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Vos ME, Cox EGM, Schagen MR, Hiemstra B, Wong A, Koeze J, van der Horst ICC, Wiersema R. Right ventricular strain measurements in critically ill patients: an observational SICS sub-study. Ann Intensive Care 2022; 12:92. [PMID: 36190597 PMCID: PMC9530097 DOI: 10.1186/s13613-022-01064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is common in critically ill patients and is associated with poor outcomes. RV function is usually evaluated by Tricuspid Annular Plane Systolic Excursion (TAPSE) which can be obtained using critical care echocardiography (CCE). Myocardial deformation imaging, measuring strain, is suitable for advanced RV function assessment and has widely been studied in cardiology. However, it is relatively new for the Intensive Care Unit (ICU) and little is known about RV strain in critically ill patients. Therefore, the objectives of this study were to evaluate the feasibility of RV strain in critically ill patients using tissue-Doppler imaging (TDI) and explore the association between RV strain and conventional CCE measurements representing RV function. METHODS This is a single-center sub-study of two prospective observational cohorts (Simple Intensive Care Studies (SICS)-I and SICS-II). All acutely admitted adults with an expected ICU stay over 24 h were included. CCE was performed within 24 h of ICU admission. In patients in which CCE was performed, TAPSE, peak systolic velocity at the tricuspid annulus (RV s') and TDI images were obtained. RV free wall longitudinal strain (RVFWSL) and RV global four-chamber longitudinal strain (RV4CSL) were measured during offline analysis. RESULTS A total of 171 patients were included. Feasibility of RVFWSL and RV4CSL was, respectively, 62% and 56% in our population; however, when measurements were performed, intra- and inter-rater reliability based on the intraclass correlation coefficient were good to excellent. RV dysfunction based on TAPSE or RV s' was found in 56 patients (33%) and 24 patients (14%) had RV dysfunction based on RVFWSL or RV4CSL. In 14 patients (8%), RVFWSL, RV4CSL, or both were reduced, despite conventional RV function measurements being preserved. These patients had significantly higher severity of illness scores. Sensitivity analysis with fractional area change showed similar results. CONCLUSIONS TDI RV strain imaging in critically ill patients is challenging; however, good-to-excellent reproducibility was shown when measurements were adequately obtained. Future studies are needed to elucidate the diagnostic and prognostic value of RV strain in critically ill patients, especially to outweigh the difficulty and effort of imaging against the clinical value.
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Affiliation(s)
- Madelon E Vos
- University Medical Center Groningen, Department of Anaesthesiology, University of Groningen, Groningen, The Netherlands.
| | - Eline G M Cox
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - Maaike R Schagen
- Erasmus Medical Center, Department of Internal Medicine, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Bart Hiemstra
- Department of Anaesthesiology, Location VU Medical Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Jacqueline Koeze
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University of Maastricht, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Renske Wiersema
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands.,Department of Cardiology, Erasmus University Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands
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Castela Forte J, Yeshmagambetova G, van der Grinten ML, Hiemstra B, Kaufmann T, Eck RJ, Keus F, Epema AH, Wiering MA, van der Horst ICC. Identifying and characterizing high-risk clusters in a heterogeneous ICU population with deep embedded clustering. Sci Rep 2021; 11:12109. [PMID: 34103544 PMCID: PMC8187398 DOI: 10.1038/s41598-021-91297-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/25/2021] [Indexed: 01/12/2023] Open
Abstract
Critically ill patients constitute a highly heterogeneous population, with seemingly distinct patients having similar outcomes, and patients with the same admission diagnosis having opposite clinical trajectories. We aimed to develop a machine learning methodology that identifies and provides better characterization of patient clusters at high risk of mortality and kidney injury. We analysed prospectively collected data including co-morbidities, clinical examination, and laboratory parameters from a minimally-selected population of 743 patients admitted to the ICU of a Dutch hospital between 2015 and 2017. We compared four clustering methodologies and trained a classifier to predict and validate cluster membership. The contribution of different variables to the predicted cluster membership was assessed using SHapley Additive exPlanations values. We found that deep embedded clustering yielded better results compared to the traditional clustering algorithms. The best cluster configuration was achieved for 6 clusters. All clusters were clinically recognizable, and differed in in-ICU, 30-day, and 90-day mortality, as well as incidence of acute kidney injury. We identified two high mortality risk clusters with at least 60%, 40%, and 30% increased. ICU, 30-day and 90-day mortality, and a low risk cluster with 25–56% lower mortality risk. This machine learning methodology combining deep embedded clustering and variable importance analysis, which we made publicly available, is a possible solution to challenges previously encountered by clustering analyses in heterogeneous patient populations and may help improve the characterization of risk groups in critical care.
