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van der Wal LI, Grim CCA, Del Prado MR, van Westerloo DJ, Schultz MJ, Helmerhorst HJF, de Vries MC, de Jonge E. Perspectives of ICU Patients on Deferred Consent in the Context of Post-ICU Quality of Life: A Substudy of a Randomized Clinical Trial. Crit Care Med 2024; 52:694-703. [PMID: 38180043 PMCID: PMC11008447 DOI: 10.1097/ccm.0000000000006184] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Deferred consent enables research to be conducted in the ICU when patients are unable to provide consent themselves, and there is insufficient time to obtain consent from surrogates before commencing (trial) treatment. The aim of this study was to evaluate how former ICU patients reflect on their participation in a study with deferred consent and examine whether their opinions are influenced by the quality of life (QoL) following hospital discharge. DESIGN Survey study by questionnaire. SETTING Eight ICUs in The Netherlands. PATIENTS Former ICU patients who participated in the ICONIC trial, a multicenter randomized clinical trial that evaluated oxygenation targets in mechanically ventilated ICU patients. INTERVENTIONS Participants enrolled in the ICONIC trial in one of the eight participating centers in The Netherlands received a questionnaire 6 months after randomization. The questionnaire included 12 close-ended questions on their opinion about the deferred consent procedure. QoL was measured using the EQ-5D-5L questionnaire. By calculating the EQ-5D index, patients were divided into four QoL quartiles, where Q1 reflects the lowest and Q4 is the highest. MEASUREMENTS AND MAIN RESULTS Of 362 participants who were contacted, 197 responded (54%). More than half of the respondents (59%) were unaware of their participation in the ICONIC study. In total 61% were content with the deferred consent procedure, 1% were not content, 25% neutral, 9% did not know, and 9% answered "other." Those with a higher QoL were more likely to be content ( p = 0.02). In all QoL groups, the legal representative was the most often preferred individual to provide consent. CONCLUSIONS Former ICU patients who participated in the ICONIC study often did not remember their participation but were predominantly positive regarding the use of deferred consent. Those with a higher QoL were most likely to be content.
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Affiliation(s)
- L Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michael R Del Prado
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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van der Hoeven AE, Bijlenga D, van der Hoeven E, Schinkelshoek MS, Hiemstra FW, Kervezee L, van Westerloo DJ, Fronczek R, Lammers GJ. Sleep in the intensive and intermediate care units: Exploring related factors of delirium, benzodiazepine use and mortality. Intensive Crit Care Nurs 2024; 81:103603. [PMID: 38171236 DOI: 10.1016/j.iccn.2023.103603] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/25/2023] [Accepted: 12/09/2023] [Indexed: 01/05/2024]
Abstract
AIM OF THE STUDY The primary purpose was to examine sleep difficulties and delirium in the Intensive and Intermediate Care Unit. Secondarily, factors impacting night-time sleep duration and quality, mortality, and the impact of benzodiazepine use on sleep outcomes were investigated. MATERIALS AND METHODS This retrospective study encompassed data from 323 intensive and intermediate care unit admissions collected in the Netherlands, spanning from November 2018 to May 2020. Sleep quality was measured using the Richards-Campbell Sleep Questionnaire. Night-time sleep duration was nurse-reported. We investigated associations of these sleep outcomes with age, sex, length-of-stay, natural daylight, disease severity, mechanical ventilation, benzodiazepine use, and delirium using Generalized Estimating Equations models. Associations with one-year post-discharge mortality were analyzed using Cox regression. RESULTS Night-time sleep duration was short (median 4.5 hours) and sleep quality poor (mean score 4.9/10). Benzodiazepine use was common (24 % of included nights) and was negatively associated with night-time sleep duration and quality (B = -0.558 and -0.533, p <.001). Delirium and overnight transfers were negatively associated with sleep quality (B = -0.716 and -1.831, p <.05). The day-to-night sleep ratio was higher in the three days before delirium onset than in non-delirious individuals (p <.05). Age, disease severity and female sex were associated with increased one-year mortality. Sleep quality was negatively, but not-significantly, associated with mortality (p =.070). CONCLUSIONS Night-time sleep in the critical care environment has a short duration and poor quality. Benzodiazepine use was not associated with improved sleep. Sleep patterns change ahead of delirium onset. IMPLICATIONS FOR CLINICAL PRACTICE Consistent sleep monitoring should be part of routine nursing practice, using a validated instrument like the Richards-Campbell Sleep Questionnaire. Given the lack of proven efficacy of benzodiazepines in promoting sleep in critical care settings, it is vital to develop more effective sleep treatments that include non-benzodiazepine medication and sleep hygiene strategies.
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Affiliation(s)
- Adrienne E van der Hoeven
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Denise Bijlenga
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Ernst van der Hoeven
- Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Mink S Schinkelshoek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Floor W Hiemstra
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands; Group of Neurophysiology, Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laura Kervezee
- Group of Neurophysiology, Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands
| | - Gert Jan Lammers
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands; Stichting Epilepsie Instellingen Nederland (SEIN), Sleep-Wake Center, Heemstede, the Netherlands.
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van der Wal LI, Grim CCA, del Prado MR, van Westerloo DJ, Boerma EC, Rijnhart-de Jong HG, Reidinga AC, Loef BG, van der Heiden PLJ, Sigtermans MJ, Paulus F, Cornet AD, Loconte M, Schoonderbeek FJ, de Keizer NF, Bakhshi-Raiez F, Le Cessie S, Serpa Neto A, Pelosi P, Schultz MJ, Helmerhorst HJF, de Jonge E. Conservative versus Liberal Oxygenation Targets in Intensive Care Unit Patients (ICONIC): A Randomized Clinical Trial. Am J Respir Crit Care Med 2023; 208:770-779. [PMID: 37552556 PMCID: PMC10563190 DOI: 10.1164/rccm.202303-0560oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/07/2023] [Indexed: 08/10/2023] Open
Abstract
Rationale: Supplemental oxygen is widely administered to ICU patients, but appropriate oxygenation targets remain unclear. Objectives: This study aimed to determine whether a low-oxygenation strategy would lower 28-day mortality compared with a high-oxygenation strategy. Methods: This randomized multicenter trial included mechanically ventilated ICU patients with an expected ventilation duration of at least 24 hours. Patients were randomized 1:1 to a low-oxygenation (PaO2, 55-80 mm Hg; or oxygen saturation as measured by pulse oximetry, 91-94%) or high-oxygenation (PaO2, 110-150 mm Hg; or oxygen saturation as measured by pulse oximetry, 96-100%) target until ICU discharge or 28 days after randomization, whichever came first. The primary outcome was 28-day mortality. The study was stopped prematurely because of the COVID-19 pandemic when 664 of the planned 1,512 patients were included. Measurements and Main Results: Between November 2018 and November 2021, a total of 664 patients were included in the trial: 335 in the low-oxygenation group and 329 in the high-oxygenation group. The median achieved PaO2 was 75 mm Hg (interquartile range, 70-84) and 115 mm Hg (interquartile range, 100-129) in the low- and high-oxygenation groups, respectively. At Day 28, 129 (38.5%) and 114 (34.7%) patients had died in the low- and high-oxygenation groups, respectively (risk ratio, 1.11; 95% confidence interval, 0.9-1.4; P = 0.30). At least one serious adverse event was reported in 12 (3.6%) and 17 (5.2%) patients in the low- and high-oxygenation groups, respectively. Conclusions: Among mechanically ventilated ICU patients with an expected mechanical ventilation duration of at least 24 hours, using a low-oxygenation strategy did not result in a reduction of 28-day mortality compared with a high-oxygenation strategy. Clinical trial registered with the National Trial Register and the International Clinical Trials Registry Platform (NTR7376).
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Affiliation(s)
| | | | | | | | - E. Christiaan Boerma
- Department of Sustainable Health, Campus Fryslân, University of Groningen, Groningen, The Netherlands
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | | | - Auke C. Reidinga
- Department of Intensive Care, Martini Hospital, Groningen, The Netherlands
| | - Bert G. Loef
- Department of Intensive Care, Martini Hospital, Groningen, The Netherlands
| | | | | | | | - Alexander D. Cornet
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | | | - Nicolette F. de Keizer
- Department of Medical Informatics, Amsterdam Public Health – Digital Health, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Ferishta Bakhshi-Raiez
- Department of Medical Informatics, Amsterdam Public Health – Digital Health, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Saskia Le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Albert Einstein Israelite Hospital, São Paulo, Brazil
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Paolo Pelosi
- Department of Anesthesiology and Intensive Care and
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, Scientific Institute for Research, Hospitalization and Healthcare for Oncology and Neurosciences, Genoa, Italy
| | - Marcus J. Schultz
- Department of Intensive Care and
- Mahidol – Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; and
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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van der Wal LI, Grim CCA, van Westerloo DJ, Schultz MJ, de Jonge E, Helmerhorst HJF. Corrigendum to "Higher versus lower oxygenation strategies in the general intensive care unit population: A systematic review, meta-analysis and meta-regression of randomized controlled trials" [Journal of Critical Care, volume 72(2022) 154151]. J Crit Care 2023; 74:154245. [PMID: 36621390 DOI: 10.1016/j.jcrc.2022.154245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Lea Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands; Mahidol - Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of medicine, University of Oxford, Oxford, United Kingdom
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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Blok SG, Mousa A, Brouwer MG, de Grooth HJ, Neto AS, Blans MJ, den Boer S, Dormans T, Endeman H, Roeleveld T, Scholten H, van Slobbe-Bijlsma ER, Scholten E, Touw H, van der Ven FSLIM, Wils EJ, van Westerloo DJ, Heunks LMA, Schultz MJ, Paulus F, Tuinman PR. Effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients (CONFIDENCE): protocol for a multicentre randomised controlled trial. Trials 2023; 24:226. [PMID: 36964614 PMCID: PMC10038369 DOI: 10.1186/s13063-023-07171-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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/14/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Fluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28. METHODS The "effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients" (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician's discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1-7 after randomisation and on days 1-7 after start of LUS examination; mean serum lactate on days 1-7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28. DISCUSSION The CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable. TRIAL REGISTRATION ClinicalTrials.gov NCT05188092. Registered since January 12, 2022.
