1
|
Aydeniz E, van Bussel BCT, de Jongh S, Schellens J, Heines SJH, van Kuijk SMJ, Tas J, van Rosmalen F, van der Horst ICC, Bergmans DCJJ. Serial electrical impedance tomography course in different treatment groups; The MaastrICCht cohort. J Crit Care 2024; 80:154506. [PMID: 38113747 DOI: 10.1016/j.jcrc.2023.154506] [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: 06/01/2023] [Revised: 10/16/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE To describe the effect of dexamethasone and tocilizumab on regional lung mechanics over admission in all mechanically ventilated COVID-19 patients. MATERIALS AND METHODS Dynamic compliance, alveolar overdistension and collapse were serially determined using electric impedance tomography (EIT). Patients were categorized into three groups; no anti-inflammatory therapy, dexamethasone therapy, dexamethasone + tocilizumab therapy. The EIT variables were (I) visualized using polynomial regression, (II) evaluated throughout admission using linear mixed-effects models, and (III) average respiratory variables were compared. RESULTS Visual inspection of EIT variables showed a pattern of decreasing dynamic compliance. Overall, optimal set PEEP was lower in the dexamethasone group (-1.4 cmH2O, -2.6; -0.2). Clinically applied PEEP was lower in the dexamethasone and dexamethasone + tocilizumab group (-1.5 cmH2O, -2.6; -0.2; -2.2 cmH2O, -5.1; 0.6). Dynamic compliance, alveolar overdistension, and alveolar collapse at optimal set PEEP did not significantly differ between the three groups. CONCLUSION Optimal and clinically applied PEEP were lower in the dexamethasone and dexamethasone + tocilizumab groups. The results suggest that the potential beneficial effects of these therapies do not affect lung mechanics favorably. However, this study cannot fully rule out any beneficial effect of anti-inflammatory treatment on pulmonary function due to its observational nature.
Collapse
Affiliation(s)
- Eda Aydeniz
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Intensive Care Medicine, Laurentius Hospital Roermond, Roermond, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Sebastiaan de Jongh
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joep Schellens
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Serge J H Heines
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, the Netherlands
| | - Frank van Rosmalen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
2
|
Zhang S, Hagens LA, Heijnen NFL, Smit MR, Brinkman P, Fenn D, van der Poll T, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Breath metabolomics for diagnosis of acute respiratory distress syndrome. Crit Care 2024; 28:96. [PMID: 38521944 PMCID: PMC10960461 DOI: 10.1186/s13054-024-04882-7] [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] [Received: 10/24/2023] [Accepted: 03/18/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) poses challenges in early identification. Exhaled breath contains metabolites reflective of pulmonary inflammation. AIM To evaluate the diagnostic accuracy of breath metabolites for ARDS in invasively ventilated intensive care unit (ICU) patients. METHODS This two-center observational study included critically ill patients receiving invasive ventilation. Gas chromatography and mass spectrometry (GC-MS) was used to quantify the exhaled metabolites. The Berlin definition of ARDS was assessed by three experts to categorize all patients into "certain ARDS", "certain no ARDS" and "uncertain ARDS" groups. The patients with "certain" labels from one hospital formed the derivation cohort used to train a classifier built based on the five most significant breath metabolites. The diagnostic accuracy of the classifier was assessed in all patients from the second hospital and combined with the lung injury prediction score (LIPS). RESULTS A total of 499 patients were included in this study. Three hundred fifty-seven patients were included in the derivation cohort (60 with certain ARDS; 17%), and 142 patients in the validation cohort (47 with certain ARDS; 33%). The metabolites 1-methylpyrrole, 1,3,5-trifluorobenzene, methoxyacetic acid, 2-methylfuran and 2-methyl-1-propanol were included in the classifier. The classifier had an area under the receiver operating characteristics curve (AUROCC) of 0.71 (CI 0.63-0.78) in the derivation cohort and 0.63 (CI 0.52-0.74) in the validation cohort. Combining the breath test with the LIPS does not significantly enhance the diagnostic performance. CONCLUSION An exhaled breath metabolomics-based classifier has moderate diagnostic accuracy for ARDS but was not sufficiently accurate for clinical use, even after combination with a clinical prediction score.
Collapse
Affiliation(s)
- Shiqi Zhang
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands.
| | - Laura A Hagens
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
| | - Paul Brinkman
- Amsterdam UMC, Location AMC, University of Amsterdam, Pulmonary Medicine, Amsterdam, The Netherlands
| | - Dominic Fenn
- Amsterdam UMC, Location AMC, University of Amsterdam, Pulmonary Medicine, Amsterdam, The Netherlands
| | - Tom van der Poll
- Amsterdam UMC, Location AMC, Division of Infectious Diseases, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location AMC, Center of Experimental and Molecular Medicine (CEMM), University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Maastricht University Medical Centre+, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam UMC, Location AMC, University of Amsterdam, Pulmonary Medicine, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Mentink MG, Latten BGH, Bakers FCH, Mihl C, Benali F, Nelemans PJ, Rennenberg RJMW, Koopmans RP, Bergmans DCJJ, Kubat B, Hofman PAM. Efficacy of postmortem CT and tissue sampling in establishing the cause of death in clinical practice: a prospective observational study. J Clin Pathol 2024; 77:259-265. [PMID: 36581447 DOI: 10.1136/jcp-2021-207946] [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: 09/13/2021] [Accepted: 12/18/2022] [Indexed: 12/30/2022]
Abstract
AIMS The aim of this study is to evaluate whether agreement with autopsy-determined cause of death (COD) increases by use of postmortem CT (PMCT) or PMCT in combination with postmortem sampling (PMS), when compared with clinical assessment only. METHODS This prospective observational study included deceased patients from the intensive care unit and internal medicine wards between October 2013 and August 2017. The primary outcome was percentage agreement on COD between the reference standard (autopsy) and the alternative postmortem examinations (clinical assessment vs PMCT or PMCT+PMS). In addition, the COD of patient groups with and without conventional autopsy were compared with respect to involved organ systems and pathologies. RESULTS Of 730 eligible cases, 144 could be included for analysis: 63 underwent PCMT without autopsy and 81 underwent both PMCT and autopsy. Agreement with autopsy-determined COD was significantly higher for both PMCT with PMS (42/57, 74%), and PMCT alone (53/81, 65%) than for clinical assessment (40/81, 51%; p=0.007 and p=0.03, respectively). The difference in agreement between PMCT with PMS and PMCT alone was not significant (p=0.13). The group with autopsy had a significantly higher prevalence of circulatory system involvement and perfusion disorders, and a lower prevalence of pulmonary system involvement. CONCLUSION PMCT and PMS confer additional diagnostic value in establishing the COD. Shortcomings in detecting vascular occlusions and perfusion disorders and susceptibility to pulmonary postmortem changes could in future be improved by additional techniques. Both PMCT and PMS are feasible in clinical practice and an alternative when autopsy cannot be performed.
