitted to the intensive care unit requiring CVVH and meeting inclusion criteria, were randomly assigned to citrate or heparin. Primary endpoints were mortality and renal outcome in intention-to-treat analysis. Secondary endpoints were safety and efficacy. Safety was defined as absence of any adverse event necessitating discontinuation of the assigned anticoagulant. For efficacy, among other parameters, survival times of the first hemofilter were studied. Results Of the 139 patients enrolled, 66 were randomized to citrate and 73 to heparin. Mortality rates at 28 and 90 days did not differ between groups: 22/66 (33%) of citrate-treated patients died versus 25/72 (35%) of heparin-treated patients at 28 days, and 27/65 (42%) of citrate-treated patients died versus 29/69 (42%) of heparin-treated patients at 90 days (P = 1.00 for both). Renal outcome, i.e. independency of renal replacement therapy 28 days after initiation of CVVH in surviving patients, did not differ between groups: 29/43 (67%) in the citrate-treated patients versus 33/47 (70%) in heparin-treated patients (P = 0.82). Heparin was discontinued in 24/73 (33%) of patients whereas citrate was discontinued in 5/66 (8%) of patients (P < 0.001). Filter survival times were superior for citrate (median 46 versus 32 hours, P = 0.02), as were the number of filters used (P = 0.002) and the off time within 72 hours (P = 0.002). The costs during the first 72 hours of prescribed CVVH were lower in citrate-based CVVH. Conclusions Renal outcome and patient mortality were similar for citrate and heparin anticoagulation during CVVH in the critically ill patient with AKI. However, citrate was superior in terms of safety, efficacy and costs. Trial registration Clinicaltrials.gov NCT00209378. Registered 13th September 2005. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0472-6) contains supplementary material, which is available to authorized users.
Collapse
|
31
|
Kuiper JW, Groeneveld ABJ, Haitsma JJ, Smeding L, Begieneman MPV, Jothy S, Vaschetto R, Plötz FB. Injurious mechanical ventilation causes kidney apoptosis and dysfunction during sepsis but not after intra-tracheal acid instillation: an experimental study. BMC Nephrol 2014; 15:126. [PMID: 25073618 PMCID: PMC4119441 DOI: 10.1186/1471-2369-15-126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 07/08/2014] [Indexed: 11/12/2022] Open
Abstract
Background Intratracheal aspiration and sepsis are leading causes of acute lung injury that frequently necessitate mechanical ventilation (MV), which may aggravate lung injury thereby potentially increasing the risk of acute kidney injury (AKI). We compared the effects of ventilation strategies and underlying conditions on the development of AKI. Methods Spraque Dawley rats were challenged by intratracheal acid instillation or 24 h of abdominal sepsis, followed by MV with a low tidal volume (LVT) and 5 cm H2O positive end-expiratory pressure (PEEP) or a high tidal volume (HVT) and no PEEP, which is known to cause more lung injury after acid instillation than in sepsis. Rats were ventilated for 4 hrs and kidney function and plasma mediator levels were measured. Kidney injury was assessed by microscopy; apoptosis was quantified by TUNEL staining. Results During sepsis, but not after acid instillation, MV with HVT caused more renal apoptosis than MV with LVT. Increased plasma active plasminogen activator inhibitor-1 correlated to kidney apoptosis in the cortex and medulla. Increased apoptosis after HVT ventilation during sepsis was associated with a 40% decrease in creatinine clearance. Conclusions AKI is more likely to develop after MV induced lung injury during an indirect (as in sepsis) than after a direct (as after intra-tracheal instillation) insult to the lungs, since it induces kidney apoptosis during sepsis but not after acid instillation, opposite to the lung injury it caused. Our findings thus suggest using protective ventilatory strategies in human sepsis, even in the absence of overt lung injury, to protect the kidney.