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Affiliation(s)
- Siebe G Blok
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands.
| | - Amne Mousa
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Michelle G Brouwer
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michiel J Blans
- Department of Intensive Care, Rijnstate Hospital, Arnhem, Netherlands
| | - Sylvia den Boer
- Department of Intensive Care, Spaarne Gasthuis, Haarlem, Hoofddorp, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Centre, Heerlen, Netherlands
- Department of Intensive Care, Zuyderland Medical Centre, Sittard-Geleen, Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | - Timo Roeleveld
- Department of Intensive Care, Amstelland Hospital, Amstelveen, Netherlands
| | - Harm Scholten
- Department of Intensive Care, Catharina Hospital, Eindhoven, Netherlands
| | | | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, Utrecht, Netherlands
| | - Hugo Touw
- Department of Intensive Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fleur Stefanie L I M van der Ven
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Hospital, Beverwijk, Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | | | - Leo M A Heunks
- Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
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Heldeweg MLA, Lopez Matta JE, Pisani L, Slot S, Haaksma ME, Smit JM, Mousa A, Magnesa G, Massaro F, Touw HRW, Schouten V, Elzo Kraemer CV, van Westerloo DJ, Heunks LMA, Tuinman PR. The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study. Crit Care Med 2023; 51:357-364. [PMID: 36562620 DOI: 10.1097/ccm.0000000000005760] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To investigate the impact of thoracic ultrasound (TUS) examinations on clinical management in adult ICU patients. DESIGN A prospective international observational study. SETTING Four centers in The Netherlands and Italy. PATIENTS Adult ICU patients (> 18 yr) that received a clinically indicated lung ultrasound examination. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinicians performing TUS completed a pre- and post-examination case report form. Patient characteristics, TUS, and resulting clinical effects were recorded. First, change of management, defined as a TUS-induced change in clinical impression leading to a change in treatment plan, was reported. Second, execution of intended management changes within 8 hours was verified. Third, change in fluid balance after 8 hours was calculated. A total of 725 TUS performed by 111 operators across 534 patients (mean age 63 ± 15.0, 70% male) were included. Almost half of TUS caused a change in clinical impression, which resulted in change of management in 39% of cases. The remainder of TUS confirmed the clinical impression, while a minority (4%) did not contribute. Eighty-nine percent of management changes indicated by TUS were executed within 8 hours. TUS examinations that led to a change in fluid management also led to distinct and appropriate changes in patient's fluid balance. CONCLUSIONS In this international observational study in adult ICU patients, use of TUS had a major impact on clinical management. These results provide grounds for future randomized controlled trials to determine if TUS-induced changes in decision-making also lead to improved health outcomes.
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Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
| | - Jorge E Lopez Matta
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care Medicine, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | - Stefanie Slot
- Department of Intensive Care Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
| | - Giovanna Magnesa
- Department of Intensive Care Medicine, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | - Fabrizia Massaro
- Department of Intensive Care Medicine, Regional General Hospital F. Miulli, Acquaviva delle Fonti, Italy
| | - Hugo R W Touw
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Radboud University Medical Hospital, Nijmegen, The Netherlands
| | - Viviane Schouten
- Department of Intensive Care Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Carlos V Elzo Kraemer
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - David J van Westerloo
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
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van der Wal LI, Grim CCA, van Westerloo DJ, Schultz MJ, de Jonge E, Helmerhorst HJF. Higher versus lower oxygenation strategies in the general intensive care unit population: A systematic review, meta-analysis and meta-regression of randomized controlled trials. J Crit Care 2022; 72:154151. [PMID: 36182731 DOI: 10.1016/j.jcrc.2022.154151] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/18/2022] [Accepted: 09/06/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Oxygen therapy is vital in adult intensive care unit (ICU) patients, but it is indistinct whether higher or lower oxygen targets are favorable. Our aim was to update the findings of randomized controlled trials (RTCs) comparing higher and lower oxygen strategies. MATERIALS AND METHODS MEDLINE, EMBASE, and Web of Science were searched. RCTs comparing higher (liberal, hyperoxia) and lower (conservative, normoxia) oxygen in adult mechanically ventilated ICU patients were included. The main outcome was 90-day mortality; other outcomes include serious adverse events (SAE), support free days and length of stay (LOS). RESULTS No significant difference was observed for 90-day mortality. A lower incidence was found for SAEs, favoring lower oxygenation (OR, 0.86; 95%CI, 0.77-0.96; I 2 13%). No differences were observed in either support free days at day 28 or ICU and hospital LOS. CONCLUSIONS No difference was found for 90-day mortality, support free days and ICU and hospital LOS. However, a lower incidence of SAEs was found for lower oxygenation. These findings may have clinical implications for practice guidelines, yet it remains of paramount importance to continue conducting clinical trials, comparing groups with a clinically relevant contrast and focusing on the impact of important side effects.
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Affiliation(s)
- Lea Imeen van der Wal
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands.
| | - Chloe C A Grim
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centre, Location AMC, Amsterdam, the Netherlands; Mahidol - Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of medicine, University of Oxford, Oxford, United Kingdom
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Hendrik J F Helmerhorst
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands; Department of Anesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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Hoogland ICM, Yik J, Westhoff D, Engelen-Lee JY, Valls Seron M, Man WK, Houben-Weerts JHPM, Tanck MW, van Westerloo DJ, van der Poll T, van Gool WA, van de Beek D. Microglial Response in Triggering Receptor Expressed on Myeloid Cells 2 (Trem2) Knock-Out Mice After Systemic Stimulation with Escherichia Coli. Neurosci Lett 2022; 790:136894. [PMID: 36183964 DOI: 10.1016/j.neulet.2022.136894] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/27/2022] [Accepted: 09/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Systemic infection is an important risk factor for delirium, associated with neurodegeneration and subsequent cognitive impairment in older people. Microglial cell response is a known key player in this process and we hypothesize that the triggering receptor expressed on myeloid cells 2 (TREM2) plays an important role in the regulation of this response. METHODS 8- to 10-week old male wild-type (WT) and TREM2 knock-out (Trem2-/-) mice were intraperitoneally inoculated with live Escherichia coli (E. coli) or saline. After inoculation, all mice were treated with ceftriaxone (an antimicrobial drug) at 12 and 24 hours and were sacrificed after 2 and 3 days. Microglial response was determined by immunohistochemical staining with an ionized calcium-binding adaptor molecule 1 (Iba-1) antibody and flow cytometry. mRNA expression of pro- and anti-inflammatory mediators was measured to quantify the inflammatory response. RESULTS We observed increased Iba-1 positive cells number in thalamus of Trem2-/- mice at 3d after inoculation compared to WT mice (mean 120 cell/mm2 [SD 8] vs. 105 cell/mm2 [SD 11]; p=0.03). Flow cytometry showed no differences in forward scatter or expression of CD11b, CD45 and CD14 between WT and Trem2-/- mice. The brain mRNA expression levels of tumor necrosis factor alpha (TNF-α) of Trem2-/- mice at 2d were higher compared to WT mice (p=0.003). Higher mRNA expression of interleukin 1 beta (IL-1β), Iba-1, CD11b and mitogen-activated protein kinase 1 (MAPK-1) was found in brain of WT mice at 2d compared to Trem2-/- mice (respectively p=0.02; p=0.001; p=0.03 and p=0.02). In spleen there were no differences in inflammatory mediators, between WT and Trem2-/- mice. INTERPRETATION Although the loss of function of TREM2 during systemic infection led to an increased number of activated microglia in the thalamus, we did not observe a consistent increase in expression of inflammatory genes in the brain. The role of TREM2 in the neuro-inflammatory response following systemic infection therefore appears to be limited.
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Affiliation(s)
- Inge C M Hoogland
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.
| | - Jutka Yik
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands
| | - Dunja Westhoff
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.
| | - Joo-Yeon Engelen-Lee
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.
| | - Merche Valls Seron
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands
| | - Wing-Kit Man
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands
| | - Judith H P M Houben-Weerts
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.
| | - Michael W Tanck
- Department of Clinical Epidemiology, Amsterdam University Medical Centres, Location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Tom van der Poll
- Centre of Experimental Molecular Medicine, Amsterdam University Medical Centres, Location Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Willem A van Gool
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.
| | - Diederik van de Beek
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Centre, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD Amsterdam, The Netherlands.
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9
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Hoogland ICM, Yik J, Westhoff D, Engelen-Lee JY, Valls Seron M, Man WK, Houben-Weerts JHPM, Tanck MWT, van Westerloo DJ, van der Poll T, van Gool WA, van de Beek D. Microglial cell response in α7 nicotinic acetylcholine receptor-deficient mice after systemic infection with Escherichia coli. J Neuroinflammation 2022; 19:94. [PMID: 35413868 PMCID: PMC9006549 DOI: 10.1186/s12974-022-02452-8] [Citation(s) in RCA: 2] [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: 12/23/2021] [Accepted: 03/29/2022] [Indexed: 12/04/2022] Open
Abstract
Background Development of neurodegeneration in older people has been associated with microglial cell activation triggered by systemic infection. We hypothesize that α7 nicotinic acetylcholine receptor (α7nAChR) plays an important role in regulation of this process. Methods 8- to 10-week-old male wild-type (WT) and α7nAChR knock-out (α7nAChR−/−) mice were intraperitoneally inoculated with live Escherichia (E.) coli or saline. After inoculation, all mice were treated with ceftriaxone (an antimicrobial drug) at 12 and 24 h and killed at 2 or 3 days. The microglial response was characterized by immunohistochemical staining with an ionized calcium-binding adaptor molecule 1 (Iba-1) antibody and flow cytometry. To quantify inflammatory response, mRNA expression of pro- and anti-inflammatory mediators was measured in brain and spleen. Results We observed no differences in Iba-1 positive cell number or morphology and flow cytometry (CD11b, CD45 and CD14) of microglial cells between WT and α7nAChR−/− mice after systemic infection. Infected α7nAChR−/− mice showed significantly higher mRNA expression in brain for tumor necrosis factor alpha (TNF-α) at day 2 and 3, interleukin 6 (IL-6) at day 2 and monocyte chemotactic protein 1 (MCP-1) and suppressor of cytokine signaling 1 (SOCS1) at day 3, there was significantly lower mRNA expression in brain for mitogen-activated protein kinase 1 (MAPK1) at day 2 and 3, high-mobility group 1 (HMGB-1) and CD11b at day 2, and deubiquitinase protein A20 (A20) at day 3 compared to infected WT mice. Interpretation Loss of function of α7nAChR during systemic infection led to an increased expression of TNF-α and IL-6 in brain after systemic infection with E. coli, but not to distinct differences in microglial cell number or morphological activation of microglia. Supplementary Information The online version contains supplementary material available at 10.1186/s12974-022-02452-8.
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Affiliation(s)
- Inge C M Hoogland
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Jutka Yik
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Dunja Westhoff
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Joo-Yeon Engelen-Lee
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Merche Valls Seron
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Wing Kit Man
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Judith H P M Houben-Weerts
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Amsterdam University Medical Centres, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Tom van der Poll
- Centre of Experimental Molecular Medicine, Amsterdam University Medical Centres, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A van Gool
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam University Medical Centres, Location Academic Medical Center, Amsterdam Neuroscience, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands.