Collapse
Affiliation(s)
- Max Guillaume Mentink
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Bart G H Latten
- Pathology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
- Pathology, Netherlands Forensic Institute, Den Haag, Netherlands
| | - Frans C H Bakers
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Casper Mihl
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
- CARIM school for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Faysal Benali
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | | | - Richard P Koopmans
- Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | | | - Bela Kubat
- Pathology, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| | - Paul A M Hofman
- Radiology & Nuclear Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, Netherlands
| |
Collapse
|
4
|
de Kok JWTM, van Rosmalen F, Koeze J, Keus F, van Kuijk SMJ, Castela Forte J, Schnabel RM, Driessen RGH, van Herpt TTW, Sels JWEM, Bergmans DCJJ, Lexis CPH, van Doorn WPTM, Meex SJR, Xu M, Borrat X, Cavill R, van der Horst ICC, van Bussel BCT. Deep embedded clustering generalisability and adaptation for integrating mixed datatypes: two critical care cohorts. Sci Rep 2024; 14:1045. [PMID: 38200252 PMCID: PMC10781731 DOI: 10.1038/s41598-024-51699-z] [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: 08/14/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024] Open
Abstract
We validated a Deep Embedded Clustering (DEC) model and its adaptation for integrating mixed datatypes (in this study, numerical and categorical variables). Deep Embedded Clustering (DEC) is a promising technique capable of managing extensive sets of variables and non-linear relationships. Nevertheless, DEC cannot adequately handle mixed datatypes. Therefore, we adapted DEC by replacing the autoencoder with an X-shaped variational autoencoder (XVAE) and optimising hyperparameters for cluster stability. We call this model "X-DEC". We compared DEC and X-DEC by reproducing a previous study that used DEC to identify clusters in a population of intensive care patients. We assessed internal validity based on cluster stability on the development dataset. Since generalisability of clustering models has insufficiently been validated on external populations, we assessed external validity by investigating cluster generalisability onto an external validation dataset. We concluded that both DEC and X-DEC resulted in clinically recognisable and generalisable clusters, but X-DEC produced much more stable clusters.
Collapse
Affiliation(s)
- Jip W T M de Kok
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - Frank van Rosmalen
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technical Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - José Castela Forte
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
| | - Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Thijs T W van Herpt
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Chris P H Lexis
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
| | - William P T M van Doorn
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Steven J R Meex
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Minnan Xu
- Takeda Pharmaceuticals, Deerfield, IL, USA
| | - Xavier Borrat
- Department of Biostatistics Harvard T.H, Chan School of Public Health, Boston, MA, USA
- Anaesthesiology and Critical Care Department, Hospital Clinic de Barcelona, Barcelona, Spain
- Medical Informatics Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Rachel Cavill
- Department of Advanced Computing Sciences, Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
5
|
Heines SJH, Becher TH, van der Horst ICC, Bergmans DCJJ. Clinical Applicability of Electrical Impedance Tomography in Patient-Tailored Ventilation: A Narrative Review. Tomography 2023; 9:1903-1932. [PMID: 37888742 PMCID: PMC10611090 DOI: 10.3390/tomography9050150] [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: 08/30/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Electrical Impedance Tomography (EIT) is a non-invasive bedside imaging technique that provides real-time lung ventilation information on critically ill patients. EIT can potentially become a valuable tool for optimising mechanical ventilation, especially in patients with acute respiratory distress syndrome (ARDS). In addition, EIT has been shown to improve the understanding of ventilation distribution and lung aeration, which can help tailor ventilatory strategies according to patient needs. Evidence from critically ill patients shows that EIT can reduce the duration of mechanical ventilation and prevent lung injury due to overdistension or collapse. EIT can also identify the presence of lung collapse or recruitment during a recruitment manoeuvre, which may guide further therapy. Despite its potential benefits, EIT has not yet been widely used in clinical practice. This may, in part, be due to the challenges associated with its implementation, including the need for specialised equipment and trained personnel and further validation of its usefulness in clinical settings. Nevertheless, ongoing research focuses on improving mechanical ventilation and clinical outcomes in critically ill patients.
Collapse
Affiliation(s)
- Serge J. H. Heines
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands; (I.C.C.v.d.H.); (D.C.J.J.B.)
| | - Tobias H. Becher
- Department of Anesthesiology and Intensive Care Medicine, Campus Kiel, University Medical Centre Schleswig-Holstein, 24118 Kiel, Germany;
| | - Iwan C. C. van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands; (I.C.C.v.d.H.); (D.C.J.J.B.)
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, 6229 HX Maastricht, The Netherlands; (I.C.C.v.d.H.); (D.C.J.J.B.)
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| |
Collapse
|
6
|
Hagens LA, Heijnen NFL, Smit MR, Verschueren ARM, Nijsen TME, Geven I, Presură CN, Rietman R, Fenn DW, Brinkman P, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Octane in exhaled breath to diagnose acute respiratory distress syndrome in invasively ventilated intensive care unit patients. ERJ Open Res 2023; 9:00214-2023. [PMID: 37850212 PMCID: PMC10577595 DOI: 10.1183/23120541.00214-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/03/2023] [Indexed: 10/19/2023] Open
Abstract
Background The concentration of exhaled octane has been postulated as a reliable biomarker for acute respiratory distress syndrome (ARDS) using metabolomics analysis with gas chromatography and mass spectrometry (GC-MS). A point-of-care (POC) breath test was developed in recent years to accurately measure octane at the bedside. The aim of the present study was to validate the diagnostic accuracy of exhaled octane for ARDS using a POC breath test in invasively ventilated intensive care unit (ICU) patients. Methods This was an observational cohort study of consecutive patients receiving invasive ventilation for at least 24 h, recruited in two university ICUs. GC-MS and POC breath tests were used to quantify the exhaled octane concentration. ARDS was assessed by three experts following the Berlin definition and used as the reference standard. The area under the receiver operating characteristic curve (AUC) was used to assess diagnostic accuracy. Results 519 patients were included and 190 (37%) fulfilled the criteria for ARDS. The median (interquartile range) concentration of octane using the POC breath test was not significantly different between patients with ARDS (0.14 (0.05-0.37) ppb) and without ARDS (0.11 (0.06-0.26) ppb; p=0.64). The AUC for ARDS based on the octane concentration in exhaled breath using the POC breath test was 0.52 (95% CI 0.46-0.57). Analysis of exhaled octane with GC-MS showed similar results. Conclusions Octane in exhaled breath has insufficient diagnostic accuracy for ARDS. This disqualifies the use of octane as a biomarker in the diagnosis of ARDS and challenges most of the research performed up to now in the field of exhaled breath metabolomics.