Collapse
Affiliation(s)
- Jan Willem Kuiper
- Department of Paediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, Dr, Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Ince C, Groeneveld ABJ. The case for 0.9% NaCl: is the undefendable, defensible? Kidney Int 2014; 86:1087-95. [PMID: 25007167 DOI: 10.1038/ki.2014.193] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/07/2014] [Accepted: 01/31/2014] [Indexed: 12/12/2022]
Abstract
Although 0.9% NaCl solution is by far the most-used fluid for fluid therapy in resuscitation, it is difficult to find a paper advocating its use over other types of crystalloid solutions. Literature on the deleterious effects of 0.9% NaCl has accumulated over the last decade, but critical appraisal of alternative crystalloid solutions is lacking. As such, the literature seems to suggest that 0.9% NaCl should be avoided at all costs, whereas alternative crystalloid solutions can be used without scrutiny. The basis of this negative evaluation of 0.9% NaCl is almost exclusively its effect on acid-base homeostasis, whereas the potentially deleterious effects present in other types of crystalloids are neglected. We have the challenging task of defending the use of 0.9% NaCl and reviewing its positive attributes, while an accompanying paper will argue against the use of 0.9% NaCl. It is challenging because of the large amount of literature, including our own, showing adverse effects of 0.9% NaCl. We will discuss why 0.9% NaCl solution is the most frequently used resuscitation fluid. Although it has some deleterious effects, all fluids share common features of concern. As such the emphasis on fluid resuscitation should be on volume rather than on composition and should be accompanied by a physiological assessment of the impact of fluids. In this paper, we hope to discuss the context within which fluids, specifically 0.9% NaCl, can be given in a safe and effective manner.
Collapse
Affiliation(s)
- Can Ince
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus MC University Hospital Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
33
|
Sprung CL, Paruk F, Kissoon N, Hartog CS, Lipman J, Du B, Argent A, Hodgson RE, Guidet B, Groeneveld ABJ, Feldman C. The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments. J Crit Care 2014; 29:890-5. [PMID: 25151218 DOI: 10.1016/j.jcrc.2014.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/23/2014] [Accepted: 06/21/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. METHODS Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. RESULTS Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. CONCLUSIONS Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.
Collapse
Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Fathima Paruk
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, Children's Hospital and Sunny Hill Health Centre for Children, University British Columbia, Vancouver, British Columbia, Canada
| | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care, Jena, Germany
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Womens Hospital and The University of Queensland, Herston, Queensland, Australia
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Andrew Argent
- School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - R Eric Hodgson
- Department of Anaesthesia and Critical Care, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal eThekwini-Durban, KwaZulu-Natal, South Africa
| | - Bertrand Guidet
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
34
|
Smorenberg A, Ince C, Groeneveld ABJ. Erratum to: Dose and type of crystalloid fluid therapy in adult hospitalized patients. Perioper Med (Lond) 2014. [PMCID: PMC4031486 DOI: 10.1186/2047-0525-3-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
35
|
Smorenberg A, Groeneveld ABJ. Diuretic response to colloid and crystalloid fluid loading in critically ill patients. J Nephrol 2014; 28:89-95. [PMID: 24828327 DOI: 10.1007/s40620-014-0101-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 04/17/2014] [Indexed: 12/30/2022]
Abstract
AIMS In the critically ill patient, fluid loading is commonly done to stabilise hemodynamics and increase diuresis, whereas the absence of diuresis may predispose to harmful overloading. The goal of the current study was to evaluate the diuretic response and determinants thereof upon crystalloid and colloid fluid loading. SUBJECTS AND METHODS This is a substudy on 42 clinically hypovolemic, septic or non-septic patients without acute kidney injury, who were randomly assigned, after stratification for sepsis, to a 90-min fluid loading protocol with either 0.9% saline or a colloid solution (gelatin, hydroxyethyl starch 200/0.5 or albumin). Hemodynamics, biochemical parameters and diuresis were recorded. A response was defined by an increase in diuresis of >10% during fluid loading. RESULTS Diuresis increased more during saline than colloid infusion, together with a decline in colloid osmotic pressure (COP) of plasma and less increase in plasma volume and global hemodynamics with saline, at similar fluid balance. Nine patients (82%) receiving saline had a diuretic response, compared to 13 patients (42%) receiving colloids (P = 0.04), and the response was not predicted by underlying condition, global hemodynamics, volume of fluid infused and COP. CONCLUSION In critically ill patients with clinical hypovolemia, diuresis increases more during saline than colloid fluid loading, only partly dependent of a fall in plasma COP.