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Affiliation(s)
- José Castela Forte
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O. Box 30.00, 9700 RB, Groningen, The Netherlands. .,Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands.
| | - Galiya Yeshmagambetova
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Maureen L van der Grinten
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas Kaufmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne H Epema
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marco A Wiering
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+, University Maastricht, Maastricht, The Netherlands
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Freire Jorge P, Boer R, Posma RA, Harms KC, Hiemstra B, Bens BWJ, Nijsten MW. Early lactate and glucose kinetics following return to spontaneous circulation after out-of-hospital cardiac arrest. BMC Res Notes 2021; 14:183. [PMID: 33985570 PMCID: PMC8120923 DOI: 10.1186/s13104-021-05604-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/06/2021] [Indexed: 11/11/2022] Open
Abstract
Objective Lactate has been shown to be preferentially metabolized in comparison to glucose after physiological stress, such as strenuous exercise. Derangements of lactate and glucose are common after out-of-hospital cardiac arrest (OHCA). Therefore, we hypothesized that lactate decreases faster than glucose after return-to-spontaneous-circulation (ROSC) after OHCA. Results We included 155 OHCA patients in our analysis. Within the first 8 h of presentation to the emergency department, 843 lactates and 1019 glucoses were available, respectively. Lactate decreased to 50% of its initial value within 1.5 h (95% CI [0.2–3.6 h]), while glucose halved within 5.6 h (95% CI [5.4–5.7 h]). Also, in the first 8 h after presentation lactate decreases more than glucose in relation to their initial values (lactate 72.6% vs glucose 52.1%). In patients with marked hyperlactatemia after OHCA, lactate decreased expediently while glucose recovered more slowly, whereas arterial pH recovered at a similar rapid rate as lactate. Hospital non-survivors (N = 82) had a slower recovery of lactate (P = 0.002) than survivors (N = 82). The preferential clearance of lactate underscores its role as a prime energy substrate, when available, during recovery from extreme stress. Supplementary Information The online version contains supplementary material available at 10.1186/s13104-021-05604-w.
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Affiliation(s)
- Pedro Freire Jorge
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, HPC TA29, 9700 RB, Groningen, The Netherlands.
| | - Rohan Boer
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rene A Posma
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, HPC TA29, 9700 RB, Groningen, The Netherlands
| | - Katharina C Harms
- Department of Emergency Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bas W J Bens
- Department of Emergency Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten W Nijsten
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, HPC TA29, 9700 RB, Groningen, The Netherlands
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4
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Eck RJ, Hulshof L, Wiersema R, Thio CHL, Hiemstra B, van den Oever NCG, Gans ROB, van der Horst ICC, Meijer K, Keus F. Incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients: data from two prospective cohort studies. Crit Care 2021; 25:27. [PMID: 33436012 PMCID: PMC7801861 DOI: 10.1186/s13054-021-03457-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 09/02/2020] [Accepted: 01/01/2021] [Indexed: 12/24/2022]
Abstract
Background The objective of this study was to describe the prevalence, incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients receiving contemporary thrombosis prophylaxis. Methods We conducted a pooled analysis of two prospective cohort studies. The outcomes of interest were in-hospital pulmonary embolism or lower extremity deep vein thrombosis (PE-LDVT), in-hospital nonleg deep vein thrombosis (NLDVT), and 90-day mortality. Multivariable logistic regression analysis was used to evaluate the association between predefined baseline prognostic factors and PE-LDVT or NLDVT. Cox regression analysis was used to evaluate the association between PE-LDVT or NLDVT and 90-day mortality. Results A total of 2208 patients were included. The prevalence of any venous thromboembolism during 3 months before ICU admission was 3.6% (95% CI 2.8–4.4%). Out of 2166 patients, 47 (2.2%; 95% CI 1.6–2.9%) developed PE-LDVT and 38 patients (1.8%; 95% CI 1.2–2.4%) developed NLDVT. Renal replacement therapy (OR 3.5 95% CI 1.4–8.6), respiratory failure (OR 2.0; 95% CI 1.1–3.8), and previous VTE (OR 3.6; 95% CI 1.7–7.7) were associated with PE-LDVT. Central venous catheters (OR 5.4; 95% CI 1.7–17.8) and infection (OR 2.2; 95% CI 1.1–4.3) were associated with NLDVT. Occurrence of PE-LDVT but not NLDVT was associated with increased 90-day mortality (HR 2.7; 95% CI 1.6–4.6, respectively, 0.92; 95% CI 0.41–2.1). Conclusion Thrombotic events are common in critically ill patients, both before and after ICU admittance. Development of PE-LDVT but not NLDVT was associated with increased mortality. Prognostic factors for developing PE-LDVT or NLDVT despite prophylaxis can be identified at ICU admission and may be used to select patients at higher risk in future randomized clinical trials. Trial registration NCT03773939.
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Affiliation(s)
- Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Lisa Hulshof
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Critical Care, Treant Zorggroep Emmen, Emmen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Chris H L Thio
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Reinold O B Gans
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Seinen J, Dieperink W, Mekonnen SA, Lisotto P, Harmsen HJM, Hiemstra B, Ott A, Schultz D, Lalk M, Oswald S, Hammerschmidt S, de Smet AMGA, van Dijl JM. Heterogeneous antimicrobial activity in broncho-alveolar aspirates from mechanically ventilated intensive care unit patients. Virulence 2020; 10:879-891. [PMID: 31662033 PMCID: PMC6844299 DOI: 10.1080/21505594.2019.1682797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Indexed: 01/23/2023] Open
Abstract
Pneumonia is an infection of the lungs, where the alveoli in the affected area are filled with pus and fluid. Although ventilated patients are at risk, not all ventilated patients develop pneumonia. This suggests that the sputum environment may possess antimicrobial activities. Despite the generally acknowledged importance of antimicrobial activity in protecting the human lung against infections, this has not been systematically assessed to date. Therefore, the objective of the present study was to measure antimicrobial activity in broncho-alveolar aspirate (‘sputum”) samples from patients in an intensive care unit (ICU) and to correlate the detected antimicrobial activity with antibiotic levels, the sputum microbiome, and the respective patients’ characteristics. To this end, clinical metadata and sputum were collected from 53 mechanically ventilated ICU patients. The antimicrobial activity of sputum samples was tested against Streptococcus pneumoniae, Staphylococcus aureus and Streptococcus anginosus. Here we show that sputa collected from different patients presented a high degree of variation in antimicrobial activity, which can be partially attributed to antibiotic therapy. The sputum microbiome, although potentially capable of producing antimicrobial agents, seemed to contribute in a minor way, if any, to the antimicrobial activity of sputum. Remarkably, despite its potentially protective effect, the level of antimicrobial activity in the investigated sputa correlated inversely with patient outcome, most likely because disease severity outweighed the beneficial antimicrobial activities.