Collapse
Affiliation(s)
- Laura A Hagens
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Tamara M E Nijsen
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Inge Geven
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Cristian N Presură
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Ronald Rietman
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Dominic W Fenn
- Department of Respiratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Brinkman
- Department of Respiratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Respiratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Smit MR, Hagens LA, Heijnen NFL, Pisani L, Cherpanath TGV, Dongelmans DA, de Grooth HJS, Pierrakos C, Tuinman PR, Zimatore C, Paulus F, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ. Lung Ultrasound Prediction Model for Acute Respiratory Distress Syndrome: A Multicenter Prospective Observational Study. Am J Respir Crit Care Med 2023; 207:1591-1601. [PMID: 36790377 PMCID: PMC10273105 DOI: 10.1164/rccm.202210-1882oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [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: 10/10/2022] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Rationale: Lung ultrasound (LUS) is a promising tool for diagnosis of acute respiratory distress syndrome (ARDS), but adequately sized studies with external validation are lacking. Objectives: To develop and validate a data-driven LUS score for diagnosis of ARDS and compare its performance with that of chest radiography (CXR). Methods: This multicenter prospective observational study included invasively ventilated ICU patients who were divided into a derivation cohort and a validation cohort. Three raters scored ARDS according to the Berlin criteria, resulting in a classification of "certain no ARDS," or "certain ARDS" when experts agreed or "uncertain ARDS" when evaluations conflicted. Uncertain cases were classified in a consensus meeting. Results of a 12-region LUS exam were used in a logistic regression model to develop the LUS-ARDS score. Measurements and Main Results: Three hundred twenty-four (16% certain ARDS) and 129 (34% certain ARDS) patients were included in the derivation cohort and the validation cohort, respectively. With an ARDS diagnosis by the expert panel as the reference test, the LUS-ARDS score, including the left and right LUS aeration scores and anterolateral pleural line abnormalities, had an area under the receiver operating characteristic (ROC) curve of 0.90 (95% confidence interval [CI], 0.85-0.95) in certain patients of the derivation cohort and 0.80 (95% CI, 0.72-0.87) in all patients of the validation cohort. Within patients who had imaging-gold standard chest computed tomography available, diagnostic accuracy of eight independent CXR readers followed the ROC curve of the LUS-ARDS score. Conclusions: The LUS-ARDS score can be used to accurately diagnose ARDS also after external validation. The LUS-ARDS score may be a useful adjunct to a diagnosis of ARDS after further validation, as it showed performance comparable with that of the current practice with experienced CXR readers but more objectifiable diagnostic accuracy at each cutoff.
Collapse
Affiliation(s)
- Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Dave A. Dongelmans
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Harm-Jan S. de Grooth
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Charalampos Pierrakos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Pieter Roel Tuinman
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Intensive Care Unit, Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; and
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
8
|
Filippini DFL, Hagens LA, Heijnen NFL, Zimatore C, Atmowihardjo LN, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ, Smit MR. Prognostic Value of the Radiographic Assessment of Lung Edema Score in Mechanically Ventilated ICU Patients. J Clin Med 2023; 12:jcm12041252. [PMID: 36835791 PMCID: PMC9960783 DOI: 10.3390/jcm12041252] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/19/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION The Radiographic Assessment of Lung Edema (RALE) score provides a semi-quantitative measure of pulmonary edema. In patients with acute respiratory distress syndrome (ARDS), the RALE score is associated with mortality. In mechanically ventilated patients in the intensive care unit (ICU) with respiratory failure not due to ARDS, a variable degree of lung edema is observed as well. We aimed to evaluate the prognostic value of RALE in mechanically ventilated ICU patients. METHODS Secondary analysis of patients enrolled in the 'Diagnosis of Acute Respiratory Distress Syndrome' (DARTS) project with an available chest X-ray (CXR) at baseline. Where present, additional CXRs at day 1 were analysed. The primary endpoint was 30-day mortality. Outcomes were also stratified for ARDS subgroups (no ARDS, non-COVID-ARDS and COVID-ARDS). RESULTS 422 patients were included, of which 84 had an additional CXR the following day. Baseline RALE scores were not associated with 30-day mortality in the entire cohort (OR: 1.01, 95% CI: 0.98-1.03, p = 0.66), nor in subgroups of ARDS patients. Early changes in RALE score (baseline to day 1) were only associated with mortality in a subgroup of ARDS patients (OR: 1.21, 95% CI: 1.02-1.51, p = 0.04), after correcting for other known prognostic factors. CONCLUSIONS The prognostic value of the RALE score cannot be extended to mechanically ventilated ICU patients in general. Only in ARDS patients, early changes in RALE score were associated with mortality.