Collapse
Affiliation(s)
- Annemieke Smorenberg
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands,
| | | |
Collapse
|
36
|
Schilder L, Nurmohamed SA, ter Wee PM, Paauw NJ, Girbes ARJ, Beishuizen A, Beelen RHJ, Groeneveld ABJ. The plasma level and biomarker value of neutrophil gelatinase-associated lipocalin in critically ill patients with acute kidney injury are not affected by continuous venovenous hemofiltration and anticoagulation applied. Crit Care 2014; 18:R78. [PMID: 24755339 PMCID: PMC4056788 DOI: 10.1186/cc13838] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/02/2014] [Indexed: 01/12/2023]
Abstract
Introduction Neutrophil gelatinase-associated lipocalin (NGAL) is a biomarker of acute kidney injury (AKI), and levels reflect severity of disease in critically ill patients. However, continuous venovenous hemofiltration (CVVH) may affect plasma levels by clearance or release of NGAL by activated neutrophils in the filter, dependent on the anticoagulation regimen applied. We therefore studied handling of NGAL by CVVH in patients with AKI. Methods Immediately before initiation of CVVH, prefilter blood was drawn. After 10, 60, 180, and 720 minutes of CVVH, samples were collected from pre- and postfilter (in- and outlet) blood and ultrafiltrate. CVVH with the following anticoagulation regimens was studied: no anticoagulation in case of a high bleeding tendency (n = 13), unfractionated heparin (n = 8), or trisodium citrate (n = 21). NGAL levels were determined with enzyme-linked immunosorbent assay (ELISA). Results Concentrations of NGAL at inlet and outlet were similar, and concentrations did not change over time in any of the anticoagulation groups; thus no net removal or production of NGAL occurred. Concentrations of NGAL at inlet correlated with disease severity at initiation of CVVH and at the end of a CVVH run. Concentrations of NGAL in the ultrafiltrate were lower with citrate-based CVVH (P = 0.03) and decreased over time, irrespective of anticoagulation administered (P < 0.001). The sieving coefficient and clearance of NGAL were low and decreased over time (P < 0.001). Conclusions The plasma level and biomarker value of NGAL in critically ill patients with AKI are not affected by CVVH, because clearance by the filter was low. Furthermore, no evidence exists for intrafilter release of NGAL by neutrophils, irrespective of the anticoagulation method applied.
Collapse
|
37
|
van der Geest PJ, Mohseni M, Brouwer R, van der Hoven B, Steyerberg EW, Groeneveld ABJ. Immature granulocytes predict microbial infection and its adverse sequelae in the intensive care unit. J Crit Care 2014; 29:523-7. [PMID: 24798344 DOI: 10.1016/j.jcrc.2014.03.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 03/05/2014] [Accepted: 03/30/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND We evaluated the predictive value of immature granulocyte (IG) percentage in comparison with white blood cell counts (WBC) and C-reactive protein (CRP), for infection, its invasiveness, and severity in critically ill patients. METHODS In 46 consecutive patients, blood samples were collected at the day (0) of a clinical suspicion of microbial infection and at days 1 and 3 thereafter. We defined infections, bloodstream infection, and septic shock within 7 days after enrollment. RESULTS Of the 46 patients, 31 patients had infection, 15 patients developed bloodstream infection, and 13 patients septic shock. C-reactive protein and IG percentage increased with increasing invasiveness and severity of infection, from day 0 onwards. Receiver operating characteristic analysis to predict infection showed an area under the curve of 0.66 (P=.10) for WBC vs 0.74 (P=.01) for CRP and 0.73 (P=.02) for IG percentage on day 0. Comparing WBC and CRP to WBC and IG percentage results in comparable prediction of microbial infection. Comparing WBC and CRP with WBC, CRP, and IG percentage suggests an additional early value of IG percentage, when not elevated, in ruling out infection. CONCLUSION Immature granulocyte percentage is a useful marker, as CRP, to predict infection, its invasiveness, and severity, in critically ill patients. However, the IG percentage adds to WBC and CRP in the early exclusion of infection and can be obtained routinely without extra blood sampling or costs.
Collapse
Affiliation(s)
| | - Mostafa Mohseni
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rob Brouwer
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ben van der Hoven
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - A B Johan Groeneveld
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
38
|
Helmi M, Gommers D, Groeneveld ABJ. A review of the hemodynamic effects of external leg and lower body compression. Minerva Anestesiol 2014; 80:355-365. [PMID: 24002462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND External leg and lower body compression (ELC) has been used for decades in the prevention of deep vein thrombosis and the treatment of leg ischemia. Because of systemic effects, the methods have regained interest in anesthesia, surgery and critical care. This review intends to summarize hemodynamic effects and their mechanisms. METHODS Compilation of relevant literature published in English as full paper and retrieved from Medline. RESULTS By compressing veins, venous stasis is diminished and venous return and arterial blood flow are increased. ELC has been suggested to improve systemic hemodynamics, in different clinical settings, such as postural hypotension, anesthesia, surgery, shock, cardiopulmonary resuscitation and mechanical ventilation. However, the hemodynamic alterations depend upon the magnitude, extent, cycle, duration and thus the modality of ELC, when applied in a static or intermittent fashion (by pneumatic inflation), respectively. CONCLUSION ELC may help future research and optimizing treatment of hemodynamically unstable, surgical or critically ill patients, independent of plasma volume expansion.