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Affiliation(s)
- Jolien Seinen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Solomon A Mekonnen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department Functional Genomics, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University Medicine of Greifswald, Greifswald, Germany
| | - Paola Lisotto
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hermie J M Harmsen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alewijn Ott
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Medical Microbiology, Certe, Groningen, The Netherlands
| | - Daniel Schultz
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Michael Lalk
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Stefan Oswald
- Department of Clinical Pharmacology, University Medicine of Greifswald, Greifswald, Germany
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Kaufmann T, Cox EGM, Wiersema R, Hiemstra B, Eck RJ, Koster G, Scheeren TWL, Keus F, Saugel B, van der Horst ICC. Non-invasive oscillometric versus invasive arterial blood pressure measurements in critically ill patients: A post hoc analysis of a prospective observational study. J Crit Care 2020; 57:118-123. [PMID: 32109843 DOI: 10.1016/j.jcrc.2020.02.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 12/21/2019] [Revised: 02/16/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim was to compare non-invasive blood pressure measurements with invasive blood pressure measurements in critically ill patients. METHODS Non-invasive blood pressure was measured via automated brachial cuff oscillometry, and simultaneously the radial arterial catheter-derived measurement was recorded as part of a prospective observational study. Measurements of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were compared using Bland-Altman and error grid analyses. RESULTS Paired measurements of blood pressure were available for 736 patients. Observed mean difference (±SD, 95% limits of agreement) between oscillometrically and invasively measured blood pressure was 0.8 mmHg (±15.7 mmHg, -30.2 to 31.7 mmHg) for SAP, -2.9 mmHg (±11.0 mmHg, -24.5 to 18.6 mmHg) for DAP, and -1.0 mmHg (±10.2 mmHg, -21.0 to 18.9 mmHg) for MAP. Error grid analysis showed that the proportions of measurements in risk zones A to E were 78.3%, 20.7%, 1.0%, 0%, and 0.1% for MAP. CONCLUSION Non-invasive blood pressure measurements using brachial cuff oscillometry showed large limits of agreement compared to invasive measurements in critically ill patients. Error grid analysis showed that measurement differences between oscillometry and the arterial catheter would potentially have triggered at least low-risk treatment decisions in one in five patients.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Geert Koster
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, the Netherlands
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Cox EGM, Koster G, Baron A, Kaufmann T, Eck RJ, Veenstra TC, Hiemstra B, Wong A, Kwee TC, Tulleken JE, Keus F, Wiersema R, van der Horst ICC. Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill. Crit Care 2020; 24:14. [PMID: 31931844 PMCID: PMC6958607 DOI: 10.1186/s13054-019-2719-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Methods This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. Results The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients. Conclusion The agreement between lung ultrasound and auscultation is poor. Trial registration NCT02912624. Registered on September 23, 2016.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Geert Koster
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Aidan Baron
- Emergency, Cardiovascular, and Critical Care Research Group, Centre for Health and Social Care Research, Kingston University and St George's University, London, UK
| | - Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T Corien Veenstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adrian Wong
- Department of Anaesthesiology and Intensive Care, Royal Surrey County Hospital, Guildford, UK
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
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8
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Koster G, Kaufmann T, Hiemstra B, Wiersema R, Vos ME, Dijkhuizen D, Wong A, Scheeren TWL, Hummel YM, Keus F, van der Horst ICC. Feasibility of cardiac output measurements in critically ill patients by medical students. Ultrasound J 2020; 12:1. [PMID: 31912438 PMCID: PMC6946766 DOI: 10.1186/s13089-020-0152-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 08/10/2019] [Accepted: 01/01/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Critical care ultrasonography (CCUS) is increasingly applied also in the intensive care unit (ICU) and performed by non-experts, including even medical students. There is limited data on the training efforts necessary for novices to attain images of sufficient quality. There is no data on medical students performing CCUS for the measurement of cardiac output (CO), a hemodynamic variable of importance for daily critical care. OBJECTIVE The aim of this study was to explore the agreement of cardiac output measurements as well as the quality of images obtained by medical students in critically ill patients compared to the measurements obtained by experts in these images. METHODS In a prospective observational cohort study, all acutely admitted adults with an expected ICU stay over 24 h were included. CCUS was performed by students within 24 h of admission. CCUS included the images required to measure the CO, i.e., the left ventricular outflow tract (LVOT) diameter and the velocity time integral (VTI) in the LVOT. Echocardiography experts were involved in the evaluation of the quality of images obtained and the quality of the CO measurements. RESULTS There was an opportunity for a CCUS attempt in 1155 of the 1212 eligible patients (95%) and in 1075 of the 1212 patients (89%) CCUS examination was performed by medical students. In 871 out of 1075 patients (81%) medical students measured CO. Experts measured CO in 783 patients (73%). In 760 patients (71%) CO was measured by both which allowed for comparison; bias of CO was 0.0 L min-1 with limits of agreement of - 2.6 L min-1 to 2.7 L min-1. The percentage error was 50%, reflecting poor agreement of the CO measurement by students compared with the experts CO measurement. CONCLUSIONS Medical students seem capable of obtaining sufficient quality CCUS images for CO measurement in the majority of critically ill patients. Measurements of CO by medical students, however, had poor agreement with expert measurements. Experts remain indispensable for reliable CO measurements. Trial registration Clinicaltrials.gov; http://www.clinicaltrials.gov; registration number NCT02912624.