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10
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Moes DJAR, van Westerloo DJ, Arend SM, Swen JJ, de Vries A, Guchelaar HJ, Joosten SA, de Boer MGJ, van Gelder T, van Paassen J. Towards Fixed Dosing of Tocilizumab in ICU-Admitted COVID-19 Patients: Results of an Observational Population Pharmacokinetic and Descriptive Pharmacodynamic Study. Clin Pharmacokinet 2021; 61:231-247. [PMID: 34633645 PMCID: PMC8502793 DOI: 10.1007/s40262-021-01074-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Accepted: 08/31/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE In the randomized controlled trial REMAP-CAP, it was shown that next to dexamethasone, the interleukin (IL)-6 receptor antagonist tocilizumab improves outcome, including survival in intensive care unit (ICU)-admitted coronavirus disease 2019 (COVID)-19 patients. Therefore tocilizumab has been added to many COVID-19 treatment guidelines. Because obesity is a risk factor for the development of severe COVID-19, concerns have been raised about overtreatment, as well as undertreatment, through weight-based dosing of tocilizumab. The currently applied dose of 8 mg/kg is based on the use of this drug for other indications, however it has not formally been investigated for COVID-19. In this study, the pharmacokinetics and pharmacodynamics of tocilizumab were investigated in ICU-admitted COVID-19 patients. METHODS This was an open-label, single-centre, observational population pharmacokinetic and descriptive pharmacodynamic evaluation study. Enrolled patients, with polymerase chain reaction-confirmed COVID-19 were admitted to the ICU for mechanical ventilation or high flow nasal canula oxygen support. All patients were 18 years of age or older and received intravenous tocilizumab 8 mg/kg (maximum 800 mg) within 24 h after admission to the ICU and received dexamethasone 6 mg daily as concomitant therapy. For evaluation of the pharmacokinetics and pharmacodynamics of tocilizumab, all time points from day 0 to 20 days after dose administration were eligible for collection. A nonlinear mixed-effects model was developed to characterize the population pharmacokinetic parameters of tocilizumab in ICU-admitted COVID-19 patients. Covariate analysis was performed to identify potential covariates for dose individualization. For the development of alternative dosing schedules, Monte Carlo simulations using the final model were performed. RESULTS Overall, 29 patients were enrolled between 15 December 2020 and 15 March 2021. A total of 139 tocilizumab plasma samples were obtained covering the pharmacokinetic curve of day 0 to day 20 after tocilizumab initiation. A population pharmacokinetic model with parallel linear and nonlinear clearance (CL) was developed and validated. Average CL was estimated to be 0.725 L/day, average volume of distribution (Vd) was 4.34 L, maximum elimination rate (Vmax) was 4.19 μg/day, and concentration at which the elimination pathway is half saturated (Km) was 0.22 μg/mL. Interindividual variability was identified for CL (18.9%) and Vd (21%). Average area under the concentration versus time curve from time zero to infinity of the first dose (AUCinf 1st DOSE) was 938 [±190] μg/mL*days. All patients had tocilizumab exposure above 1 μg/mL for at least 15 days. Bodyweight-based dosing increases variability in exposure compared with fixed dosing. CONCLUSIONS This study provides evidence to support a fixed dose of tocilizumab 600 mg in COVID-19 patients. Fixed dosing is a safe, logistically attractive, and drug expenses saving alternative compared with the current 8 mg/kg recommendation.
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Affiliation(s)
- Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Leiden Network for Personalised Therapeutics, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Sandra M Arend
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Annick de Vries
- Biologics Lab, Sanquin Diagnostic Services, Plesmanlaan 125, 1066 CX, Amsterdam, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Simone A Joosten
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Leiden Network for Personalised Therapeutics, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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11
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Heldeweg MLA, Lopez Matta JE, Haaksma ME, Smit JM, Elzo Kraemer CV, de Grooth HJ, de Jonge E, Meijboom LJ, Heunks LMA, van Westerloo DJ, Tuinman PR. Lung ultrasound and computed tomography to monitor COVID-19 pneumonia in critically ill patients: a two-center prospective cohort study. Intensive Care Med Exp 2021; 9:1. [PMID: 33491147 PMCID: PMC7829056 DOI: 10.1186/s40635-020-00367-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 09/04/2020] [Accepted: 12/21/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Lung ultrasound can adequately monitor disease severity in pneumonia and acute respiratory distress syndrome. We hypothesize lung ultrasound can adequately monitor COVID-19 pneumonia in critically ill patients. METHODS Adult patients with COVID-19 pneumonia admitted to the intensive care unit of two academic hospitals who underwent a 12-zone lung ultrasound and a chest CT examination were included. Baseline characteristics, and outcomes including composite endpoint death or ICU stay > 30 days were recorded. Lung ultrasound and CT images were quantified as a lung ultrasound score involvement index (LUSI) and CT severity involvement index (CTSI). Primary outcome was the correlation, agreement, and concordance between LUSI and CTSI. Secondary outcome was the association of LUSI and CTSI with the composite endpoints. RESULTS We included 55 ultrasound examinations in 34 patients, which were 88% were male, with a mean age of 63 years and mean P/F ratio of 151. The correlation between LUSI and CTSI was strong (r = 0.795), with an overall 15% bias, and limits of agreement ranging - 40 to 9.7. Concordance between changes in sequentially measured LUSI and CTSI was 81%. In the univariate model, high involvement on LUSI and CTSI were associated with a composite endpoint. In the multivariate model, LUSI was the only remaining independent predictor. CONCLUSIONS Lung ultrasound can be used as an alternative for chest CT in monitoring COVID-19 pneumonia in critically ill patients as it can quantify pulmonary involvement, register changes over the course of the disease, and predict death or ICU stay > 30 days. TRIAL REGISTRATION NTR, NL8584. Registered 01 May 2020-retrospectively registered, https://www.trialregister.nl/trial/8584.
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Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands.
- VU University Medical Center Amsterdam, Postbox 7507, 1007 MB, Amsterdam, The Netherlands.
| | - Jorge E Lopez Matta
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
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12
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Haaksma ME, Heldeweg MLA, Lopez Matta JE, Smit JM, van Trigt JD, Nooitgedacht JS, Elzo Kraemer CV, van de Wiel M, Girbes ARJ, Heunks L, van Westerloo DJ, Tuinman PR. Lung ultrasound findings in patients with novel SARS-CoV-2. ERJ Open Res 2020; 6:00238-2020. [PMID: 33257915 PMCID: PMC7548922 DOI: 10.1183/23120541.00238-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/02/2020] [Accepted: 09/25/2020] [Indexed: 12/23/2022] Open
Abstract
Background Over 2 million people worldwide have been infected with severe acute respiratory distress syndrome-coronavirus-2 (SARS CoV-2). Lung ultrasound has been proposed to diagnose and monitor it, despite the fact that little is known about the ultrasound appearance due to the novelty of the illness. The aim of this manuscript is to characterise the lung ultrasonographic appearance of critically ill patients with SARS-CoV-2 pneumonia, with particular emphasis on its relationship with the time course of the illness and clinical parameters. Methods Adult patients from the intensive care unit of two academic hospitals who tested positive for SARS-CoV-2 were included. Images were analysed using internationally recognised techniques which included assessment of the pleura, number of B-lines, pathology in the PLAPS (posterolateral alveolar and/or pleural syndrome) point, bedside lung ultrasound in emergency profiles, and the lung ultrasound score. The primary outcomes were frequencies, percentages and differences in lung ultrasound findings overall and between short (≤14 days) and long (>14 days) durations of symptoms and their correlation with clinical parameters. Results In this pilot observational study, 61 patients were included with 76 examinations available for analysis. 26% of patients had no anterior lung abnormalities, while the most prevalent pathological ultrasound findings were thickening of the pleura (42%), ≥3 B-lines per view (38%) and presence of PLAPS (74%). Patients with "long" duration of symptoms presented more frequently with a thickened and irregular pleura (32 (21%) versus 11 (9%)), C-profile (18 (47%) versus 8 (25%)) and pleural effusion (14 (19%) versus 3 (5%)), compared to patients with short duration of symptoms. Lung ultrasound findings did not correlate with arterial oxygen tension/inspiratory oxygen fraction ratio, fluid balance or dynamic compliance. Conclusion SARS-CoV-2 results in significant, but not specific, ultrasound changes, with decreased lung sliding, thickening of the pleura and a B-profile being the most commonly observed. With time, a thickened and irregular pleura, C-profile and pleural effusion become more common findings. When screening patients, a comprehensive ultrasound protocol might be necessary.
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Affiliation(s)
- Mark E Haaksma
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands
| | - Micah L A Heldeweg
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands
| | - Jorge E Lopez Matta
- Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands.,Dept of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jasper M Smit
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands
| | - Jessica D van Trigt
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jip S Nooitgedacht
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Carlos V Elzo Kraemer
- Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands.,Dept of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark van de Wiel
- Dept of Epidemiology and Data Science, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Leo Heunks
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - David J van Westerloo
- Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands.,Dept of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter R Tuinman
- Dept of Intensive Care Medicine, Amsterdam University Medical Centers, VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography, Amsterdam, The Netherlands
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13
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Grim CC, Helmerhorst HJ, Schultz MJ, Winters T, van der Voort PH, van Westerloo DJ, de Jonge E. Changes in Attitudes and Actual Practice of Oxygen Therapy in ICUs after Implementation of a Conservative Oxygenation Guideline. Respir Care 2020; 65:1502-1510. [PMID: 32209714 DOI: 10.4187/respcare.07527] [Citation(s) in RCA: 1] [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: 11/05/2022]
Abstract
BACKGROUND Little is known to what extent attitudes of ICU clinicians are influenced by new insights and recommendations to be more conservative with oxygen therapy. Our aim was to investigate whether implementation of a conservative oxygenation guideline structurally changed self-reported attitudes and actual clinical practice. METHODS After the implementation of a conservative oxygen therapy guideline in 3 teaching hospitals in the Netherlands, ICU clinicians were surveyed regarding their attitudes toward oxygen therapy. The survey results were compared with survey results taken before the introduction of the new guideline. Arterial blood gas analysis data and ventilator settings were retrieved from all patients admitted to the participating ICUs in the studied period, and changes after implementing the guideline were assessed. RESULTS In total, 180 ICU clinicians returned the survey. Compared to before implementation of a conservative oxygen guideline, more clinicians chose a preferred [Formula: see text] and an oxygen saturation measured from an arterial sample ([Formula: see text]) limit after implementation of the guideline. In general, clinicians reported a more conservative approach toward management of [Formula: see text] and less frequently increased the [Formula: see text]. In the period after the active implementation of the guideline, 5,840 subjects were admitted to the participating ICUs and 101,869 arterial blood gas analyses were retrieved. Actual practice changed with overall lower oxygenation levels (median [Formula: see text] 77.93 mm Hg, compared to 86.93 mm Hg before implementation) of arterial blood and a decrease of PEEP and [Formula: see text]. CONCLUSIONS Implementing a conservative oxygenation guideline was an effective method that changed self-reported attitudes and actual clinical practice and improved adherence to conservative oxygenation targets in a short period of time.