Collapse
Affiliation(s)
- M Helmi
- Department of Intensive Care Adults, Erasmus Medical Center, Rotterdam, The Netherlands -
| | | | | |
Collapse
|
39
|
Choo WP, Groeneveld ABJ, Driessen RH, Swart EL. Normal saline to dilute parenteral drugs and to keep catheters open is a major and preventable source of hypernatremia acquired in the intensive care unit. J Crit Care 2014; 29:390-4. [PMID: 24603000 DOI: 10.1016/j.jcrc.2014.01.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 01/12/2014] [Accepted: 01/27/2014] [Indexed: 02/08/2023]
Abstract
PURPOSE We wanted to identify modifiable risk factors for intensive care unit (ICU)-acquired hypernatremia. MATERIALS AND METHODS We retrospectively studied sodium and fluid loads and balances up to 7 days prior to the development of hypernatremia (first serum sodium concentration, [Na+], >150 mmol/L; H) vs control (maximum [Na+] ≤150 mmol/L; N), in consecutive patients admitted into the ICU with a normal serum sodium (<145 mmol/L) and without cerebral disease, within a period of 8 months. RESULTS There were 57 H and 150 N patients. Severity of disease and organ failure was greater, and length of stay and mechanical ventilation in the ICU were longer in H (P<.001), with a mortality rate of 28% vs 16% in N (P=.002). Sodium input was higher in H than in N, particularly from 0.9% saline to dissolve drugs for infusion and to keep catheters open during the week prior to the first day of hypernatremia (P<.001). Fluid balances were positive and did not differ from N on most days in the presence of slightly higher plasma creatinine and more frequent administration of furosemide, at higher doses, in H than in N. CONCLUSIONS High sodium input by 0.9% saline used to dilute drugs and keep catheters open is a modifiable risk factor for ICU-acquired H. Dissolving drugs in dextrose 5% may partially prevent potentially harmful sodium overloading and H.
Collapse
Affiliation(s)
- Wai-Ping Choo
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands.
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ronald H Driessen
- Department of Intensive care, VU University Medical Center, Amsterdam, The Netherlands
| | - Eleonora L Swart
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
40
|
Schilder L, Nurmohamed SA, ter Wee PM, Paauw NJ, Girbes ARJ, Beishuizen A, Beelen RHJ, Groeneveld ABJ. Citrate confers less filter-induced complement activation and neutrophil degranulation than heparin when used for anticoagulation during continuous venovenous haemofiltration in critically ill patients. BMC Nephrol 2014; 15:19. [PMID: 24438360 PMCID: PMC3898382 DOI: 10.1186/1471-2369-15-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 01/02/2014] [Indexed: 12/02/2022] Open
Abstract
Background During continuous venovenous haemofiltration (CVVH), regional anticoagulation with citrate may be superior to heparin in terms of biocompatibility, since heparin as opposed to citrate may activate complement (reflected by circulating C5a) and induce neutrophil degranulation in the filter and myeloperoxidase (MPO) release from endothelium. Methods No anticoagulation (n = 13), unfractionated heparin (n = 8) and trisodium citrate (n = 17) regimens during CVVH were compared. Blood samples were collected pre- and postfilter; C5a, elastase and MPO were determined by ELISA. Additionally, C5a was also measured in the ultrafiltrate. Results In the heparin group, there was C5a production across the filter which most decreased over time as compared to other groups (P = 0.007). There was also net production of elastase and MPO across the filter during heparin anticoagulation (P = 0.049 or lower), while production was minimal and absent in the no anticoagulation and citrate group, respectively. During heparin anticoagulation, plasma concentrations of MPO at the inlet increased in the first 10 minutes of CVVH (P = 0.024). Conclusion Citrate confers less filter-induced, potentially harmful complement activation and neutrophil degranulation and less endothelial activation than heparin when used for anticoagulation during continuous venovenous haemofiltration in critically ill patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| |
Collapse
|
41
|
Slagt C, Malagon I, Groeneveld ABJ. Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation. Br J Anaesth 2014; 112:626-37. [PMID: 24431387 DOI: 10.1093/bja/aet429] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