Collapse
Affiliation(s)
- Daan F. L. Filippini
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence:
| | - Laura A. Hagens
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Nanon F. L. Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht University, 6229 HX Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, 70124 Bari, Italy
| | - Leila N. Atmowihardjo
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Department of Research and Development, Hamilton Medical AG, 7402 Bonaduz, Switzerland
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht University, 6229 HX Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Pulmonology, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marry R. Smit
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
9
|
Wanrooij VHM, Cobussen M, Stoffers J, Buijs J, Bergmans DCJJ, Zelis N, Stassen PM. Sex differences in clinical presentation and mortality in emergency department patients with sepsis. Ann Med 2023; 55:2244873. [PMID: 37566727 PMCID: PMC10424597 DOI: 10.1080/07853890.2023.2244873] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/20/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND There is growing awareness that sex differences are associated with different patient outcomes in a variety of diseases. Studies investigating the effect of patient sex on sepsis-related mortality remain inconclusive and mainly focus on patients with severe sepsis and septic shock in the intensive care unit. We therefore investigated the association between patient sex and both clinical presentation and 30-day mortality in patients with the whole spectrum of sepsis severity presenting to the emergency department (ED) who were admitted to the hospital. MATERIALS AND METHODS In our multi-centre cohort study, we retrospectively investigated adult medical patients with sepsis in the ED. Multivariable analysis was used to evaluate the association between patient sex and all-cause 30-day mortality. RESULTS Of 2065 patients included, 47.6% were female. Female patients had significantly less comorbidities, lower Sequential Organ Failure Assessment score and abbreviated Mortality Emergency Department Sepsis score, and presented less frequently with thrombocytopenia and fever, compared to males. For both sexes, respiratory tract infections were predominant while female patients more often had urinary tract infections. Females showed lower 30-day mortality (10.1% vs. 13.6%; p = .016), and in-hospital mortality (8.0% vs. 11.1%; p = .02) compared to males. However, a multivariable logistic regression model showed that patient sex was not an independent predictor of 30-day mortality (OR 0.90; 95% CI 0.67-1.22; p = .51). CONCLUSIONS Females with sepsis presenting to the ED had fewer comorbidities, lower disease severity, less often thrombocytopenia and fever and were more likely to have a urinary tract infection. Females had a lower in-hospital and 30-day mortality compared to males, but sex was not an independent predictor of 30-day mortality. The lower mortality in female patients may be explained by differences in comorbidity and clinical presentation compared to male patients.KEY MESSAGESOnly limited data exist on sex differences in sepsis patients presenting to the emergency department with the whole spectrum of sepsis severity.Female sepsis patients had a lower incidence of comorbidities, less disease severity and a different source of infection, which explains the lower 30-day mortality we found in female patients compared to male patients.We found that sex was not an independent predictor of 30-day mortality; however, the study was probably underpowered to evaluate this outcome definitively.
Collapse
Affiliation(s)
- Vera H. M. Wanrooij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maarten Cobussen
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
- School of CARIM, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
| | - Judith Stoffers
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
| | - Jacqueline Buijs
- Department of Internal Medicine, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism NUTRIM, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Noortje Zelis
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
| | - Patricia M. Stassen
- School of CARIM, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Division of General Internal Medicine, Section Acute Medicine, Maastricht University Medical Centre+, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
10
|
de Jongh SAM, Heines SJH, de Jongh FHC, Segers RPJ, van der Horst ICC, van Bussel BCT, Bergmans DCJJ. Regional peak flow as a novel approach to assess regional pulmonary mechanics by electrical impedance tomography: an observational validation study. Ann Transl Med 2023; 11:253. [PMID: 37082694 PMCID: PMC10113082 DOI: 10.21037/atm-22-3420] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/02/2022] [Indexed: 01/17/2023]
Abstract
Background Spontaneous breathing efforts during mechanical ventilation are a widely accepted weaning approach for acute respiratory distress syndrome (ARDS) patients. These efforts can be too vigorous, possibly inflicting lung and diaphragm damage. Higher positive end expiratory pressure (PEEP) levels can be used to lower the magnitude of vigorous breathing efforts. Nevertheless, PEEP titrating tools are lacking in spontaneous mechanical ventilation (SMV). Therefore, the aim is to develop an electrical impedance tomography (EIT) algorithm for quantifying regional lung mechanics independent from a stable plateau pressure phase based on regional peak flow (RPF) by EIT, which is hypothetically applicable in SMV and to validate this algorithm in patients on controlled mechanical ventilation (CMV). Methods The RPF algorithm quantifies a cumulative overdistension (ODRPF) and collapse (CLRPF) rate and is validated in a prospective cohort of mechanically ventilated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients on CMV. ODRPF and CLRPF are compared with compliance-based cumulative overdistension (ODP500) and collapse (CLP500) rates from the Pulmovista 500 EIT device at multiple PEEP levels (PEEP 10 cmH2O to PEEP 24 cmH2O) in EIT measurements from CMV patients by linear mixed models, Bland-Altman analysis and intraclass correlation coefficient (ICC). Results Seventy-eight patients were included. Linear mixed models revealed an association between ODRPF and ODP500 of 1.02 (0.98-1.07, P<0.001) and between CLRPF and CLP500 of 0.93 (0.80-1.05, P<0.001). ICC values ranged from 0.78 to 0.86 (P<0.001) for ODRPF and ODP500 and from 0.70 to 0.85 (P<0.001) for CLRPF and CLP500 (PEEP 10 to PEEP 24). The mean bias between ODRPF and ODP500 in these PEEP levels ranged from 0.80% to 4.19% and from -1.31% to 0.13% between CLRPF and CLP500. Conclusions A RPF approach for quantifying regional lung mechanics showed a moderate to good agreement in coronavirus disease 2019 (COVID-19) related ARDS patients on CMV compared to the compliance-based approach. This, in addition to being independent of a plateau pressure phase, indicates that the RPF approach is a valid method to explore for quantifying regional lung mechanics in SMV.
Collapse
Affiliation(s)
| | - Serge J. H. Heines
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Ruud P. J. Segers
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bas C. T. van Bussel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
11
|
Atmowihardjo LN, Heijnen NFL, Smit MR, Hagens LA, Filippini DFL, Zimatore C, Schultz MJ, Schnabel RM, Bergmans DCJJ, Aman J, Bos LDJ. Biomarkers of alveolar epithelial injury and endothelial dysfunction are associated with scores of pulmonary edema in invasively ventilated patients. Am J Physiol Lung Cell Mol Physiol 2023; 324:L38-L47. [PMID: 36348302 PMCID: PMC9799153 DOI: 10.1152/ajplung.00185.2022] [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] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pulmonary edema is a central hallmark of acute respiratory distress syndrome (ARDS). Endothelial dysfunction and epithelial injury contribute to alveolar-capillary permeability but their differential contribution to pulmonary edema development remains understudied. Plasma levels of surfactant protein-D (SP-D), soluble receptor for advanced glycation end products (sRAGE), and angiopoietin-2 (Ang-2) were measured in a prospective, multicenter cohort of invasively ventilated patients. Pulmonary edema was quantified using the radiographic assessment of lung edema (RALE) and global lung ultrasound (LUS) score. Variables were collected within 48 h after intubation. Linear regression was used to examine the association of the biomarkers with pulmonary edema. In 362 patients, higher SP-D, sRAGE, and Ang-2 concentrations were significantly associated with higher RALE and global LUS scores. After stratification by ARDS subgroups (pulmonary, nonpulmonary, COVID, non-COVID), the positive association of SP-D levels with pulmonary edema remained, whereas sRAGE and Ang-2 showed less consistent associations throughout the subgroups. In a multivariable analysis, SP-D levels were most strongly associated with pulmonary edema when combined with sRAGE (RALE score: βSP-D = 6.79 units/log10 pg/mL, βsRAGE = 3.84 units/log10 pg/mL, R2 = 0.23; global LUS score: βSP-D = 3.28 units/log10 pg/mL, βsRAGE = 2.06 units/log10 pg/mL, R2 = 0.086), whereas Ang-2 did not further improve the model. Biomarkers of epithelial injury and endothelial dysfunction were associated with pulmonary edema in invasively ventilated patients. SP-D and sRAGE showed the strongest association, suggesting that epithelial injury may form a final common pathway in the alveolar-capillary barrier dysfunction underlying pulmonary edema.