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Affiliation(s)
- Chloe Ca Grim
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - Hendrik Jf Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Tineke Winters
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
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14
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Hoogland ICM, Westhoff D, Engelen-Lee JY, Melief J, Valls Serón M, Houben-Weerts JHMP, Huitinga I, van Westerloo DJ, van der Poll T, van Gool WA, van de Beek D. Microglial Activation After Systemic Stimulation With Lipopolysaccharide and Escherichia coli. Front Cell Neurosci 2018; 12:110. [PMID: 29755322 PMCID: PMC5932388 DOI: 10.3389/fncel.2018.00110] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [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: 01/17/2018] [Accepted: 04/05/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Microglial activation after systemic infection has been suggested to mediate sepsis-associated delirium. A systematic review of animal studies suggested distinct differences between microglial activation after systemic challenge with live bacteria and lipopolysaccharide (LPS). Here, we describe a mouse model of microglial activation after systemic challenge with live Escherichia coli (E. coli) and compare results with systemic challenge with LPS. Methods: Sixty mice were intraperitoneally injected with E. coli (1 × 104 colony-forming units) and sacrificed at 12, 20, 48, and 72 h after inoculation. For 48 and 72 h time points, mice were treated with ceftriaxone. Thirty mice were intraperitoneally injected with LPS (5 mg/kg) and sacrificed 3 and 48 h after inoculation; 48 control mice were intraperitoneally injected with isotonic saline. Microglial response was monitored by immunohistochemical staining with Iba-1 antibody and flow cytometry; and inflammatory response by mRNA expression of pro- and anti-inflammatory mediators. Results: Mice infected with live E. coli showed microglial activation 72 h post-inoculation, with increased cell number in cortex (p = 0.0002), hippocampus (p = 0.003), and thalamus (p = 0.0001), but not in the caudate nucleus/putamen (p = 0.33), as compared to controls. At 72 h, flow cytometry of microglia from E. coli infected mice showed increased cell size (p = 0.03) and CD45 expression (p = 0.03), but no increase in CD11b expression, and no differences in brain mRNA expression of inflammatory mediators as compared to controls. In mice with systemic LPS stimulation, microglial cells were morphologically activated at the 48 h time point with increased cell numbers in cortex (p = 0.002), hippocampus (p = 0.0003), thalamus (p = 0.007), and caudate nucleus/putamen (p < 0.0001), as compared to controls. At 48 h, flow cytometry of microglia from LPS stimulated mice showed increased cell size (p = 0.03), CD45 (p = 0.03), and CD11b (p = 0.04) expression. Brain mRNA expression of TNF-α (p = 0.02), IL-1β (p = 0.02), and MCP-1 (p = 0.03) were increased as compared to controls. Interpretation: Systemic challenge with live E. coli causes a neuro-inflammatory response, but this response occurs at a later time point and is less vigorous as compared to LPS stimulation.The E. coli model mimics the clinical situation of infection associated delirium more closely than stimulation with supra-natural LPS.
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Affiliation(s)
- Inge C M Hoogland
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Dunja Westhoff
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Joo-Yeon Engelen-Lee
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jeroen Melief
- Netherlands Institute for Neuroscience - KNAW, Amsterdam, Netherlands
| | - Mercedes Valls Serón
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Judith H M P Houben-Weerts
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Inge Huitinga
- Netherlands Institute for Neuroscience - KNAW, Amsterdam, Netherlands
| | | | - Tom van der Poll
- Center of Experimental Molecular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Willem A van Gool
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Diederik van de Beek
- Department of Neurology, Center of Infection and Immunity Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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15
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Affiliation(s)
- David J van Westerloo
- From the Departments of Intensive Care (D.J.v.W.), Cardiogenetics (D.Q.B.-S.), Psychiatry (M.S.v.N.), and Neurology (M.R.T.), Leiden University Medical Centre, Leiden; and Department of Clinical Genetics (H.B.), Academic Medical Centre, Amsterdam, the Netherlands.
| | - Daniela Q Barge-Schaapveld
- From the Departments of Intensive Care (D.J.v.W.), Cardiogenetics (D.Q.B.-S.), Psychiatry (M.S.v.N.), and Neurology (M.R.T.), Leiden University Medical Centre, Leiden; and Department of Clinical Genetics (H.B.), Academic Medical Centre, Amsterdam, the Netherlands
| | - Hennie Bikker
- From the Departments of Intensive Care (D.J.v.W.), Cardiogenetics (D.Q.B.-S.), Psychiatry (M.S.v.N.), and Neurology (M.R.T.), Leiden University Medical Centre, Leiden; and Department of Clinical Genetics (H.B.), Academic Medical Centre, Amsterdam, the Netherlands
| | - Martijn S van Noorden
- From the Departments of Intensive Care (D.J.v.W.), Cardiogenetics (D.Q.B.-S.), Psychiatry (M.S.v.N.), and Neurology (M.R.T.), Leiden University Medical Centre, Leiden; and Department of Clinical Genetics (H.B.), Academic Medical Centre, Amsterdam, the Netherlands
| | - Martijn R Tannemaat
- From the Departments of Intensive Care (D.J.v.W.), Cardiogenetics (D.Q.B.-S.), Psychiatry (M.S.v.N.), and Neurology (M.R.T.), Leiden University Medical Centre, Leiden; and Department of Clinical Genetics (H.B.), Academic Medical Centre, Amsterdam, the Netherlands
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16
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de Vries VA, Müller MCA, Sesmu Arbous M, Biemond BJ, Blijlevens NMA, Kusadasi N, Choi GCW, Vlaar APJ, van Westerloo DJ, Kluin-Nelemans HC, van den Bergh WM. Time trend analysis of long term outcome of patients with haematological malignancies admitted at dutch intensive care units. Br J Haematol 2018; 181:68-76. [PMID: 29468848 DOI: 10.1111/bjh.15140] [Citation(s) in RCA: 11] [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: 09/25/2017] [Accepted: 11/21/2017] [Indexed: 01/18/2023]
Abstract
A few decades ago, the chances of survival for patients with a haematological malignancy needing Intensive Care Unit (ICU) support were minimal. As a consequence, ICU admission policy was cautious. We hypothesized that the long-term outcome of patients with a haematological malignancy admitted to the ICU has improved in recent years. Furthermore, our objective was to evaluate the predictive value of the Acute Physiology and Chronic Health Evaluation (APACHE) II score. A total of 1095 patients from 5 Dutch university hospitals were included from 2003 until 2015. We studied the prevalence of patients' characteristics over time. By using annual odds ratios, we analysed which patients' characteristics could have had influenced possible trends in time. A approximated mortality rate was compared with the ICU mortality rate, to study the predictive value of the APACHE II score. Overall one-year mortality was 62%. The annual decrease in one-year mortality was 7%, whereas the APACHE II score increased over time. Decreased mortality rates were particularly observed in high-risk patients (acute myeloid leukaemia, old age, low platelet count, bleeding as admission reason and need for mechanical ventilation within 24 h of ICU admission). Furthermore, the APACHE II score overestimates mortality in this patient category.
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Affiliation(s)
- Vera A de Vries
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bart J Biemond
- Department of Haematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole M A Blijlevens
- Department of Haematology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Nuray Kusadasi
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.,University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Goda C W Choi
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hanneke C Kluin-Nelemans
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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17
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Engel MF, Muijsken MA, Mooi-Kokenberg E, Kuijper EJ, van Westerloo DJ. Vibrio cholerae non-O1 bacteraemia: description of three cases in the Netherlands and a literature review. ACTA ACUST UNITED AC 2017; 21:30197. [PMID: 27104237 DOI: 10.2807/1560-7917.es.2016.21.15.30197] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 01/22/2016] [Indexed: 11/20/2022]
Abstract
Vibrio cholerae non-O1 serogroup (VCNO) bacteraemia is a severe condition with a high case-fatality rate. We report three cases diagnosed in the Netherlands, identified during a national microbiological congress, and provide a literature review on VCNO bacteraemia. A search strategy including synonyms for 'VCNO' and 'bacteraemia' was applied to PubMed, Medline, Web of Science and Embase databases. The three cases were reported in elderly male patients after fish consumption and/or surface water contact. The literature search yielded 82 case reports on 90 cases and six case series. Thirty case reports were from Asia (30/90; 33%), concerned males (67/90; 74%), and around one third (38/90; 42%) involved a history of alcohol abuse and/or liver cirrhosis The presenting symptom often was gastroenteritis (47/90; 52%) which occurred after seafood consumption in 32% of the cases (15/47).Aside from the most frequent symptom being fever, results of case series concurred with these findings. Published cases also included rare presentations e.g. endophthalmitis and neonatal meningitis. Based on the limited data available, cephalosporins seemed the most effective treatment. Although mainly reported in Asia, VCNO bacteraemia occurs worldwide. While some risk factors for VCNO were identified in this study, the source of infection remains often unclear. Clinical presentation may vary greatly and therefore a quick microbiological diagnosis is indispensable.