UNLABELLED The FloTrac/Vigileo™, introduced in 2005, uses arterial pressure waveform analysis to calculate cardiac output (CO) and stroke volume variation (SVV) without external calibration. The aim of this systematic review is to evaluate the performance of the system. Sixty-five full manuscripts on validation of CO measurements in humans, published in English, were retrieved; these included 2234 patients and 44,592 observations. RESULTS have been analysed according to underlying patient conditions, that is, general critical illness and surgery as normodynamic conditions, cardiac and (post)cardiac surgery as hypodynamic conditions, and liver surgery and sepsis as hyperdynamic conditions, and subsequently released software versions. Eight studies compared SVV with other dynamic indices. CO, bias, precision, %error, correlation, and concordance differed among underlying conditions, subsequent software versions, and their interactions, suggesting increasing accuracy and precision, particularly in hypo- and normodynamic conditions. The bias and the trending capacity remain dependent on (changes in) vascular tone with most recent software. The SVV only moderately agreed with other dynamic indices, although it was helpful in predicting fluid responsiveness in 85% of studies addressing this. Since its introduction, the performance of uncalibrated FloTrac/Vigileo™ has improved particularly in hypo- and normodynamic conditions. A %error at or below 30% with most recent software allows sufficiently accurate and precise CO measurements and trending for routine clinical use in normo- and hypodynamic conditions, in the absence of large changes in vascular tone. The SVV may usefully supplement these measurements.
Collapse
Affiliation(s)
- C Slagt
- Department of Anaesthesiology and Intensive Care, Zaans Medical Centre, Koningin Julianaplein 58, 1502 DV Zaandam, The Netherlands
| | | | | |
Collapse
|
42
|
Abstract
Renal dysfunction following cardiac surgery is well recognised and mainly is of ischaemic origin. The spectrum varies from subclinical injuryto established renal failure requiring renal replacement therapy. Depending on definitions, acute kidney injury (AKI) may occur in up to 30% of post cardiac surgery patients. A new grading system for renal dysfunction, based on three levels of plasma creatinine and urine output, as well as the use of biomarkers may help the early identification of patients at risk and thereby hopefully improve outcome. Despite therapeutic advances, the morbidity and mortality associated with AKI have not changed markedly in the last decade.
Collapse
Affiliation(s)
- R Vaschetto
- Department of Intensive Care Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | | |
Collapse
|
43
|
Tuinman PR, Cornet AD, Kuipers MT, Vlaar AP, Schultz MJ, Beishuizen A, Groeneveld ABJ, Juffermans NP. Soluble receptor for advanced glycation end products as an indicator of pulmonary vascular injury after cardiac surgery. BMC Pulm Med 2013; 13:76. [PMID: 24341821 PMCID: PMC3866278 DOI: 10.1186/1471-2466-13-76] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 12/05/2013] [Indexed: 01/11/2023] Open
Abstract
Background Cardiac surgery is frequently complicated by an acute vascular lung injury and this may be mediated, at least in part, by the (soluble) receptor for advanced glycation end products (sRAGE). Methods In two university hospital intensive care units, circulating sRAGE was measured together with the 68Gallium-transferrin pulmonary leak index (PLI), a measure of pulmonary vascular permeabiliy, in 60 consecutive cardiac surgery patients stratified by the amount of blood transfusion, within 3 hours of admission to the intensive care. Results Cardiac surgery resulted in elevated plasma sRAGE levels compared to baseline (315 ± 181 vs 110 ± 55 pg/ml, P = 0.001). In 37 patients the PLI was elevated 50% above normal. The PLI correlated with sRAGE (r2 = 0.11, P = 0.018). Plasma sRAGE discriminated well between those with an elevated PLI and those with a normal PLI (area under the operator curve 0.75; P = 0.035; 95% CI 0.55-0.95), with 91% sensitivity but low specificity of 36% at a cutoff value of 200 pg/mL. Blood transfusion did not influence sRAGE levels. Conclusions sRAGE is elevated in plasma after cardiac surgery and indicates increased pulmonary vascular permeability. The level of sRAGE is not affected by transfusion.