Collapse
Affiliation(s)
| | - Nanon F. L. Heijnen
- 2Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands,8School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Marry R. Smit
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laura A. Hagens
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Daan F. L. Filippini
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Claudio Zimatore
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,3Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Marcus J. Schultz
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,4Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand,5Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom,6Department of Research and Development, Hamilton Medical AG, Bonaduz, Switzerland
| | - Ronny M. Schnabel
- 2Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
| | - Dennis C. J. J. Bergmans
- 2Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands,8School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Jurjan Aman
- 7Department of Pulmonology, Amsterdam UMC, Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,7Department of Pulmonology, Amsterdam UMC, Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
12
|
Hagens LA, Van der Ven FLIM, Heijnen NFL, Smit MR, Gietema HA, Gerretsen SC, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Improvement of an interobserver agreement of ARDS diagnosis by adding additional imaging and a confidence scale. Front Med (Lausanne) 2022; 9:950827. [PMID: 36117964 PMCID: PMC9473335 DOI: 10.3389/fmed.2022.950827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) often is not recognized in clinical practice, largely due to variation in the interpretation of chest x-ray (CXR) leading to poor interobserver reliability. We hypothesized that the agreement in the interpretation of chest imaging for the diagnosis of ARDS in invasively ventilated intensive care unit patients between experts improves when using an 8-grade confidence scale compared to using a dichotomous assessment and that the agreement increases after adding chest computed tomography (CT) or lung ultrasound (LUS) to CXR. Three experts scored ARDS according to the Berlin definition based on case records from an observational cohort study using a dichotomous assessment and an 8-grade confidence scale. The intraclass correlation (ICC), imaging modality, and the scoring method were calculated per day and compared using bootstrapping. A consensus judgement on the presence of ARDS was based on the combined confidence grades of the experts, followed by a consensus meeting for conflicting scores. In total, 401 patients were included in the analysis. The best ICC was found using an 8-grade confidence scale for LUS (ICC: 0.49; 95%-CI: 0.29–0.63) and CT evaluation (ICC: 0.49; 95%-CI: 0.34–0.61). The ICC of CXR increased by 0.022 and of CT by 0.065 when 8-grade scoring was used instead of the dichotomous assessment. Adding information from LUS or chest CT increased the ICC by 0.25 when using the 8-grade confidence assessment. An agreement on the diagnosis of ARDS can increase substantially by adapting the scoring system from a dichotomous assessment to an 8-grade confidence scale and by adding additional imaging modalities such as LUS or chest CT. This suggests that a simple assessment of the diagnosis of ARDS with a chart review by one assessor is insufficient to define ARDS in future studies.
Collapse
Affiliation(s)
- Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Laura A. Hagens
| | - Fleur L. I. M. Van der Ven
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Ziekenhuis, Brandwondencentrum, Beverwijk, Netherlands
| | - Nanon F. L. Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hester A. Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Suzanne C. Gerretsen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
13
|
Heines SJH, de Jongh SAM, Strauch U, van der Horst ICC, van de Poll MCG, Bergmans DCJJ. The global inhomogeneity index assessed by electrical impedance tomography overestimates PEEP requirement in patients with ARDS: an observational study. BMC Anesthesiol 2022; 22:258. [PMID: 35971060 PMCID: PMC9377133 DOI: 10.1186/s12871-022-01801-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background Electrical impedance tomography (EIT) visualises alveolar overdistension and alveolar collapse and enables optimisation of ventilator settings by using the best balance between alveolar overdistension and collapse (ODCL). Besides, the global inhomogeneity index (GI), measured by EIT, may also be of added value in determining PEEP. Optimal PEEP is often determined based on the best dynamic compliance without EIT at the bedside. This study aimed to assess the effect of a PEEP trial on ODCL, GI and dynamic compliance in patients with and without ARDS. Secondly, PEEP levels from “optimal PEEP” approaches by ODCL, GI and dynamic compliance are compared. Methods In 2015–2016, we included patients with ARDS using postoperative cardiothoracic surgery patients as a reference group. A PEEP trial was performed with four consecutive incremental followed by four decremental PEEP steps of 2 cmH2O. Primary outcomes at each step were GI, ODCL and best dynamic compliance. In addition, the agreement between ODCL, GI, and dynamic compliance was determined for the individual patient. Results Twenty-eight ARDS and 17 postoperative cardiothoracic surgery patients were included. The mean optimal PEEP, according to best compliance, was 10.3 (±2.9) cmH2O in ARDS compared to 9.8 (±2.5) cmH2O in cardiothoracic surgery patients. Optimal PEEP according to ODCL was 10.9 (±2.5) in ARDS and 9.6 (±1.6) in cardiothoracic surgery patients. Optimal PEEP according to GI was 17.1 (±3.9) in ARDS compared to 14.2 (±3.4) in cardiothoracic surgery patients. Conclusions Currently, no golden standard to titrate PEEP is available. We showed that when using the GI, PEEP requirements are higher compared to ODCL and best dynamic compliance during a PEEP trial in patients with and without ARDS. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01801-7.