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Affiliation(s)
- Madelon F Engel
- Medical Microbiology Department, Leiden University Medical Centre, Leiden, the Netherlands
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18
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Helmerhorst HJF, Schouten LRA, Wagenaar GTM, Juffermans NP, Roelofs JJTH, Schultz MJ, de Jonge E, van Westerloo DJ. Hyperoxia provokes a time- and dose-dependent inflammatory response in mechanically ventilated mice, irrespective of tidal volumes. Intensive Care Med Exp 2017; 5:27. [PMID: 28550659 PMCID: PMC5446430 DOI: 10.1186/s40635-017-0142-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [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: 01/27/2017] [Accepted: 05/18/2017] [Indexed: 01/26/2023] Open
Abstract
Background Mechanical ventilation and hyperoxia have the potential to independently promote lung injury and inflammation. Our purpose was to study both time- and dose-dependent effects of supplemental oxygen in an experimental model of mechanically ventilated mice. Methods Healthy male C57Bl/6J mice, aged 9–10 weeks, were intraperitoneally anesthetized and randomly assigned to the mechanically ventilated group or the control group. In total, 100 mice were tracheotomized and mechanically ventilated for either 8 or 12 h after allocation to different settings for the applied fractions of inspired oxygen (FiO2, 30, 50, or 90%) and tidal volumes (7.5 or 15 ml/kg). After euthanisation arterial blood, bronchoalveolar lavage fluid (BALf) and tissues were collected for analyses. Results Mechanical ventilation significantly increased the lung injury score (P < 0.05), mean protein content (P < 0.001), and the mean number of cells (P < 0.01), including neutrophils in BALf (P < 0.001). In mice ventilated for 12 h, a significant increase in TNF-α, IFN-γ, IL-1β, IL-10, and MCP-1 (P < 0.01) was observed with 90% FiO2, whereas IL-6 showed a decreasing trend (P for trend = 0.03) across FiO2 groups. KC, MIP-2, and sRAGE were similar between FiO2 groups. HMGB-1 was significantly higher in BALf of mechanically ventilated mice compared to controls and showed a gradual increase in expression with increasing FiO2. Cytokine and chemokine levels in BALf did not markedly differ between FiO2 groups after 8 h of ventilation. Differences between the tidal volume groups were small and did not appear to significantly interact with the oxygen levels. Conclusions We demonstrated a severe vascular leakage and a pro-inflammatory pulmonary response in mechanically ventilated mice, which was enhanced by severe hyperoxia and longer duration of mechanical ventilation. Prolonged ventilation with high oxygen concentrations induced a time-dependent immune response characterized by elevated levels of neutrophils, cytokines, and chemokines in the pulmonary compartment. Electronic supplementary material The online version of this article (doi:10.1186/s40635-017-0142-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hendrik J F Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, 2300 RC, Leiden, The Netherlands. .,Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Laura R A Schouten
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Gerry T M Wagenaar
- Department of Pediatrics, Laboratory of Neonatology, University Medical Center Leiden, Leiden, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, 2300 RC, Leiden, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, 2300 RC, Leiden, The Netherlands
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19
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Helmerhorst HJF, de Wilde RBP, Lee DH, Palmen M, Jansen JRC, van Westerloo DJ, de Jonge E. Hemodynamic effects of short-term hyperoxia after coronary artery bypass grafting. Ann Intensive Care 2017; 7:20. [PMID: 28233196 PMCID: PMC5323416 DOI: 10.1186/s13613-017-0246-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 11/26/2016] [Accepted: 02/14/2017] [Indexed: 01/11/2023] Open
Abstract
Background Although oxygen is generally administered in a liberal manner in the perioperative setting, the effects of oxygen administration on dynamic cardiovascular parameters, filling status and cerebral perfusion have not been fully unraveled. Our aim was to study the acute hemodynamic and microcirculatory changes before, during and after arterial hyperoxia in mechanically ventilated patients after coronary artery bypass grafting (CABG) surgery. Methods This was a single-center physiological study in a tertiary care ICU in the Netherlands. Twenty-two patients scheduled for ICU admission after elective CABG were enrolled in the study between September 2014 and September 2015. In the ICU, patients were exposed to a fraction of inspired oxygen (FiO2) of 90% allowing a 15-min wash-in period. Various hemodynamic parameters were measured using direct pressure signals and continuous arterial waveform analysis at three sequential time points: before, during and after hyperoxia. Results During a 15-min exposure to a fraction of inspired oxygen (FiO2) of 90%, the partial pressure of arterial oxygen (PaO2) and arterial oxygen saturation (SaO2) were significantly higher. The systemic resistance increased (P < 0.0001), without altering the heart rate. Stroke volume variation and pulse pressure variation decreased slightly. The cardiac output did not significantly decrease (P = 0.08). Mean systemic filling pressure and arterial critical closing pressure increased (P < 0.01), whereas the percentage of perfused microcirculatory vessels decreased (P < 0.01). Other microcirculatory parameters and cerebral blood flow velocity showed only slight changes. Conclusions We found that short-term hyperoxia affects hemodynamics in ICU patients after CABG. This was translated in several changes in central circulatory variables, but had only slight effects on cardiac output, cerebral blood flow and the microcirculation. Clinical trial registration Netherlands Trial Register: NTR5064
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Affiliation(s)
- Hendrik J F Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands. .,Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.
| | - Rob B P de Wilde
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands
| | - Dae Hyun Lee
- Department of Nephrology, Einthoven Laboratory for Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos R C Jansen
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands
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20
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Westhoff D, Witlox J, van Aalst C, Scholtens RM, de Rooij SE, van Munster BC, de Jonghe JFM, Houdijk APJ, Eikelenboom P, van Westerloo DJ, van de Beek D, van Gool WA, Koenderman L. Preoperative protein profiles in cerebrospinal fluid in elderly hip fracture patients at risk for delirium: A proteomics and validation study. BBA Clin 2015; 4:115-22. [PMID: 26675981 PMCID: PMC4661734 DOI: 10.1016/j.bbacli.2015.10.002] [Citation(s) in RCA: 16] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 10/12/2015] [Accepted: 10/26/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND A neuroinflammatory response is suggested to play an important role in delirium, a common complication in older hospitalized patients. We examined whether hip fracture patients who develop postoperative delirium have a different proteome in cerebrospinal fluid (CSF) prior to surgery. METHODS Patients (≥ 75 years) were admitted for hip fracture surgery. CSF was collected during spinal anaesthesia; proteins were separated using gel electrophoresis and identified with mass spectrometry. We compared the proteome of patients with and without postoperative delirium. Findings were validated in an independent, comparable cohort using immuno-assays. RESULTS In the derivation cohort 53 patients were included, 35.8% developed postoperative delirium. We identified differences in levels of eight CSF proteins between patients with and without subsequent delirium: complement factor C3, contactin-1, fibulin-1 and I-beta-1,3-N-acetylglucosaminyltransferase were significantly lower in patients with postoperative delirium, while neural cell adhesion molecule-2, fibrinogen, zinc-α-2-glycoprotein and haptoglobin levels were significantly higher. In the validation cohort 21.2% of 52 patients developed postoperative delirium. Immuno-assays confirmed contactin-1 results although not statistically significant. Complement factor C3 was significantly higher in patients with postoperative delirium. CONCLUSION Our results show the complexity of pathophysiological mechanisms involved in delirium and emphasizes the need of independent validation of findings. GENERAL SIGNIFICANCE This study highlights the challenges and inconsistent findings in studies of delirium, a serious complication in older patients. We analysed proteins in CSF, the most proximal fluid to the brain. All patients were free from delirium at the time of sampling.
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Affiliation(s)
- Dunja Westhoff
- Department of Neurology, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Joost Witlox
- Department of Geriatrics, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Corneli van Aalst
- Department of Respiratory Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Rikie M Scholtens
- Department of Geriatrics, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Sophia E de Rooij
- Department of Geriatrics, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands ; Department of Geriatrics, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Barbara C van Munster
- Department of Geriatrics, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands ; Department of Geriatrics, Gelre hospitals, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, The Netherlands
| | - Jos F M de Jonghe
- Department of Geriatrics, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Alexander P J Houdijk
- Department of Surgery, Medical Center Alkmaar, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands ; Trial Center Holland Health, Alkmaar, The Netherlands
| | | | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Willem A van Gool
- Department of Neurology, Academic Medical Center, PO box 22660, 1100 DD Amsterdam, The Netherlands
| | - Leo Koenderman
- Department of Respiratory Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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21
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Helmerhorst HJF, Roos-Blom MJ, van Westerloo DJ, Abu-Hanna A, de Keizer NF, de Jonge E. Associations of arterial carbon dioxide and arterial oxygen concentrations with hospital mortality after resuscitation from cardiac arrest. Crit Care 2015; 19:348. [PMID: 26415731 PMCID: PMC4587673 DOI: 10.1186/s13054-015-1067-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/12/2015] [Indexed: 01/21/2023]
Abstract
Introduction Arterial concentrations of carbon dioxide (PaCO2) and oxygen (PaO2) during admission to the intensive care unit (ICU) may substantially affect organ perfusion and outcome after cardiac arrest. Our aim was to investigate the independent and synergistic effects of both parameters on hospital mortality. Methods This was a cohort study using data from mechanically ventilated cardiac arrest patients in the Dutch National Intensive Care Evaluation (NICE) registry between 2007 and 2012. PaCO2 and PaO2 levels from arterial blood gas analyses corresponding to the worst oxygenation in the first 24 h of ICU stay were retrieved for analyses. Logistic regression analyses were performed to assess the relationship between hospital mortality and both categorized groups and a spline-based transformation of the continuous values of PaCO2 and PaO2. Results In total, 5,258 cardiac arrest patients admitted to 82 ICUs in the Netherlands were included. In the first 24 h of ICU admission, hypocapnia was encountered in 22 %, and hypercapnia in 35 % of included cases. Hypoxia and hyperoxia were observed in 8 % and 3 % of the patients, respectively. Both PaCO2 and PaO2 had an independent U-shaped relationship with hospital mortality and after adjustment for confounders, hypocapnia and hypoxia were significant predictors of hospital mortality: OR 1.37 (95 % CI 1.17–1.61) and OR 1.34 (95 % CI 1.08–1.66). A synergistic effect of concurrent derangements of PaCO2 and PaO2 was not observed (P = 0.75). Conclusions The effects of aberrant arterial carbon dioxide and arterial oxygen concentrations were independently but not synergistically associated with hospital mortality after cardiac arrest. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1067-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hendrik J F Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - Marie-José Roos-Blom
- Department of Medical Informatics, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. .,National Intensive Care Evaluation (NICE) foundation, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands.
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - Nicolette F de Keizer
- Department of Medical Informatics, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. .,National Intensive Care Evaluation (NICE) foundation, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Post Box 9600, Leiden, 2300 RC, The Netherlands. .,National Intensive Care Evaluation (NICE) foundation, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
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22
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Helmerhorst HJF, Schultz MJ, van der Voort PHJ, de Jonge E, van Westerloo DJ. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care 2015; 19:284. [PMID: 26278383 PMCID: PMC4538738 DOI: 10.1186/s13054-015-0996-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Oxygen administration is uniformly used in emergency and intensive care medicine and has life-saving potential in critical conditions. However, excessive oxygenation also has deleterious properties in various pathophysiological processes and consequently both clinical and translational studies investigating hyperoxia during critical illness have gained increasing interest. Reactive oxygen species are notorious by-products of hyperoxia and play a pivotal role in cell signaling pathways. The effects are diverse, but when the homeostatic balance is disturbed, reactive oxygen species typically conserve a vicious cycle of tissue injury, characterized by cell damage, cell death, and inflammation. The most prominent symptoms in the abundantly exposed lungs include tracheobronchitis, pulmonary edema, and respiratory failure. In addition, absorptive atelectasis results as a physiological phenomenon with increasing levels of inspiratory oxygen. Hyperoxia-induced vasoconstriction can be beneficial during vasodilatory shock, but hemodynamic changes may also impose risk when organ perfusion is impaired. In this context, oxygen may be recognized as a multifaceted agent, a modifiable risk factor, and a feasible target for intervention. Although most clinical outcomes are still under extensive investigation, careful titration of oxygen supply is warranted in order to secure adequate tissue oxygenation while preventing hyperoxic harm.