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Affiliation(s)
- Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Thomas Kaufmann
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Madelon E. Vos
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Devon Dijkhuizen
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Adrian Wong
- Department of Anaesthesia and Intensive Care, Royal Surrey Hospital, Guildford, UK
| | - Thomas W. L. Scheeren
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yoran M. Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center+, University Maastricht, Maastricht, The Netherlands
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9
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Wiersema R, Koeze J, Eck RJ, Kaufmann T, Hiemstra B, Koster G, Franssen CFM, Vaara ST, Keus F, Van der Horst ICC. Clinical examination findings as predictors of acute kidney injury in critically ill patients. Acta Anaesthesiol Scand 2020; 64:69-74. [PMID: 31465554 PMCID: PMC6916375 DOI: 10.1111/aas.13465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 06/08/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute Kidney Injury (AKI) in critically ill patients is associated with a markedly increased morbidity and mortality. The aim of this study was to establish the predictive value of clinical examination for AKI in critically ill patients. METHODS This was a sub-study of the SICS-I, a prospective observational cohort study of critically ill patients acutely admitted to the Intensive Care Unit (ICU). Clinical examination was performed within 24 hours of ICU admission. The occurrence of AKI was determined at day two and three after admission according to the KDIGO definition including serum creatinine and urine output. Multivariable regression modeling was used to assess the value of clinical examination for predicting AKI, adjusted for age, comorbidities and the use of vasopressors. RESULTS A total of 1003 of 1075 SICS-I patients (93%) were included in this sub-study. 414 of 1003 patients (41%) fulfilled the criteria for AKI. Increased heart rate (OR 1.12 per 10 beats per minute increase, 98.5% CI 1.04-1.22), subjectively cold extremities (OR 1.52, 98.5% CI 1.07-2.16) and a prolonged capillary refill time on the sternum (OR 1.89, 98.5% CI 1.01-3.55) were associated with AKI. This multivariable analysis yielded an area under the receiver-operating curve (AUROC) of 0.70 (98.5% CI 0.66-0.74). The model performed better when lactate was included (AUROC of 0.72, 95%CI 0.69-0.75), P = .04. CONCLUSION Clinical examination findings were able to predict AKI with moderate accuracy in a large cohort of critically ill patients. Findings of clinical examination on ICU admission may trigger further efforts to help predict developing AKI.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Ruben J. Eck
- Department of Internal Medicine University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Thomas Kaufmann
- Department of Anesthesiology University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Geert Koster
- Department of Internal Medicine University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Casper F. M. Franssen
- Department of Internal Medicine University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Suvi T. Vaara
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Frederik Keus
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Iwan C. C. Van der Horst
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
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10
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Hiemstra B, Keus F, Wetterslev J, Gluud C, van der Horst ICC. DEBATE-statistical analysis plans for observational studies. BMC Med Res Methodol 2019; 19:233. [PMID: 31818263 PMCID: PMC6902479 DOI: 10.1186/s12874-019-0879-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background All clinical research benefits from transparency and validity. Transparency and validity of studies may increase by prospective registration of protocols and by publication of statistical analysis plans (SAPs) before data have been accessed to discern data-driven analyses from pre-planned analyses. Main message Like clinical trials, recommendations for SAPs for observational studies increase the transparency and validity of findings. We appraised the applicability of recently developed guidelines for the content of SAPs for clinical trials to SAPs for observational studies. Of the 32 items recommended for a SAP for a clinical trial, 30 items (94%) were identically applicable to a SAP for our observational study. Power estimations and adjustments for multiplicity are equally important in observational studies and clinical trials as both types of studies usually address multiple hypotheses. Only two clinical trial items (6%) regarding issues of randomisation and definition of adherence to the intervention did not seem applicable to observational studies. We suggest to include one new item specifically applicable to observational studies to be addressed in a SAP, describing how adjustment for possible confounders will be handled in the analyses. Conclusion With only few amendments, the guidelines for SAP of a clinical trial can be applied to a SAP for an observational study. We suggest SAPs should be equally required for observational studies and clinical trials to increase their transparency and validity.
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Affiliation(s)
- Bart Hiemstra
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700, RB, Groningen, The Netherlands.