Collapse
Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (L,E,I,C,A,), Academic Medical Center, Meibergdreef 9, Amsterdam 1105, AZ, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
44
|
de Geus HRH, Fortrie G, Betjes MGH, van Schaik RHN, Groeneveld ABJ. Time of injury affects urinary biomarker predictive values for acute kidney injury in critically ill, non-septic patients. BMC Nephrol 2013; 14:273. [PMID: 24321290 PMCID: PMC3878913 DOI: 10.1186/1471-2369-14-273] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 11/06/2013] [Indexed: 01/24/2023] Open
Abstract
Background The predictive value of acute kidney injury (AKI) urinary biomarkers may depend on the time interval following tubular injury, thereby explaining in part the heterogeneous performance of these markers that has been reported in the literature. We studied the influence of timing on the predictive values of tubular proteins, measured before the rise of serum creatinine (SCr) in critically ill, non-septic patients. Methods Seven hundred adult critically ill patients were prospectively included for urine measurements at four time-points prior to the rise in serum creatinine (T = 0, -16, -20 and -24 h). Patients with sepsis and or AKI at ICU entry were excluded. The urinary excretion of the proteins, neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1), which are up-regulated in the distal and proximal tubules, respectively, were measured as well as the constitutive cytoplasmatic enzymes, π- and α-glutathione-S-transferase (GST), which are released by the distal and proximal tubules, respectively. Results Five hundred and forty-three subjects were eligible for further analyses; however, 49 developed AKI in the first 48 h. Both NGAL (P = 0.001 at T = -24 vs. non-AKI patients) and KIM-1 (P < 0.0001 at T = 0 vs. non-AKI patients) concentrations gradually increased until AKI diagnosis, whereas π- and α-GST peaked at T = -24 before AKI (P = 0.006 and P = 0.002, respectively vs. non-AKI patients) and showed a rapid decline afterwards. The predictive values at T = -24 prior to AKI were modest for π- and α-GST, whereas NGAL sufficiently predicted AKI at T = -24 and its predictive power improved as the time interval to AKI presentation decreased (area under the receiver operating characteristic curve; AUC = 0.79, P < 0.0001). KIM-1 was a good discriminator at T = 0 only (AUC = 0.73, P < 0.0001). Conclusions NGAL, KIM-1, pi- and alpha-GST displayed unique and mutually incomparable time dependent characteristics during the development of non-sepsis related AKI. Therefore, the time-relationship between the biomarker measurements and the injurious event influences the individual test results.
Collapse
Affiliation(s)
- Hilde R H de Geus
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | | | | | | | | |
Collapse
|
45
|
Almac E, Johannes T, Bezemer R, Mik EG, Unertl KE, Groeneveld ABJ, Ince C. Activated protein C ameliorates impaired renal microvascular oxygenation and sodium reabsorption in endotoxemic rats. Intensive Care Med Exp 2013; 1:24. [PMID: 26266793 PMCID: PMC4796218 DOI: 10.1186/2197-425x-1-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 10/10/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction We aimed to test whether continuous recombinant human activated protein C (APC) administration would be able to protect renal oxygenation and function during endotoxemia in order to provide more insight into the role of coagulation and inflammation in the development of septic acute kidney injury. Methods In anesthetized, mechanically ventilated Wistar rats, endotoxemia was induced by lipopolysaccharide administration (10 mg/kg i.v. over 30 min). One hour later, the rats received fluid resuscitation with 0 (LPS + FR group; n = 8), 10 (APC10 group; n = 8), or 100 (APC100 group; n = 8) μg/kg/h APC for 2 h. Renal microvascular oxygenation in the cortex and medulla were measured using phosphorimetry, and renal creatinine clearance rate and sodium reabsorption were measured as indicators of renal function. Statistical significance of differences between groups was tested using two-way ANOVA with Bonferroni post hoc tests. Results APC did not have notable effects on systemic and renal hemodynamic and oxygenation variables or creatinine clearance. The changes in renal microvascular oxygenation in both the cortex (r = 0.66; p < 0.001) and medulla (r = 0.80; p < 0.001) were correlated to renal sodium reabsorption. Conclusion Renal sodium reabsorption is closely correlated to renal microvascular oxygenation during endotoxemia. In this study, fluid resuscitation and APC supplementation were not significantly effective in protecting renal microvascular oxygenation and renal function. The specific mechanisms responsible for these effects of APC warrant further study. Electronic supplementary material The online version of this article (doi:10.1186/2197-425X-1-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Emre Almac
- Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
| | | | | | | | | | | | | |
Collapse
|
46
|