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Affiliation(s)
- Hendrik J F Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.,Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, Amsterdam, 1091 AZ, The Netherlands.,TIAS School for Business and Society, Tilburg University, Warandelaan 2, Tilburg, 5000 LE, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, Leiden, 2300 RC, The Netherlands
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Hoogland ICM, Houbolt C, van Westerloo DJ, van Gool WA, van de Beek D. Systemic inflammation and microglial activation: systematic review of animal experiments. J Neuroinflammation 2015; 12:114. [PMID: 26048578 PMCID: PMC4470063 DOI: 10.1186/s12974-015-0332-6] [Citation(s) in RCA: 572] [Impact Index Per Article: 63.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/26/2015] [Indexed: 12/20/2022] Open
Abstract
Background Animal studies show that peripheral inflammatory stimuli may activate microglial cells in the brain implicating an important role for microglia in sepsis-associated delirium. We systematically reviewed animal experiments related to the effects of systemic inflammation on the microglial and inflammatory response in the brain. Methods We searched PubMed between January 1, 1950 and December 1, 2013 and Embase between January 1, 1988 and December 1, 2013 for animal studies on the influence of peripheral inflammatory stimuli on microglia and the brain. Identified studies were systematically scored on methodological quality. Two investigators extracted independently data on animal species, gender, age, and genetic background; number of animals; infectious stimulus; microglial cells; and other inflammatory parameters in the brain, including methods, time points after inoculation, and brain regions. Results Fifty-one studies were identified of which the majority was performed in mice (n = 30) or in rats (n = 19). Lipopolysaccharide (LPS) (dose ranging between 0.33 and 200 mg/kg) was used as a peripheral infectious stimulus in 39 studies (76 %), and live or heat-killed pathogens were used in 12 studies (24 %). Information about animal characteristics such as species, strain, sex, age, and weight were defined in 41 studies (80 %), and complete methods of the disease model were described in 35 studies (68 %). Studies were also heterogeneous with respect to methods used to assess microglial activation; markers used mostly were the ionized calcium binding adaptor molecule-1 (Iba-1), cluster of differentiation 68 (CD68), and CD11b. After LPS challenge microglial activation was seen 6 h after challenge and remained present for at least 3 days. Live Escherichia coli resulted in microglial activation after 2 days, and heat-killed bacteria after 2 weeks. Concomitant with microglial response, inflammatory parameters in the brain were reviewed in 23 of 51 studies (45 %). Microglial activation was associated with an increase in Toll-like receptor (TLR-2 and TLR-4), tumor necrosis factor alpha (TNF-α), and interleukin 1 beta (IL-1β) messenger ribonucleic acid (mRNA) expression or protein levels. Interpretation Animal experiments robustly showed that peripheral inflammatory stimuli cause microglial activation. We observed distinct differences in microglial activation between systemic stimulation with (supranatural doses) LPS and live or heat-killed bacteria.
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Affiliation(s)
- Inge C M Hoogland
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Carin Houbolt
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Willem A van Gool
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Diederik van de Beek
- Department of Neurology, Center of Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
Since the critical care physician will most likely be involved in a life-threatening expression of systemic mastocytosis, recognition of this disease is of utmost importance in the critical care management of these patients. Mastocytosis is a severely under-recognized disease because it typically occurs secondary to another condition and thus may occur more frequently than assumed. In this article, we will review the current knowledge on the treatment of mastocytosis crises with an emphasis on critical care management. Mastocytosis is characterized by the clonal proliferation and accumulation of mast cells in different tissues. Mast cell mediators contain a wide range of biologically active substances that may lead to itching and hives but may ultimately lead to anaphylactic shock caused by the release of histamine and other mediators from mast cells. The mainstay of therapy is the avoidance of potential triggers of mast cell degranulation and, if unsuccessful, blocking the cascade of mast cell mediators. The critical care physician should be well aware of the special precautions which should be kept in mind throughout the management of a mastocytosis crisis to avoid massive mast cell degranulation. Histamine-releasing drugs and certain physical triggers like temperature change should be avoided.
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Affiliation(s)
- Hinke Y van der Weide
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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Helmerhorst HJF, Schultz MJ, van der Voort PHJ, Bosman RJ, Juffermans NP, de Jonge E, van Westerloo DJ. Self-reported attitudes versus actual practice of oxygen therapy by ICU physicians and nurses. Ann Intensive Care 2014; 4:23. [PMID: 25512878 PMCID: PMC4240734 DOI: 10.1186/s13613-014-0023-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [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: 04/01/2014] [Accepted: 06/27/2014] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND High inspiratory oxygen concentrations are frequently administered in ventilated patients in the intensive care unit (ICU) but may induce lung injury and systemic toxicity. We compared beliefs and actual clinical practice regarding oxygen therapy in critically ill patients. METHODS In three large teaching hospitals in the Netherlands, ICU physicians and nurses were invited to complete a questionnaire about oxygen therapy. Furthermore, arterial blood gas (ABG) analysis data and ventilator settings were retrieved to assess actual oxygen practice in the same hospitals 1 year prior to the survey. RESULTS In total, 59% of the 215 respondents believed that oxygen-induced lung injury is a concern. The majority of physicians and nurses stated that minimal acceptable oxygen saturation and partial arterial oxygen pressure (PaO2) ranges were 85% to 95% and 7 to 10 kPa (52.5 to 75 mmHg), respectively. Analysis of 107,888 ABG results with concurrent ventilator settings, derived from 5,565 patient admissions, showed a median (interquartile range (IQR)) PaO2 of 11.7 kPa (9.9 to 14.3) [87.8 mmHg], median fractions of inspired oxygen (FiO2) of 0.4 (0.4 to 0.5), and median positive end-expiratory pressure (PEEP) of 5 (5 to 8) cm H2O. Of all PaO2 values, 73% were higher than the upper limit of the commonly self-reported acceptable range, and in 58% of these cases, neither FiO2 nor PEEP levels were lowered until the next ABG sample was taken. CONCLUSIONS Most ICU clinicians acknowledge the potential adverse effects of prolonged exposure to hyperoxia and report a low tolerance for high oxygen levels. However, in actual clinical practice, a large proportion of their ICU patients was exposed to higher arterial oxygen levels than self-reported target ranges.
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Affiliation(s)
- Hendrik JF Helmerhorst
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden 2300, RC, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam 1105, AZ, The Netherlands
| | - Marcus J Schultz
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam 1105, AZ, The Netherlands
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam 1105, AZ, The Netherlands
| | - Peter HJ van der Voort
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam 1091, AC, The Netherlands
| | - Robert J Bosman
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam 1091, AC, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam 1105, AZ, The Netherlands
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam 1105, AZ, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden 2300, RC, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden 2300, RC, The Netherlands
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Vermeij JD, Aslami H, Fluiter K, Roelofs JJ, van den Bergh WM, Juffermans NP, Schultz MJ, Van der Sluijs K, van de Beek D, van Westerloo DJ. Traumatic brain injury in rats induces lung injury and systemic immune suppression. J Neurotrauma 2013; 30:2073-9. [PMID: 23937270 DOI: 10.1089/neu.2013.3060] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Traumatic brain injury (TBI) is frequently complicated by acute lung injury, which is predictive for poor outcome. However, it is unclear whether lung injury develops independently or as a result of mechanical ventilation after TBI. Further, TBI is strongly associated with the development of pneumonia, suggesting a specific vulnerability for the development of nosocomial infections in the lung after TBI. In this study, we evaluated whether indeed pulmonary injury and immune suppression develop spontaneously in an animal model of mild TBI (mTBI). TBI was induced in male PVG rats by closed-head trauma using a weight-drop device. Subsequently, we evaluated the effects of this on the lungs as well as on the excitability of the systemic immune system. Finally, we performed an experiment in which TBI was followed by induction of pneumonitis and evaluated whether TBI affects the severity of subsequent pneumonitis induced by intratracheal instillation of heat-killed Staphylococcus aureus. mTBI resulted in significant lung injury, as evidenced by pulmonary edema, protein leakage to the alveolar compartment, and increased concentrations of interleukin-1 and -6 in broncho alveolar lavage fluid (all p<0.05 vs. sham-treated animals). Further, after TBI, the release of tumor necrosis factor alpha was decreased when whole blood was stimulated ex vivo (p<0.05 TBI vs. sham), indicating systemic immune suppression. When TBI was followed by pneumonitis, the severity of subsequent pneumonitis was not different in rats previously subjected to TBI or sham treatment (p>0.05), suggesting that systemic immune suppression is not translated toward the pulmonary compartment in this specific model. We here show that during mild experimental TBI, acute pulmonary injury, as well as a decrease in the excitability of the systemic immune system, can be observed.
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Affiliation(s)
- Jan-Dirk Vermeij
- 1 Department of Neurology, Academic Medical Center , Amsterdam, the Netherlands
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Westhoff D, Witlox J, Koenderman L, Kalisvaart KJ, de Jonghe JFM, van Stijn MFM, Houdijk APJ, Hoogland ICM, Maclullich AMJ, van Westerloo DJ, van de Beek D, Eikelenboom P, van Gool WA. Preoperative cerebrospinal fluid cytokine levels and the risk of postoperative delirium in elderly hip fracture patients. J Neuroinflammation 2013; 10:122. [PMID: 24093540 PMCID: PMC3851488 DOI: 10.1186/1742-2094-10-122] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [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: 07/19/2013] [Accepted: 09/27/2013] [Indexed: 01/01/2023] Open
Abstract
Background Aging and neurodegenerative disease predispose to delirium and are both associated with increased activity of the innate immune system resulting in an imbalance between pro- and anti-inflammatory mediators in the brain. We examined whether hip fracture patients who develop postoperative delirium have altered levels of inflammatory mediators in cerebrospinal fluid (CSF) prior to surgery. Methods Patients were 75 years and older and admitted for surgical repair of an acute hip fracture. CSF samples were collected preoperatively. In an exploratory study, we measured 42 cytokines and chemokines by multiplex analysis. We compared CSF levels between patients with and without postoperative delirium and examined the association between CSF cytokine levels and delirium severity. Delirium was diagnosed with the Confusion Assessment Method; severity of delirium was measured with the Delirium Rating Scale Revised-98. Mann–Whitney U tests or Student t-tests were used for between-group comparisons and the Spearman correlation coefficient was used for correlation analyses. Results Sixty-one patients were included, of whom 23 patients (37.7%) developed postsurgical delirium. Concentrations of Fms-like tyrosine kinase-3 (P=0.021), Interleukin-1 receptor antagonist (P=0.032) and Interleukin-6 (P=0.005) were significantly lower in patients who developed delirium postoperatively. Conclusions Our findings fit the hypothesis that delirium after surgery results from a dysfunctional neuroinflammatory response: stressing the role of reduced levels of anti-inflammatory mediators in this process. Trial registration The Effect of Taurine on Morbidity and Mortality in the Elderly Hip Fracture Patient. Registration number: NCT00497978. Local ethical protocol number: NL16222.094.07.
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Affiliation(s)
- Dunja Westhoff
- Department of Neurology, Academic Medical Center/University of Amsterdam, PO box 22660, 1100 DD Amsterdam, the Netherlands.
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van Westerloo DJ, Landman GW, Prichard R, Lespine A, Visser LG. Persistent coma in Strongyloides hyperinfection syndrome associated with persistently increased ivermectin levels. Clin Infect Dis 2013; 58:143-4. [PMID: 24065325 DOI: 10.1093/cid/cit656] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Kruyt ND, van Westerloo DJ, DeVries JH. Stress-induced hyperglycemia in healthy bungee jumpers without diabetes due to decreased pancreatic β-cell function and increased insulin resistance. Diabetes Technol Ther 2012; 14:311-4. [PMID: 22283617 DOI: 10.1089/dia.2011.0171] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Acute diseases are associated with increased stress and immune responses. Both of these responses are associated with disturbances of glucose metabolism, and it is therefore difficult to ascertain whether these disturbances are related to increased stress alone or a result of the systemic inflammatory response. We investigated the effects that acute stress has on glucose metabolism in an acute stress model that is not accompanied by an increased immune response. SUBJECTS AND METHODS Glucose levels as well as pancreatic β-cell function, insulin resistance, and parameters of stress and immune responses were assessed in healthy bungee jumpers 2 h before, immediately before, and after the jump. RESULTS Glucose levels and stress hormones were increased, right before and after the jump, whereas the immune response was decreased. Pancreatic β-cell function was decreased right before the jump, and insulin resistance was increased right after the jump. Higher levels of cortisol correlated with increased insulin resistance after the jump. Furthermore, larger increments of cortisol before and of epinephrine after the jump were associated with decreased pancreatic β-cell function. CONCLUSIONS Acute stress in healthy bungee jumpers induces acute disturbances of glucose metabolism that are independent from a systemic inflammatory response.