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit (CTU), Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit (CTU), Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Iwan C C van der Horst
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center+, Maastricht, the Netherlands
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11
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Kaufmann T, Castela Forte J, Hiemstra B, Wiering MA, Grzegorczyk M, Epema AH, van der Horst ICC. A Bayesian Network Analysis of the Diagnostic Process and Its Accuracy to Determine How Clinicians Estimate Cardiac Function in Critically Ill Patients: Prospective Observational Cohort Study. JMIR Med Inform 2019; 7:e15358. [PMID: 31670697 PMCID: PMC6913745 DOI: 10.2196/15358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hemodynamic assessment of critically ill patients is a challenging endeavor, and advanced monitoring techniques are often required to guide treatment choices. Given the technical complexity and occasional unavailability of these techniques, estimation of cardiac function based on clinical examination is valuable for critical care physicians to diagnose circulatory shock. Yet, the lack of knowledge on how to best conduct and teach the clinical examination to estimate cardiac function has reduced its accuracy to almost that of "flipping a coin." OBJECTIVE The aim of this study was to investigate the decision-making process underlying estimates of cardiac function of patients acutely admitted to the intensive care unit (ICU) based on current standardized clinical examination using Bayesian methods. METHODS Patient data were collected as part of the Simple Intensive Care Studies-I (SICS-I) prospective cohort study. All adult patients consecutively admitted to the ICU with an expected stay longer than 24 hours were included, for whom clinical examination was conducted and cardiac function was estimated. Using these data, first, the probabilistic dependencies between the examiners' estimates and the set of clinically measured variables upon which these rely were analyzed using a Bayesian network. Second, the accuracy of cardiac function estimates was assessed by comparison to the cardiac index values measured by critical care ultrasonography. RESULTS A total of 1075 patients were included, of which 783 patients had validated cardiac index measurements. A Bayesian network analysis identified two clinical variables upon which cardiac function estimate is conditionally dependent, namely, noradrenaline administration and presence of delayed capillary refill time or mottling. When the patient received noradrenaline, the probability of cardiac function being estimated as reasonable or good P(ER,G) was lower, irrespective of whether the patient was mechanically ventilated (P[ER,G|ventilation, noradrenaline]=0.63, P[ER,G|ventilation, no noradrenaline]=0.91, P[ER,G|no ventilation, noradrenaline]=0.67, P[ER,G|no ventilation, no noradrenaline]=0.93). The same trend was found for capillary refill time or mottling. Sensitivity of estimating a low cardiac index was 26% and 39% and specificity was 83% and 74% for students and physicians, respectively. Positive and negative likelihood ratios were 1.53 (95% CI 1.19-1.97) and 0.87 (95% CI 0.80-0.95), respectively, overall. CONCLUSIONS The conditional dependencies between clinical variables and the cardiac function estimates resulted in a network consistent with known physiological relations. Conditional probability queries allow for multiple clinical scenarios to be recreated, which provide insight into the possible thought process underlying the examiners' cardiac function estimates. This information can help develop interactive digital training tools for students and physicians and contribute toward the goal of further improving the diagnostic accuracy of clinical examination in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov NCT02912624; https://clinicaltrials.gov/ct2/show/NCT02912624.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - José Castela Forte
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marco A Wiering
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Marco Grzegorczyk
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Anne H Epema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, Netherlands
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12
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Kaufmann T, Clement RP, Hiemstra B, Vos JJ, Scheeren TWL, Keus F, van der Horst ICC. Disagreement in cardiac output measurements between fourth-generation FloTrac and critical care ultrasonography in patients with circulatory shock: a prospective observational study. J Intensive Care 2019; 7:21. [PMID: 31011425 PMCID: PMC6460822 DOI: 10.1186/s40560-019-0373-5] [Citation(s) in RCA: 4] [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: 01/17/2019] [Accepted: 03/14/2019] [Indexed: 02/01/2023] Open
Abstract
Background Cardiac output measurements may inform diagnosis and provide guidance of therapeutic interventions in patients with hemodynamic instability. The FloTrac™ algorithm uses uncalibrated arterial pressure waveform analysis to estimate cardiac output. Recently, a new version of the algorithm has been developed. The aim was to assess the agreement between FloTrac™ and routinely performed cardiac output measurements obtained by critical care ultrasonography in patients with circulatory shock. Methods A prospective observational study was performed in a tertiary hospital from June 2016 to January 2017. Adult critically ill patients with circulatory shock were eligible for inclusion. Cardiac output was measured simultaneously using FloTrac™ with a fourth-generation algorithm (COAP) and critical care ultrasonography (COCCUS). The strength of linear correlation of both methods was determined by the Pearson coefficient. Bland-Altman plot and four-quadrant plot were used to track agreement and trending ability. Result Eighty-nine paired cardiac output measurements were performed in 17 patients during their first 24 h of admittance. COAP and COCCUS had strong positive linear correlation (r2 = 0.60, p < 0.001). Bias of COAP and COCCUS was 0.2 L min−1 (95% CI − 0.2 to 0.6) with limits of agreement of − 3.6 L min−1 (95% CI − 4.3 to − 2.9) to 4.0 L min−1 (95% CI 3.3 to 4.7). The percentage error was 65.6% (95% CI 53.2 to 77.3). Concordance rate was 64.4%. Conclusions In critically ill patients with circulatory shock, there was disagreement and clinically unacceptable trending ability between values of cardiac output obtained by uncalibrated arterial pressure waveform analysis and critical care ultrasonography. Trial registration Clinicaltrials.gov, NCT02912624, registered on September 23, 2016 Electronic supplementary material The online version of this article (10.1186/s40560-019-0373-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Kaufmann
- 1Department of Anesthesiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Ramon P Clement