Collapse
Affiliation(s)
- Serge J H Heines
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands.
| | - Sebastiaan A M de Jongh
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
| | - Ulrich Strauch
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, the Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, P.O. Box 5800, 6202, AZ, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
14
|
Strauch U, Florack MCDM, Jansen J, van Bussel BCT, Beckers SK, Habers J, Winkens B, van der Horst ICC, van Mook WNKA, Bergmans DCJJ. The QUality of Interhospital Transportation in the Euregion Meuse-Rhine (QUIT-EMR) score: a cross-validation study. BMJ Open 2021; 11:e051100. [PMID: 34799362 PMCID: PMC8606780 DOI: 10.1136/bmjopen-2021-051100] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Interhospital transports of critically ill patients are high-risk medical interventions. Well-established parameters to quantify the quality of transports are currently lacking. We aimed to develop and cross-validate a score for interhospital transports. SETTING An expert panel developed a score for interhospital transport by a Mobile Intensive Care Unit (MICU), the QUality of Interhospital Transportation in the Euregion Meuse-Rhine (QUIT-EMR) score. The QUIT-EMR score is an overall sum score that includes component scores of monitoring and intervention variables of the neurological (proxy for airway patency), respiratory and circulatory organ systems, ranging from -12 to +12. A score of 0 or higher defines an adequate transport. The QUIT-EMR score was tested to help to quantify the quality of transport. PARTICIPANTS One hundred adult patients were randomly included and the transport charts were independently reviewed and classified as adequate or inadequate by four transport experts (ie, anaesthetists/intensivists). OUTCOME MEASURES Subsequently, the level of agreement between the QUIT-EMR score and expert classification was calculated using Gwet's AC1. RESULTS From April 2012 to May 2014, a total of 100 MICU transports were studied. The median (IQR) QUIT-EMR score was 1 (0-2). Experts classified six transports as inadequate. The percentage agreement between the QUIT-EMR score and experts' classification for adequate/inadequate transport ranged from 84% to 92% (Gwet's AC10.81-0.91). The interobserver agreement between experts was 87% to 94% (Gwet's AC10.89-0.98). CONCLUSION The QUIT-EMR score is a novel validated tool to score MICU transportation adequacy in future studies contributing to quality control and improvement. TRIAL REGISTRATION NUMBER NTR 4937.
Collapse
Affiliation(s)
- Ulrich Strauch
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Simulation Center, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Micheline C D M Florack
- Department of Anesthesiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Jochen Jansen
- Department of Anesthesiology, Laurentius Hospital Roermond, Roermond, Limburg, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Department of Methodology and Statistics, Universiteit Maastricht Care and Public Health Research Institute, Maastricht, The Netherlands
| | | | | | - Bjorn Winkens
- Department of Methodology and Statistics, Universiteit Maastricht Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Academy for Postgraduate Medical Training, Maastricht University Medical Centre+, Maastricht, The Netherlands
- School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| |
Collapse
|
15
|
Hagens LA, Heijnen NFL, Smit MR, Verschueren ARM, Nijsen TME, Geven I, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Diagnosis of acute respiratory distress syndrome (DARTS) by bedside exhaled breath octane measurements in invasively ventilated patients: protocol of a multicentre observational cohort study. Ann Transl Med 2021; 9:1262. [PMID: 34532399 PMCID: PMC8421964 DOI: 10.21037/atm-21-1384] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/28/2021] [Indexed: 11/08/2022]
Abstract
Background Acute respiratory distress syndrome (ARDS) is currently diagnosed by the Berlin Definition. Diagnosis is subjective and often late. Untargeted metabolomics analysis of exhaled breath with gas chromatography and mass spectrometry (GC-MS) showed that the breath concentration of octane has a high diagnostic accuracy for ARDS. To facilitate rapid bedside measurement of this biomarker, a point-of-care (POC) breath test was developed. A prototype already showed good reproducibility and repeatability for the detection of octane. In this study we aim to measure octane in exhaled breath of invasively ventilated intensive care unit (ICU) patients and validate the diagnostic accuracy of the breath test for the early diagnosis of ARDS. Methods This is a multicentre observational cohort study in patients admitted to the ICU receiving invasive ventilation for at least 24 hours. At least 500 patients in two academic hospitals in The Netherlands will be included. ARDS patients will be compared to patients without ARDS. ARDS diagnosis will be based on the Berlin Definition. Two diagnostic assessments will be performed during the first 72 hours of invasive ventilation, including breath sampling, arterial blood gas analysis and lung ultrasound (LUS). In patients fulfilling the criteria for ARDS, three additional breath samples will be taken to assess resolution. The primary endpoint is the diagnostic accuracy for ARDS, defined by the area under the receiver operating characteristics curve (AUROCC) of octane concentration in exhaled breath. Secondary endpoints are the association between exhaled breath octane and ARDS adjusted for confounders, and the added diagnostic accuracy of the breath test on top of the Lung Injury Prediction Score (LIPS). Discussion This is the first study that validates a metabolic biomarker of ARDS in an adequate sample size. The major novelty is the use of a POC breath test that has been specifically developed for the purpose of diagnosing ARDS. Strengths are; assessment in the early phase, in patients at risk for ARDS, longitudinal sampling and an expert panel to reliably diagnose ARDS. This study will provide a decisive answer on the question if exhaled breath metabolomics can be used to diagnose ARDS. Trial registration The trial is registered at trialregister.nl (ID: NL8226) with the tag “DARTS”.
Collapse
Affiliation(s)
- Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alwin R M Verschueren
- Sleep & Respiratory Solutions, Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Tamara M E Nijsen
- Sleep & Respiratory Solutions, Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Inge Geven
- Sleep & Respiratory Solutions, Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
16
|
Heijnen NFL, Hagens LA, Smit MR, Cremer OL, Ong DSY, van der Poll T, van Vught LA, Scicluna BP, Schnabel RM, van der Horst ICC, Schultz MJ, Bergmans DCJJ, Bos LDJ. Biological Subphenotypes of Acute Respiratory Distress Syndrome Show Prognostic Enrichment in Mechanically Ventilated Patients without Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 203:1503-1511. [PMID: 33465019 DOI: 10.1164/rccm.202006-2522oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [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: 12/12/2022] Open
Abstract
Rationale: Recent studies showed that biological subphenotypes in acute respiratory distress syndrome (ARDS) provide prognostic enrichment and show potential for predictive enrichment. Objectives: To determine whether these subphenotypes and their prognostic and potential for predictive enrichment could be extended to other patients in the ICU, irrespective of fulfilling the definition of ARDS. Methods: This is a secondary analysis of a prospective observational study of adult patients admitted to the ICU. We tested the prognostic enrichment of both cluster-derived and latent-class analysis (LCA)-derived biological ARDS subphenotypes by evaluating the association with clinical outcome (ICU-day, 30-day mortality, and ventilator-free days) using logistic regression and Cox regression analysis. We performed a principal component analysis to compare blood leukocyte gene expression profiles between subphenotypes and the presence of ARDS. Measurements and Main Results: We included 2,499 mechanically ventilated patients (674 with and 1,825 without ARDS). The cluster-derived "reactive" subphenotype was, independently of ARDS, significantly associated with a higher probability of ICU mortality, higher 30-day mortality, and a lower probability of successful extubation while alive compared with the "uninflamed" subphenotype. The blood leukocyte gene expression profiles of individual subphenotypes were similar for patients with and without ARDS. LCA-derived subphenotypes also showed similar profiles. Conclusions: The prognostic and potential for predictive enrichment of biological ARDS subphenotypes may be extended to mechanically ventilated critically ill patients without ARDS. Using the concept of biological subphenotypes for splitting cohorts of critically ill patients could add to improving future precision-based trial strategies and lead to identifying treatable traits for all critically ill patients.