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Affiliation(s)
- Nyika D Kruyt
- Department of Neurology, Slotervaartziekenhuis Amsterdam,Louwesweg 6, Amsterdam, The Netherlands
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van Westerloo DJ. The present is pregnant with the future. Crit Care Med 2010; 39:215-6. [PMID: 21178545 DOI: 10.1097/ccm.0b013e3181fd6530] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Westerloo DJ, Choi G, Löwenberg EC, Truijen J, de Vos AF, Endert E, Meijers JCM, Zhou L, Pereira MPFL, Queiroz KCS, Diks SH, Levi M, Peppelenbosch MP, van der Poll T. Acute stress elicited by bungee jumping suppresses human innate immunity. Mol Med 2010; 17:180-8. [PMID: 21203694 DOI: 10.2119/molmed.2010.00204] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 12/09/2010] [Indexed: 11/06/2022] Open
Abstract
Although a relation between diminished human immunity and stress is well recognized both within the general public and the scientific literature, the molecular mechanisms by which stress alters immunity remain poorly understood. We explored a novel model for acute human stress involving volunteers performing a first-time bungee jump from an altitude of 60 m and exploited this model to characterize the effects of acute stress in the peripheral blood compartment. Twenty volunteers were included in the study; half of this group was pretreated for 3 d with the β-receptor blocking agent propranolol. Blood was drawn 2 h before, right before, immediately after and 2 h after the jump. Plasma catecholamine and cortisol levels increased significantly during jumping, which was accompanied by significantly reduced ex vivo inducibility of proinflammatory cytokines as well as activation of coagulation and vascular endothelium. Kinome profiles obtained from the peripheral blood leukocyte fraction contained a strong noncanonical glucocorticoid receptor signal transduction signature after jumping. In apparent agreement, jumping down-regulated Lck/Fyn and cellular innate immune effector function (phagocytosis). Pretreatment of volunteers with propranolol abolished the effects of jumping on coagulation and endothelial activation but left the inhibitory effects on innate immune function intact. Taken together, these results indicate that bungee jumping leads to a catecholamine-independent immune suppressive phenotype and implicate noncanonical glucocorticoid receptor signal transduction as a major pathway linking human stress to impaired functioning of the human innate immune system.
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Affiliation(s)
- David J van Westerloo
- Department of Intensive Care Medicine, University of Amsterdam, Amsterdam, the Netherlands.
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Giebelen IAJ, van Westerloo DJ, LaRosa GJ, de Vos AF, van der Poll T. Local stimulation of alpha7 cholinergic receptors inhibits LPS-induced TNF-alpha release in the mouse lung. Shock 2008; 28:700-3. [PMID: 17621262 DOI: 10.1097/shk.0b013e318054dd89] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The cholinergic nervous system can inhibit the release of proinflammatory cytokines such as TNF-alpha from LPS-stimulated macrophages. Acetylcholine, the principal neurotransmitter of the vagus nerve, is the key mediator of this so-called cholinergic anti-inflammatory pathway, specifically interacting with alpha7 cholinergic receptors expressed by macrophages and other cell types to inhibit TNF-alpha production. The aim of the current study was to determine the capacity of the selective alpha7 cholinergic receptor agonist 3-(2,4-dimethoxybenzylidene) anabaseine (GTS-21), administered locally into the airways, to inhibit LPS-induced inflammatory responses in the mouse lung in vivo. GTS-21 dose-dependently inhibited LPS-induced TNF-alpha release by MH-S mouse alveolar macrophages in vitro. Intranasal inoculation with GTS-21 also dose-dependently inhibited TNF-alpha release into the lung compartment after intrapulmonary delivery of LPS in mice in vivo, whereas IL-6 concentrations were not affected. However, GTS-21 did not influence the influx of neutrophils into bronchoalveolar lavage fluid elicited by LPS and increased the concentrations of the neutrophil-attracting chemokines cytokine-induced neutrophil chemoattractant and macrophage inflammatory protein 2. These data indicate that local administration of GTS-21 inhibits TNF-alpha release in the lung during LPS-induced inflammation.
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Affiliation(s)
- Ida A J Giebelen
- Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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van Westerloo DJ. Summertime and the living is easy*. Crit Care Med 2007; 35:2450-1. [PMID: 17885387 DOI: 10.1097/01.ccm.0000284737.54540.f8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
CONTEXT Frequently, during grand rounds and other medical conferences, bold statements are made regarding 'exotic medical facts'. Such exotic expert opinions are frequently voiced with great conviction and are usually subsequently assimilated by junior staff as medical fact. METHODS The level of scientific evidence for each exotic expert opinion expressed during daily grand rounds over a 4-month period was evaluated. If, following a short discussion of the statement, any doubt as to the merits of the claim persisted, the person who made the statement was asked to perform a search in the medical literature on the subject. RESULTS In total, 25 cases of exotic expert opinion were identified during the study period. Of these, 22 statements were made by senior staff and 3 by residents. Careful review of the literature showed only 8 of the statements were actually evidence-based. In 17 cases the available literature actually contradicted the statement (n = 13) or no literature on the subject could be located (n = 4). Although opinions were most often expressed by staff members, the reviews of their merits were more often performed by residents. CONCLUSIONS The vast majority of exotic expert opinions expressed by senior staff members during grand rounds are not evidence-based. Thus, great care must be taken to ensure that exotic expert opinion is not accepted as factual without careful review. Furthermore, this study shows that although seniority is (as expected) associated with a higher incidence of voicing exotic expert opinion, it is negatively associated with reviewing the merits of such opinion.
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Giebelen IAJ, van Westerloo DJ, LaRosa GJ, de Vos AF, van der Poll T. Stimulation of alpha 7 cholinergic receptors inhibits lipopolysaccharide-induced neutrophil recruitment by a tumor necrosis factor alpha-independent mechanism. Shock 2007; 27:443-7. [PMID: 17414429 DOI: 10.1097/01.shk.0000245016.78493.bb] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The cholinergic nervous system controls inflammation by inhibiting the release of proinflammatory cytokines such as tumor necrosis factor (TNF) alpha from lipopolysaccharide (LPS)-stimulated macrophages. The key endogenous mediator of this so-called cholinergic anti-inflammatory pathway is acetylcholine, the principal neurotransmitter of the vagus nerve, which specifically interacts with alpha7 cholinergic receptors expressed by macrophages and other cell types to inhibit TNF-alpha production. We here investigated the capacity of the selective alpha7 cholinergic receptor agonist 3-(2,4-dimethoxybenzylidene) anabaseine (GTS-21) to inhibit LPS-induced inflammatory responses in mice in vivo. To this end, mice received an intraperitoneal injection of LPS (from Escherichia coli, 200 microg) preceded by GTS-21 (4 mg/kg) or vehicle. GTS-21 strongly inhibited LPS-induced TNF-alpha release into the peritoneal cavity and the circulation. In addition, GTS-21 attenuated the influx of neutrophils into peritoneal fluid upon administration of LPS. This inhibitory effect on neutrophil recruitment by GTS-21 was independent of its effect on TNF-alpha release, considering that etanercept, a potent TNF-alpha-blocking protein containing the extracellular domain of the p75 TNF-alpha receptor, did not influence LPS-induced neutrophil influx either in the presence or in the absence of GTS-21 treatment. GTS-21 did not reduce the local secretion of macrophage inflammatory protein 2 and keratinocyte-derived cytokine, suggesting that altered concentrations of these neutrophil-attracting chemokines did not contribute to GTS-21-induced inhibition of neutrophil migration. These data identify a novel anti-inflammatory effect of chemical alpha7 cholinergic receptor stimulation that is independent from its capacity to inhibit TNF-alpha production.
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Affiliation(s)
- Ida A J Giebelen
- Center for Infection and Immunity Amsterdam (CINIMA), University of Amsterdam, Amsterdam, The Netherlands
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van Westerloo DJ, Giebelen IA, Florquin S, Bruno MJ, Larosa GJ, Ulloa L, Tracey KJ, van der Poll T. The vagus nerve and nicotinic receptors modulate experimental pancreatitis severity in mice. Gastroenterology 2006; 130:1822-30. [PMID: 16697744 DOI: 10.1053/j.gastro.2006.02.022] [Citation(s) in RCA: 290] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2004] [Accepted: 01/25/2006] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The nervous system, through the vagus nerve, controls inflammation by decreasing the release of tumor necrosis factor-alpha from endotoxin stimulated macrophages. This anti-inflammatory effect is mediated by an interaction of acetylcholine, the principal neurotransmitter of the vagus nerve, with macrophage cholinergic nicotinic receptors expressing the alpha7 subunit. METHODS To determine the role of this "nicotinic anti-inflammatory pathway" in experimental pancreatitis, we induced pancreatitis in mice by 12 hourly intraperitoneal injections of cerulein. Pancreatitis was preceded by unilateral left cervical vagotomy or pretreatment with the nicotinic receptor antagonist mecamylamine or by pretreatment with the selective alpha7 nicotinic receptor agonist 3-(2,4-dimethoxybenzylidene) anabaseine (GTS-21). RESULTS Vagotomy or pretreatment with mecamylamine resulted in an enhanced severity of pancreatitis, as reflected by histology, edema, plasma hydrolases, and interleukin-6 levels. Furthermore, the number of neutrophils migrated to the pancreas was increased in these mice, as shown by myeloperoxidase content and intrapancreatic staining of neutrophils. Conversely, GTS-21 pretreatment strongly decreased the severity of pancreatitis. Pancreatitis-associated pulmonary inflammation was independent of the integrity of the vagus nerve and nicotinic receptors. CONCLUSIONS This study provides the first evidence for a therapeutic potential of the vagus nerve and the "nicotinic anti-inflammatory pathway" in attenuating inflammation and injury during experimental pancreatitis.