- 1Department of Anesthesiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Bart Hiemstra
- 1Department of Anesthesiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.,2Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap Jan Vos
- 1Department of Anesthesiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Thomas W L Scheeren
- 1Department of Anesthesiology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Frederik Keus
- 2Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- 2Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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13
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Hiemstra B, Koster G, Wetterslev J, Gluud C, Jakobsen JC, Scheeren TWL, Keus F, van der Horst ICC. Dopamine in critically ill patients with cardiac dysfunction: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2019; 63:424-437. [PMID: 30515766 PMCID: PMC6587868 DOI: 10.1111/aas.13294] [Citation(s) in RCA: 11] [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: 09/12/2018] [Revised: 10/18/2018] [Accepted: 10/25/2018] [Indexed: 01/06/2023]
Abstract
Background Dopamine has been used in patients with cardiac dysfunction for more than five decades. Yet, no systematic review has assessed the effects of dopamine in critically ill patients with cardiac dysfunction. Methods This systematic review was conducted following The Cochrane Handbook for Systematic Reviews of Interventions. We searched for trials including patients with observed cardiac dysfunction published until 19 April 2018. Risk of bias was evaluated and Trial Sequential Analyses were conducted. The primary outcome was all‐cause mortality at longest follow‐up. Secondary outcomes were serious adverse events, myocardial infarction, arrhythmias, and renal replacement therapy. We used GRADE to assess the certainty of the evidence. Results We identified 17 trials randomising 1218 participants. All trials were at high risk of bias and only one trial used placebo. Dopamine compared with any control treatment was not significantly associated with relative risk of mortality (60/457 [13%] vs 90/581 [15%]; RR 0.91; 95% confidence interval 0.68‐1.21) or any other patient‐centred outcomes. Trial Sequential Analyses of all outcomes showed that there was insufficient information to confirm or reject our anticipated intervention effects. There were also no statistically significant associations for any of the outcomes in subgroup analyses by type of comparator (inactive compared to potentially active), dopamine dose (low compared to moderate dose), or setting (cardiac surgery compared to heart failure). Conclusion Evidence for dopamine in critically ill patients with cardiac dysfunction is sparse, of low quality, and inconclusive. The use of dopamine for cardiac dysfunction can neither be recommended nor refuted.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Geert Koster
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit (CTU); Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit (CTU); Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Janus C. Jakobsen
- The Copenhagen Trial Unit (CTU); Centre for Clinical Intervention Research; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - Thomas W. L. Scheeren
- Department of Anesthesiology; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Frederik Keus
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
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14
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Wiersema R, Koeze J, Hiemstra B, Pettilä V, Perner A, Keus F, van der Horst ICC. Associations between tricuspid annular plane systolic excursion to reflect right ventricular function and acute kidney injury in critically ill patients: a SICS-I sub-study. Ann Intensive Care 2019; 9:38. [PMID: 30868290 PMCID: PMC6419793 DOI: 10.1186/s13613-019-0513-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 11/17/2018] [Accepted: 03/05/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) occurs in up to 50% of all critically ill patients and hemodynamic abnormalities are assumed to contribute, but their nature and share is still unclear. We explored the associations between hemodynamic variables, including cardiac index and right ventricular function, and the occurrence of AKI in critically ill patients. METHODS In this prospective cohort study, we included all patients acutely admitted to an intensive care unit (ICU). Within 24 h after ICU admission clinical and hemodynamic variables were registered including ultrasonographic measurements of cardiac index and right ventricular function, assessed using tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic excursion (RV S'). Maximum AKI stage was assessed according to the KDIGO criteria during the first 72 h after admission. Multivariable logistic regression modeling was used including both known predictors and univariable significant predictors of AKI. Secondary outcomes were days alive outside ICU and 90-day mortality. RESULTS A total of 622 patients were included, of which 338 patients (54%) had at least AKI stage 1 within 72 h after ICU admission. In the final multivariate model higher age (OR 1.01, 95% CI 1.00-1.03, for each year), higher weight (OR 1.03 CI 1.02-1.04, for each kg), higher APACHE IV score (OR 1.02, CI 1.01-1.03, per point), lower mean arterial pressure (OR 1.02, CI 1.01-1.03, for each mmHg decrease) and lower TAPSE (OR 1.05, CI 1.02-1.09 per millimeter decrease) were all independent predictors for AKI in the final multivariate logistic regression model. Sepsis, cardiac index, RV S' and use of vasopressors were not significantly associated with AKI in our data. AKI patients had fewer days alive outside of ICU, and their mortality rate was significantly higher than those without AKI. CONCLUSIONS In our cohort of acutely admitted ICU patients, the incidence of AKI was 54%. Hemodynamic variables were significantly different between patients with and without AKI. A worse right ventricle function was associated with AKI in the final model, whereas cardiac index was not.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Perner
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - SICS Study Group
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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15