Collapse
Affiliation(s)
- Nanon F L Heijnen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | | | | | - David S Y Ong
- Division of Infectious Diseases.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Infection and Immunity
| | - Tom van der Poll
- Laboratory of Experimental Intensive Care and Anesthesiology, and.,Department of Respiratory Medicine, Amsterdam University Medical Centers, location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Brendon P Scicluna
- Laboratory of Experimental Intensive Care and Anesthesiology, and.,Department of Intensive Care Medicine and
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Medical Microbiology and Infection Control, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; and
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care Medicine.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
17
|
Hagens LA, Verschueren ARM, Lammers A, Heijnen NFL, Smit MR, Nijsen TME, Geven I, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Development and validation of a point-of-care breath test for octane detection. Analyst 2021; 146:4605-4614. [PMID: 34160491 DOI: 10.1039/d1an00378j] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is a demand for a non-invasive bedside method to diagnose Acute Respiratory Distress Syndrome (ARDS). Octane was discovered and validated as the most important breath biomarker for diagnosis of ARDS using gas-chromatography and mass-spectrometry (GC-MS). However, GC-MS is unsuitable as a point-of-care (POC) test in the intensive care unit (ICU). Therefore, we determined if a newly developed POC breath test can reliably detect octane in exhaled breath of invasively ventilated ICU patients. METHODS Two developmental steps were taken to design a POC breath test that relies on gas-chromatography using air as carrier gas with a photoionization detector. Calibration measurements were performed with a laboratory prototype in healthy subjects. Subsequently, invasively ventilated patients were included for validation and assessment of repeatability. After evolving to a POC breath test, this device was validated in a second group of invasively ventilated patients. Octane concentration was based on the area under the curve, which was extracted from the chromatogram and compared to known values from calibration measurements. RESULTS Five healthy subjects and 53 invasively ventilated patients were included. Calibration showed a linear relation (R2 = 1.0) between the octane concentration and the quantified octane peak in the low parts per billion (ppb) range. For the POC breath test the repeatability was excellent (R2 = 0.98, ICC = 0.97 (95% CI 0.94-0.99)). CONCLUSION This is the first study to show that a POC breath test can rapidly and reliably detect octane, with excellent repeatability, at clinically relevant levels of low ppb in exhaled breath of ventilated ICU patients. This opens possibilities for targeted exhaled breath analysis to be used as a bedside test and makes it a potential diagnostic tool for the early detection of ARDS.
Collapse
Affiliation(s)
- Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Alwin R M Verschueren
- Remote Patient Monitoring & Connected Care, Philips Research, High Tech Campus 4, 5656 AE, Eindhoven, Netherlands
| | - Ariana Lammers
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Tamara M E Nijsen
- Remote Patient Monitoring & Connected Care, Philips Research, High Tech Campus 4, 5656 AE, Eindhoven, Netherlands
| | - Inge Geven
- Remote Patient Monitoring & Connected Care, Philips Research, High Tech Campus 4, 5656 AE, Eindhoven, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands and Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands and School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands and Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
18
|
Driessen RGH, Groven RVM, van Koll J, Oudhuis GJ, Posthouwer D, van der Horst ICC, Bergmans DCJJ, Schnabel RM. Appropriateness of empirical antibiotic therapy and added value of adjunctive gentamicin in patients with septic shock: a prospective cohort study in the ICU. Infect Dis (Lond) 2021; 53:830-838. [PMID: 34156899 DOI: 10.1080/23744235.2021.1942543] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES To determine the appropriateness of empiric antibiotic therapy and the possible benefit of adding short-course gentamicin in septic shock patients with abdominal, urogenital, or an unknown focus. Secondary objectives were the effect of gentamicin addition on shock reversal and the incidence of a fungal infection. METHODS Microbiological cultures, antibiotic treatment, and antibiotic resistance patterns of the cultured microorganisms were recorded during the first 5 days of admission. Inappropriate antibiotic therapy was defined as a prescription within the first 24 h that did not cover cultured bacteria during the first 5 days of admission and was determined in the overall group and in patients receiving adjunctive gentamicin (combination therapy) versus patients receiving monotherapy. Binomial logistic regression analysis was used to investigate the association of gentamicin addition with shock reversal. RESULTS Of 203 septic shock patients, with abdominal (n = 143), urogenital (n = 27) or unknown (n = 33) focus, 115 patients received monotherapy, and 88 patients received combination therapy. Inappropriate therapy occurred in 29 patients (14%), more frequently in monotherapy (17%) versus combination therapy (10%). Combination therapy would have been effective in 55% of patients with inappropriate monotherapy. We found no association between gentamicin addition and shock reversal (p = .223). A fungal infection was present in 22 patients (11%). CONCLUSION Inappropriate empirical antibiotic therapy occurs in 17% of septic shock patients receiving monotherapy. In 55% of these patients, additional gentamicin would have resulted in appropriate therapy. When clinical course is unfavourable, lowering the threshold for administering adjunctive aminoglycoside and antifungal therapy should be considered.