Van Den Akker JPC, Groeneveld ABJ. Do we need alternatives for bicarbonate and anion gap? Minerva Anestesiol 2013; 79:1111-1112. [PMID: 23857449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- J P C Van Den Akker
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands -
| | | |
Collapse
|
47
|
Kuiper AN, Trof RJ, Groeneveld ABJ. Mixed venous O2 saturation and fluid responsiveness after cardiac or major vascular surgery. J Cardiothorac Surg 2013; 8:189. [PMID: 24053433 PMCID: PMC3848814 DOI: 10.1186/1749-8090-8-189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 09/17/2013] [Indexed: 11/10/2022] Open
Abstract
Background It is unclear if and how SvO2 can serve as an indicator of fluid responsiveness in patients after cardiac or major vascular surgery. Methods This was a substudy of a randomized single-blinded clinical trial reported earlier on critically ill patients with clinical hypovolemia after cardiac or major vascular surgery. Colloid fluid loading was done for 90 min, guided by changes in pulmonary artery occlusion pressure (PAOP) or central venous pressure (CVP). Fluid responsiveness was defined as ≥15% increase in cardiac index (CI). Hemodynamics, including transpulmonary dilution-derived global end-diastolic volume index (GEDVI) and global ejection fraction (GEF), were measured and blood samples taken. Results Whereas baseline SvO2 (>70% in 68% of patients) did not differ, the SvO2 increased in patients responding to fluid loading (≥15% in CI in n = 26) versus those not responding (n = 11; P = 0.03). The increase in GEDVI was also greater in responders (P = 0.005). The area under the receiver operating characteristic curve for fluid responsiveness of changes in SvO2 was 0.73 (P = 0.007), with an optimal cutoff of 2%, and of those in GEDVI 0.82 (P < 0.001), while the areas did not differ. However, the value of SvO2 increases to reflect CI increases with fluid loading was greatest when GEF was ≤20% (in 53% of patients). Conclusions An increase in SvO2 ≥2%, irrespective of a relatively high baseline value, can thus be used as a monitor of fluid responsiveness in clinically hypovolemic patients after cardiac or major vascular surgery, particularly in those with systolic cardiac dysfunction. Fluid responsiveness concurs with increased tissue O2 delivery.
Collapse
Affiliation(s)
- Arjan N Kuiper
- Departments of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands.
| | | | | |
Collapse
|
48
|
Hettling H, Alders DJC, Heringa J, Binsl TW, Groeneveld ABJ, van Beek JHGM. Computational estimation of tricarboxylic acid cycle fluxes using noisy NMR data from cardiac biopsies. BMC Syst Biol 2013; 7:82. [PMID: 23965343 PMCID: PMC3765389 DOI: 10.1186/1752-0509-7-82] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 08/15/2013] [Indexed: 11/16/2022]
Abstract
Background The aerobic energy metabolism of cardiac muscle cells is of major importance for the contractile function of the heart. Because energy metabolism is very heterogeneously distributed in heart tissue, especially during coronary disease, a method to quantify metabolic fluxes in small tissue samples is desirable. Taking tissue biopsies after infusion of substrates labeled with stable carbon isotopes makes this possible in animal experiments. However, the appreciable noise level in NMR spectra of extracted tissue samples makes computational estimation of metabolic fluxes challenging and a good method to define confidence regions was not yet available. Results Here we present a computational analysis method for nuclear magnetic resonance (NMR) measurements of tricarboxylic acid (TCA) cycle metabolites. The method was validated using measurements on extracts of single tissue biopsies taken from porcine heart in vivo. Isotopic enrichment of glutamate was measured by NMR spectroscopy in tissue samples taken at a single time point after the timed infusion of 13C labeled substrates for the TCA cycle. The NMR intensities for glutamate were analyzed with a computational model describing carbon transitions in the TCA cycle and carbon exchange with amino acids. The model dynamics depended on five flux parameters, which were optimized to fit the NMR measurements. To determine confidence regions for the estimated fluxes, we used the Metropolis-Hastings algorithm for Markov chain Monte Carlo (MCMC) sampling to generate extensive ensembles of feasible flux combinations that describe the data within measurement precision limits. To validate our method, we compared myocardial oxygen consumption calculated from the TCA cycle flux with in vivo blood gas measurements for 38 hearts under several experimental conditions, e.g. during coronary artery narrowing. Conclusions Despite the appreciable NMR noise level, the oxygen consumption in the tissue samples, estimated from the NMR spectra, correlates with blood-gas oxygen uptake measurements for the whole heart. The MCMC method provides confidence regions for the estimated metabolic fluxes in single cardiac biopsies, taking the quantified measurement noise level and the nonlinear dependencies between parameters fully into account.