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Wiersema R, Castela Forte JN, Kaufmann T, de Haas RJ, Koster G, Hummel YM, Koeze J, Franssen CFM, Vos ME, Hiemstra B, Keus F, van der Horst ICC. Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies. J Vis Exp 2019. [PMID: 30735183 DOI: 10.3791/58802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) may detect adverse events of interventions such as fluid overload at an early stage. The Simple Intensive Care Studies (SICS) is a research line that focuses on the prognostic and diagnostic value of combinations of clinical variables. The SICS-I specifically focused on the use of clinical variables obtained within 24 h of acute admission for prediction of cardiac output (CO) and mortality. Its sequel, SICS-II, focuses on repeated evaluations during ICU admission. The first clinical examination by trained researchers is performed within 3 h after admission consisting of physical examination and educated guessing. The second clinical examination is performed within 24 h after admission and includes physical examination and educated guessing, biochemical analysis and CCUS assessments of heart, lungs, inferior vena cava (IVC) and kidney. This evaluation is repeated at days 3 and 5 after admission. CCUS images are validated by an independent expert, and all data is registered in an online secured database. Follow-up at 90 days includes registration of complications and survival status according to patient's medical charts and the municipal person registry. The primary focus of SICS-II is the association between venous congestion and organ dysfunction. The purpose of publishing this protocol is to provide details on the structure and methods of this on-going prospective observational cohort study allowing answering multiple research questions. The design of the data collection of combined clinical examination and CCUS assessments in critically ill patients are explicated. The SICS-II is open for other centers to participate and is open for other research questions that can be answered with our data.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen;
| | - Jose N Castela Forte
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Thomas Kaufmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen
| | - Robbert J de Haas
- Department of Radiology, University of Groningen, University Medical Center Groningen
| | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen
| | - Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Casper F M Franssen
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen
| | - Madelon E Vos
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen
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16
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Hiemstra B, Bergman R, Absalom AR, van der Naalt J, van der Harst P, de Vos R, Nieuwland W, Nijsten MW, van der Horst ICC. Long-term outcome of elderly out-of-hospital cardiac arrest survivors as compared with their younger counterparts and the general population. Ther Adv Cardiovasc Dis 2018; 12:341-349. [PMID: 30231773 PMCID: PMC6266245 DOI: 10.1177/1753944718792420] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 06/20/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND: Over the past decade, prehospital and in-hospital treatment for out-of-hospital cardiac arrest (OHCA) has improved considerably. There are sparse data on the long-term outcome, especially in elderly patients. We studied whether elderly patients benefit to the same extent compared with younger patients and at long-term follow up as compared with the general population. METHODS: Between 2001 and 2010, data from all patients presented to our hospital after OHCA were recorded. Elderly patients (⩾75 years) were compared with younger patients. Neurological outcome was classified as cerebral performance category (CPC) at hospital discharge and long-term survival was compared with younger patients and predicted survival rates of the general population. RESULTS: Of the 810 patients admitted after OHCA, a total of 551 patients (68%) achieved return of spontaneous circulation, including 125 (23%) elderly patients with a mean age of 81 ± 5 years. In-hospital survival was lower in elderly patients compared with younger patients with rates of 33% versus 57% ( p < 0.001). A CPC of 1 was present in 73% of the elderly patients versus 86% of the younger patients ( p = 0.031). In 7.3% of the elderly patients, a CPC >2 was observed versus 2.5% of their younger counterparts ( p = 0.103). Elderly patients had a median survival of 6.5 [95% confidence interval (CI) 2.0-7.9] years compared with 7.7 (95% CI 7.5-7.9) years of the general population ( p = 0.019). CONCLUSIONS: The survival rate after OHCA in elderly patients is approximately half that of younger patients. Elderly patients who survive to discharge frequently have favorable neurological outcomes and a long-term survival that approximates that of the general population.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care, University of
Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001,
Groningen, 9700 RB, The Netherlands
| | - Remco Bergman
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Anthony R. Absalom
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Joukje van der Naalt
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Ronald de Vos
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Wybe Nieuwland
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
| | - Maarten W. Nijsten
- University of Groningen, University Medical
Center Groningen, Groningen, The Netherlands
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Hiemstra B, Eck RJ, Koster G, Wetterslev J, Perner A, Pettilä V, Snieder H, Hummel YM, Wiersema R, de Smet AMGA, Keus F, van der Horst ICC. Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I. BMJ Open 2017; 7:e017170. [PMID: 28963297 PMCID: PMC5623575 DOI: 10.1136/bmjopen-2017-017170] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE In the Simple Intensive Care Studies-I (SICS-I), we aim to unravel the value of clinical and haemodynamic variables obtained by physical examination and critical care ultrasound (CCUS) that currently guide daily practice in critically ill patients. We intend to (1) measure all available clinical and haemodynamic variables, (2) train novices in obtaining values for advanced variables based on CCUS in the intensive care unit (ICU) and (3) create an infrastructure for a registry with the flexibility of temporarily incorporating specific (haemodynamic) research questions and variables. The overall purpose is to investigate the diagnostic and prognostic value of clinical and haemodynamic variables. PARTICIPANTS The SICS-I includes all patients acutely admitted to the ICU of a tertiary teaching hospital in the Netherlands with an ICU stay expected to last beyond 24 hours. Inclusion started on 27 March 2015. FINDINGS TO DATE On 31 December 2016, 791 eligible patients fulfilled our inclusion criteria of whom 704 were included. So far 11 substudies with additional variables have been designed, of which six were feasible to implement in the basic study, and two are planned and awaiting initiation. All researchers received focused training for obtaining specific CCUS images. An independent Core laboratory judged that 632 patients had CCUS images of sufficient quality. FUTURE PLANS We intend to optimise the set of variables for assessment of the haemodynamic status of the critically ill patient used for guiding diagnostics, prognosis and interventions. Repeated evaluations of these sets of variables are needed for continuous improvement of the diagnostic and prognostic models. Future plans include: (1) more advanced imaging; (2) repeated clinical and haemodynamic measurements; (3) expansion of the registry to other departments or centres; and (4) exploring possibilities of integration of a randomised clinical trial superimposed on the registry. STUDY REGISTRATION NUMBER NCT02912624; Pre-results.