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Affiliation(s)
- David J van Westerloo
- Laboratory of Experimental Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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van Westerloo DJ, Knapp S, van't Veer C, Buurman WA, de Vos AF, Florquin S, van der Poll T. Aspiration pneumonitis primes the host for an exaggerated inflammatory response during pneumonia. Crit Care Med 2005; 33:1770-8. [PMID: 16096455 DOI: 10.1097/01.ccm.0000172277.41033.f0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Nosocomial pneumonia is a feared complication in the critically ill patient. Aspiration pneumonitis is frequently complicated by infections. The objective of this study was to determine the influence of aspiration pneumonitis on the host response to a common nosocomial respiratory pathogen. DESIGN Controlled, in vivo laboratory study. SETTING Research laboratory of a health sciences university. SUBJECTS Female C57Bl/6 mice. INTERVENTIONS Mice received hydrochloric acid or saline intratracheally followed 16 hrs later by Klebsiella pneumoniae. MEASUREMENTS AND MAIN RESULTS Hydrochloric acid induced a mild aspiration pneumonitis. Nonetheless, hydrochloric acid aspiration resulted in a markedly increased inflammatory response in the lung on infection with K. pneumoniae. This enhanced inflammatory reaction was accompanied by a greatly increased outgrowth of K. pneumoniae in lungs of mice previously exposed to hydrochloric acid. Preexisting aspiration pneumonitis also triggered mouse lungs in vivo and alveolar macrophages ex vivo for enhanced release of proinflammatory mediators on stimulation with Klebsiella lipopolysaccharide. Inhibition of tumor necrosis factor-alpha resulted in an increased inflammatory reaction and enhanced bacterial outgrowth in mice with primary K. pneumoniae pneumonia, whereas it had no effect in mice with preexisting aspiration pneumonitis. CONCLUSIONS These data indicate a) that aspiration pneumonitis renders the host more susceptible to respiratory tract infection with K. pneumoniae, concurrently priming the lung for an exaggerated inflammatory response; and b) that although tumor necrosis factor-alpha plays a major role in the host response to primary infection, it does not affect lung inflammation or defense after aspiration pneumonitis.
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Affiliation(s)
- David J van Westerloo
- Divisions of Experimental Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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de Jonge WJ, van der Zanden EP, The FO, Bijlsma MF, van Westerloo DJ, Bennink RJ, Berthoud HR, Uematsu S, Akira S, van den Wijngaard RM, Boeckxstaens GE. Stimulation of the vagus nerve attenuates macrophage activation by activating the Jak2-STAT3 signaling pathway. Nat Immunol 2005; 6:844-51. [PMID: 16025117 DOI: 10.1038/ni1229] [Citation(s) in RCA: 801] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2005] [Accepted: 06/23/2005] [Indexed: 02/06/2023]
Abstract
Acetylcholine released by efferent vagus nerves inhibits macrophage activation. Here we show that the anti-inflammatory action of nicotinic receptor activation in peritoneal macrophages was associated with activation of the transcription factor STAT3. STAT3 was phosphorylated by the tyrosine kinase Jak2 that was recruited to the alpha7 subunit of the nicotinic acetylcholine receptor. The anti-inflammatory effect of nicotine required the ability of phosphorylated STAT3 to bind and transactivate its DNA response elements. In a mouse model of intestinal manipulation, stimulation of the vagus nerve ameliorated surgery-induced inflammation and postoperative ileus by activating STAT3 in intestinal macrophages. We conclude that the vagal anti-inflammatory pathway acts by alpha7 subunit-mediated Jak2-STAT3 activation.
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Affiliation(s)
- Wouter J de Jonge
- Division of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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van Westerloo DJ, Weijer S, Bruno MJ, de Vos AF, Van't Veer C, van der Poll T. Toll-like receptor 4 deficiency and acute pancreatitis act similarly in reducing host defense during murine Escherichia coli peritonitis. Crit Care Med 2005; 33:1036-43. [PMID: 15891333 DOI: 10.1097/01.ccm.0000162684.11375.85] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Acute pancreatitis is frequently complicated by Gram-negative sepsis. Mammalian cells recognize lipopolysaccharide from Gram-negative bacteria via Toll-like receptor (TLR) 4. The objective of this study was to determine the role of TLR4 in the defense against Gram-negative sepsis in previously healthy mice and in animals with preexisting pancreatitis. DESIGN A controlled, in vivo laboratory study. SETTING Research laboratory of a health sciences university. SUBJECTS Female C3H/HeJ (nonfunctional TLR4 mutant) and C3H/HeN (wild-type) mice. INTERVENTIONS Abdominal sepsis was induced by the intraperitoneal injection of Escherichia coli. Pancreatitis was induced by 12 hourly intraperitoneal injections of cerulein. MEASUREMENTS AND MAIN RESULTS The following experiments were performed. First, healthy TLR4 mutant mice demonstrated an enhanced bacterial load and dissemination of the infection relative to wild-type mice after intraperitoneal injection with E. coli, associated with a reduced early release of proinflammatory cytokines and an attenuated influx of neutrophils into the peritoneal fluid. Second, wild-type mice in which acute pancreatitis was induced by repeated cerulein injections showed an increased bacterial load and dissemination of E. coli relative to wild-type mice without pancreatitis, which was accompanied by a blunted proinflammatory cytokine response by peritoneal macrophages ex vivo and a diminished early cytokine and neutrophil response in vivo. Third, whereas the severity of cerulein-induced pancreatitis was similar in TLR4 mutant and wild-type mice, the important contribution of TLR4 to an effective host defense against E. coli sepsis observed in previously healthy mice was no longer present in mice with preexisting pancreatitis. CONCLUSIONS These data suggest that TLR4 deficiency and acute pancreatitis act similarly in reducing host defense against E. coli peritonitis and that the role of TLR4 in severe Gram-negative infection depends, at least in part, on the presence of preexisting critical illness.
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Affiliation(s)
- David J van Westerloo
- Laboratory of Experimental Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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van Westerloo DJ, Giebelen IAJ, Florquin S, Daalhuisen J, Bruno MJ, de Vos AF, Tracey KJ, van der Poll T. The cholinergic anti-inflammatory pathway regulates the host response during septic peritonitis. J Infect Dis 2005; 191:2138-48. [PMID: 15898001 DOI: 10.1086/430323] [Citation(s) in RCA: 233] [Impact Index Per Article: 12.3] [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: 10/05/2004] [Accepted: 01/15/2005] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The nervous system, through the vagus nerve, can down-regulate inflammation in vivo by decreasing the release of tumor necrosis factor- alpha by endotoxin-stimulated macrophages. This anti-inflammatory effect is mediated by an interaction between acetylcholine, the principal neurotransmitter of the vagus nerve, and cholinergic nicotinic acetylcholine receptors on macrophages. METHODS We determined the role of this "cholinergic anti-inflammatory pathway" during septic peritonitis induced in mice by intraperitoneal injection of live Escherichia coli. Septic peritonitis was preceded by inhibition of the cholinergic anti-inflammatory pathway by unilateral cervical vagotomy, by stimulation of this pathway by pretreatment of mice with nicotine, or by a combination of both interventions. RESULTS Initial cytokine release during septic peritonitis was enhanced after previous vagotomy and was decreased after nicotine pretreatment, independently of the integrity of the vagus nerve. Further study established that vagotomy before septic peritonitis resulted in an enhanced influx of neutrophils and a marked increase in proinflammatory cytokine levels and liver damage. Conversely, nicotine pretreatment strongly decreased cell influx, proinflammatory cytokine levels, and liver damage, whereas bacterial clearance and survival were impaired. DISCUSSION These data provide the first evidence, to our knowledge, of an important role of the vagus nerve in regulating the innate immune response to a severe bacterial infection.
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Affiliation(s)
- David J van Westerloo
- Laboratory of Experimental Internal Medicine and Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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van Westerloo DJ, Florquin S, de Boer AM, Daalhuisen J, de Vos AF, Bruno MJ, van der Poll T. Therapeutic effects of troglitazone in experimental chronic pancreatitis in mice. Am J Pathol 2005; 166:721-8. [PMID: 15743784 PMCID: PMC1602356 DOI: 10.1016/s0002-9440(10)62293-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Peroxisome proliferator-activated receptor (PPAR)-gamma controls growth, differentiation, and inflammation. PPAR-gamma agonists exert anti-inflammatory effects in vitro and inhibit the activation of pancreas stellate cells, implicated in the formation and progression of fibrosis. We determined the influence of troglitazone, a ligand for PPAR-gamma, on pancreatic damage and fibrosis in experimental chronic pancreatitis. Mice received six hourly intraperitoneal injections with 50 microg/kg of cerulein or saline, three times a week for 6 weeks. One week after the last injection all mice were sacrificed. Untreated mice were compared with mice treated with troglitazone either during weeks 1 to 6 or weeks 4 to 6. All mice that received cerulein injections displayed histopathological signs of chronic pancreatitis at week 7. Troglitazone treatment improved all markers for severity of pancreatitis. Moreover, early and postponed troglitazone treatments were equally effective in diminishing intrapancreatic fibrosis as quantified by Sirius red staining, hydroxyproline content, and laminin staining as well as the increased number of pancreatic stellate cells and pancreas levels of transforming growth factor-beta. Thus, troglitazone attenuated pancreatic damage and inflammation in experimental chronic pancreatitis and remained beneficial in a therapeutic setting when given after initial damage had been established.
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Affiliation(s)
- David J van Westerloo
- Laboratory of Experimental Internal Medicine, University of Amsterdam, Amsterdam, The Netherlands.
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van Westerloo DJ, Schultz MJ, Bruno MJ, de Vos AF, Florquin S, van der Poll T. Acute pancreatitis in mice impairs bacterial clearance from the lungs, whereas concurrent pneumonia prolongs the course of pancreatitis*. Crit Care Med 2004; 32:1997-2001. [PMID: 15483406 DOI: 10.1097/01.ccm.0000142658.22254.74] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Nosocomial pneumonia is a feared complication in the critically ill patient. Serious acute pancreatitis is frequently complicated by infections. The objectives of this study were to determine the influence of acute pancreatitis on host defense against Pseudomonas pneumonia and to determine the influence of Pseudomonas pneumonia on the severity of concurrent pancreatitis. DESIGN A controlled, in vivo laboratory study. SETTING Research laboratory of a health sciences university. SUBJECTS Female C57Bl/6 mice. INTERVENTIONS Pancreatitis was induced by 12 hourly intraperitoneal injections of cerulein (pancreatitis) or saline (sham) immediately followed by intranasal administration of Pseudomonas aeruginosa (to induce pneumonia) or saline (controls). Mice were killed 24 hrs later. Hence, four groups were studied: sham/control, pancreatitis/control, sham/pneumonia, and pancreatitis/pneumonia mice. MEASUREMENTS AND MAIN RESULTS When compared with sham/pneumonia mice, pancreatitis/pneumonia mice demonstrated exaggerated lung inflammation, higher bacterial counts in lungs and pancreas, and enhanced dissemination of the infection. Concurrently, pneumonia prolonged the course of pancreatitis, as reflected by histopathology and higher plasma amylase and relative pancreas weights (all p < .05 for the difference between pancreatitis/pneumonia and pancreatitis/control mice), which was associated with the localization of Pseudomonas in the pancreas. CONCLUSIONS Acute pancreatitis impairs host defense against Pseudomonas pneumonia, whereas pneumonia prolongs the course of pancreatitis.
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Affiliation(s)
- David J van Westerloo
- Laboratory of Experimental Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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