Collapse
Affiliation(s)
- Hannes Hettling
- Centre for Integrative Bioinformatics (IBIVU), Vrije Universiteit Amsterdam, de Boelelaan 1081A, 1081 HV Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
49
|
Hoeboer SH, Groeneveld ABJ. Changes in circulating procalcitonin versus C-reactive protein in predicting evolution of infectious disease in febrile, critically ill patients. PLoS One 2013; 8:e65564. [PMID: 23762396 PMCID: PMC3675153 DOI: 10.1371/journal.pone.0065564] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 04/26/2013] [Indexed: 01/09/2023] Open
Abstract
Objective Although absolute values for C-reactive protein (CRP) and procalcitonin (PCT) are well known to predict sepsis in the critically ill, it remains unclear how changes in CRP and PCT compare in predicting evolution of: infectious disease, invasiveness and severity (e.g. development of septic shock, organ failure and non-survival) in response to treatment. The current study attempts to clarify these aspects. Methods In 72 critically ill patients with new onset fever, CRP and PCT were measured on Day 0, 1, 2 and 7 after inclusion, and clinical courses were documented over a week with follow up to Day 28. Infection was microbiologically defined, while septic shock was defined as infection plus shock. The sequential organ failure assessment (SOFA) score was assessed. Results From peak at Day 0–2 to Day 7, CRP decreased when (bloodstream) infection and septic shock (Day 0–2) resolved and increased when complications such as a new (bloodstream) infection or septic shock (Day 3–7) supervened. PCT decreased when septic shock resolved and increased when a new bloodstream infection or septic shock supervened. Increased or unchanged SOFA scores were best predicted by PCT increases and Day 7 PCT, in turn, was predictive for 28-day outcome. Conclusion The data, obtained during ICU-acquired fever and infections, suggest that CRP may be favoured over PCT courses in judging response to antibiotic treatment. PCT, however, may better indicate the risk of complications, such as bloodstream infection, septic shock, organ failure and mortality, and therefore might help deciding on safe discontinuation of antibiotics. The analysis may thus help interpreting current literature and design future studies on guiding antibiotic therapy in the ICU.
Collapse
Affiliation(s)
- Sandra H Hoeboer
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
| | | |
Collapse
|
50
|
Assink-de Jong E, Groeneveld ABJ, Pettersson AM, Koek A, Vandenbroucke-Grauls CMJE, Beishuizen A, Simoons-Smit AM. Clinical correlates of herpes simplex virus type 1 loads in the lower respiratory tract of critically ill patients. J Clin Virol 2013; 58:79-83. [PMID: 23731844 DOI: 10.1016/j.jcv.2013.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/05/2013] [Accepted: 05/07/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND The significance of isolation of herpes simplex virus (HSV) type 1 from the lower respiratory tract in critically ill patients on mechanical ventilation is still unclear. In the current study, we used polymerase chain reaction techniques to quantify HSV-1 to further evaluate its role. OBJECTIVES The hypothesis was that high loads reflect invasive pulmonary disease related to prolonged mechanical ventilation and increased mortality, as opposed to shedding from the upper respiratory tract, which leads to lower viral loads. STUDY DESIGN We prospectively studied 77 consecutive patients admitted to the intensive care unit and analyzed 136 tracheal aspirates or bronchoalveolar lavage fluids, taken when clinically indicated in the diagnostic workup of fever, radiologic pulmonary infiltrates, progressive respiratory insufficiency or combinations. Samples were cultured for bacteria and yeasts according to routine microbiological methods and HSV-1 loads were determined by real time quantitative PCR. Viral loads were expressed per number of cells recovered. RESULTS HSV-1 load was directly related to the simplified acute physiology score II (rs=0.47, P=0.04) when the first specimen taken proved positive for HSV-1. HSV-1 positivity concurred with Candida spp. colonization. Patients with and without a HSV-1 load did not differ with respect to pulmonary and systemic courses and vital outcomes. CONCLUSIONS The data suggest that HSV-1 in the lower respiratory tract originates from shedding in the upper respiratory tract in about 30% of critically ill patients, following immune suppression and reactivation, without invasively infecting the lung. No attributable mortality was observed.
Collapse
|