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Bergman R, Hiemstra B, Nieuwland W, Lipsic E, Absalom A, van der Naalt J, Zijlstra F, van der Horst IC, Nijsten MW. Long-term outcome of patients after out-of-hospital cardiac arrest in relation to treatment: a single-centre study. Eur Heart J Acute Cardiovasc Care 2015; 5:328-38. [PMID: 26068962 DOI: 10.1177/2048872615590144] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 05/15/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Outcome after out-of-hospital cardiac arrest (OHCA) remains poor. With the introduction of automated external defibrillators, percutaneous coronary intervention (PCI) and mild therapeutic hypothermia (MTH) the prognosis of patients after OHCA appears to be improving. The aim of this study was to evaluate short and long-term outcome among a non-selected population of patients who experienced OHCA and were admitted to a hospital working within a ST elevation myocardial infarction network. METHODS All patients who achieved return of spontaneous circulation (ROSC) (n=456) admitted to one hospital after OHCA were included. Initial rhythm, reperfusion therapy with PCI, implementation of MTH and additional medical management were recorded. The primary outcome measure was survival (hospital and long term). Neurological status was measured as cerebral performance category. The inclusion period was January 2003 to August 2010. Follow-up was complete until April 2014. RESULTS The mean patient age was 63±14 years and 327 (72%) were men. The initial rhythm was ventricular fibrillation, pulseless electrical activity, asystole and pulseless ventricular tachycardia in 322 (71%), 58 (13%), 55 (12%) and 21 (5%) of the 456 patients, respectively. Treatment included PCI in 191 (42%) and MTH in 188 (41%). Overall in-hospital and long-term (5-year) survival was 53% (n=240) and 44% (n=202), respectively. In the 170 patients treated with primary PCI, in-hospital survival was 112/170 (66%). After hospital discharge these patients had a 5-year survival rate of 99% and cerebral performance category was good in 92%. CONCLUSIONS In this integrated ST elevation myocardial infarction network survival and neurological outcome of selected patients with ROSC after OHCA and treated with PCI was good. There is insufficient evidence about the outcome of this approach, which has a significant impact on utilisation of resources. Good quality randomised controlled trials are needed. In selected patients successfully resuscitated after OHCA of presumed cardiac aetiology, we believe that a more liberal application of primary PCI may be considered in experienced acute cardiac referral centres.
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Affiliation(s)
- Remco Bergman
- Department of Critical Care, University Medical Center Groningen, The Netherlands Department of Anaesthesiology, University Medical Center Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University Medical Center Groningen, The Netherlands
| | - Wybe Nieuwland
- Department of Cardiology, University Medical Center Groningen, The Netherlands
| | - Eric Lipsic
- Department of Cardiology, University Medical Center Groningen, The Netherlands
| | - Anthony Absalom
- Department of Anaesthesiology, University Medical Center Groningen, The Netherlands
| | | | - Felix Zijlstra
- Department of Cardiology, Erasmus University Rotterdam, The Netherlands
| | | | - Maarten Wn Nijsten
- Department of Critical Care, University Medical Center Groningen, The Netherlands
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Groot HE, Wieringa WG, Mahmoud KD, Lexis CP, Hiemstra B, van der Harst P, Lipsic E. Characteristics of patients with false- ST-segment elevation myocardial infarction diagnoses. Eur Heart J Acute Cardiovasc Care 2015; 5:339-46. [PMID: 25872973 DOI: 10.1177/2048872615581500] [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] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 03/22/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND A subgroup of patients presenting with suspected ST-elevation myocardial infarction (STEMI) have no culprit lesion during coronary angiography (false-positive STEMI). Little is known about patient- and system-related factors that are associated with false-positive STEMI. We evaluated the incidence, correlates, delay, final diagnosis, and outcome of patients with false-positive STEMI. METHODS We studied 827 consecutive patients presenting with suspected STEMI between January 2011-September 2012. RESULTS A false positive STEMI activation was identified in 68 patients (8.2%). Patients with false-positive STEMI were younger (57 vs 63 year; p=0.020), less often had hypercholesterolemia (19 vs 43%; p=0.001), and had a higher heart rate (82 vs 75 bpm; p=0.014). The association between these factors and false-positive STEMI activation persisted in multivariate analysis. The duration of symptoms to call was longer in false-positive STEMI patients (128 vs 83 min; p=0.030), although this did not reach statistical significance in multivariate analysis. Final diagnosis in patients with false-positive STEMI activation was particularly from unknown origin (41%). There were no significant differences in mortality at 30 days and one year between patients with STEMI and false-positive STEMI. CONCLUSION The incidence of false-positive STEMI was 8.2% in patients suspected of STEMI. Patients with false-positive STEMI differ from STEMI patients in certain baseline characteristics and in patient delay. Interestingly, absence of coronary disease did not translate into better clinical outcome.
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Affiliation(s)
- Hilde E Groot
- Department of Cardiology, University of Groningen, The Netherlands
| | | | - Karim D Mahmoud
- Department of Cardiology, University of Groningen, The Netherlands
| | - Chris Ph Lexis
- Department of Cardiology, University of Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Cardiology, University of Groningen, The Netherlands
| | | | - Erik Lipsic
- Department of Cardiology, University of Groningen, The Netherlands
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Lexis CPH, Wieringa WG, Hiemstra B, Van Deursen VM, Lipsic E, Van Der Harst P, Van Vedlhuisen DJ, Van Der Horst ICC. Metformin is associated with reduced myocardial infarct size in diabetic patients with ST elevation myocardial infarction. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.p1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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