Collapse
Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rald V M Groven
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Johan van Koll
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Guy J Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Dirk Posthouwer
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Internal Medicine, Department of Infectious Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
19
|
Vanderbeke L, Janssen NAF, Bergmans DCJJ, Bourgeois M, Buil JB, Debaveye Y, Depuydt P, Feys S, Hermans G, Hoiting O, van der Hoven B, Jacobs C, Lagrou K, Lemiale V, Lormans P, Maertens J, Meersseman P, Mégarbane B, Nseir S, van Oers JAH, Reynders M, Rijnders BJA, Schouten JA, Spriet I, Thevissen K, Thille AW, Van Daele R, van de Veerdonk FL, Verweij PE, Wilmer A, Brüggemann RJM, Wauters J. Posaconazole for prevention of invasive pulmonary aspergillosis in critically ill influenza patients (POSA-FLU): a randomised, open-label, proof-of-concept trial. Intensive Care Med 2021; 47:674-686. [PMID: 34050768 PMCID: PMC8164057 DOI: 10.1007/s00134-021-06431-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/05/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE Influenza-associated pulmonary aspergillosis (IAPA) is a frequent complication in critically ill influenza patients, associated with significant mortality. We investigated whether antifungal prophylaxis reduces the incidence of IAPA. METHODS We compared 7 days of intravenous posaconazole (POS) prophylaxis with no prophylaxis (standard-of-care only, SOC) in a randomised, open-label, proof-of-concept trial in patients admitted to an intensive care unit (ICU) with respiratory failure due to influenza (ClinicalTrials.gov, NCT03378479). Adult patients with PCR-confirmed influenza were block randomised (1:1) within 10 days of symptoms onset and 48 h of ICU admission. The primary endpoint was the incidence of IAPA during ICU stay in patients who did not have IAPA within 48 h of ICU admission (modified intention-to-treat (MITT) population). RESULTS Eighty-eight critically ill influenza patients were randomly allocated to POS or SOC. IAPA occurred in 21 cases (24%), the majority of which (71%, 15/21) were diagnosed within 48 h of ICU admission, excluding them from the MITT population. The incidence of IAPA was not significantly reduced in the POS arm (5.4%, 2/37) compared with SOC (11.1%, 4/36; between-group difference 5.7%; 95% CI - 10.8 to 21.7; p = 0.32). ICU mortality of early IAPA was high (53%), despite rapid antifungal treatment. CONCLUSION The higher than expected incidence of early IAPA precludes any definite conclusion on POS prophylaxis. High mortality of early IAPA, despite timely antifungal therapy, indicates that alternative management strategies are required. After 48 h, still 11% of patients developed IAPA. As these could benefit from prophylaxis, differentiated strategies are likely needed to manage IAPA in the ICU.
Collapse
Affiliation(s)
- Lore Vanderbeke
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Nico A F Janssen
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc Bourgeois
- Department of Intensive Care, Algemeen Ziekenhuis Sint-Jan Brugge-Oostende, Brugge, Belgium
| | - Jochem B Buil
- Center of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Simon Feys
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Oscar Hoiting
- Department of Intensive Care Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Ben van der Hoven
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cato Jacobs
- Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Laboratory Medicine and National Reference Center for Mycosis, University Hospitals Leuven, Leuven, Belgium
| | - Virginie Lemiale
- Department of Intensive Care Medicine, Saint-Louis Hospital, Paris, France
| | - Piet Lormans
- Department of Anesthesiology and Intensive Care Medicine, Algemeen Ziekenhuis Delta, Roeselare, Belgium
| | - Johan Maertens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Haematology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Meersseman
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, University of Paris, Paris, France
| | - Saad Nseir
- Department of Intensive Care Medicine, Critical Care Center, University Hospital Lille, INSERM U995-E2, Lille Inflammation Research International Center, University of Lille, Lille, France
| | - Jos A H van Oers
- Department of Intensive Care Medicine, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Marijke Reynders
- Department of Laboratory Medicine, Algemeen Ziekenhuis Sint-Jan Brugge-Oostende, Brugge, Belgium
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium
| | - Karin Thevissen
- Department of Microbial and Molecular Systems, Center of Microbial and Plant Genetics (CMPG), KU Leuven, Leuven, Belgium
| | - Arnaud W Thille
- Department of Intensive Care Medicine, University Hospital Poitiers, Poitiers, France
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Center of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Paul E Verweij
- Center of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.,Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander Wilmer
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Roger J M Brüggemann
- Center of Expertise in Mycology Radboudumc/CWZ, Radboudumc Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost Wauters
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium. .,Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.
| | | |
Collapse
|
20
|
Heijnen NFL, Hagens LA, Smit MR, Schultz MJ, van der Poll T, Schnabel RM, van der Horst ICC, Dickson RP, Bergmans DCJJ, Bos LDJ. Biological subphenotypes of acute respiratory distress syndrome may not reflect differences in alveolar inflammation. Physiol Rep 2021; 9:e14693. [PMID: 33547768 PMCID: PMC7865405 DOI: 10.14814/phy2.14693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 12/12/2022] Open
Abstract
Biological subphenotypes have been identified in acute respiratory distress syndrome (ARDS) based on two parsimonious models: the "uninflamed" and "reactive" subphenotype (cluster-model) and "hypo-inflammatory" and "hyper-inflammatory" (latent class analysis (LCA) model). The distinction between the subphenotypes is mainly driven by inflammatory and coagulation markers in plasma. However, systemic inflammation is not specific for ARDS and it is unknown whether these subphenotypes also reflect differences in the alveolar compartment. Alveolar inflammation and dysbiosis of the lung microbiome have shown to be important mediators in the development of lung injury. This study aimed to determine whether the "reactive" or "hyper-inflammatory" biological subphenotype also had higher concentrations of inflammatory mediators and enrichment of gut-associated bacteria in the lung. Levels of alveolar inflammatory mediators myeloperoxidase (MPO), surfactant protein D (SPD), interleukin (IL)-1b, IL-6, IL-10, IL-8, interferon gamma (IFN-ƴ), and tumor necrosis factor-alpha (TNFα) were determined in the mini-BAL fluid. Key features of the lung microbiome were measured: bacterial burden (16S rRNA gene copies/ml), community diversity (Shannon Diversity Index), and community composition. No statistically significant differences between the "uninflamed" and "reactive" ARDS subphenotypes were found in a selected set of alveolar inflammatory mediators and key features of the lung microbiome. LCA-derived subphenotypes and stratification based on cause of ARDS (direct vs. indirect) showed similar profiles, suggesting that current subphenotypes may not reflect the alveolar host response. It is important for future research to elucidate the pulmonary biology within each subphenotype properly, which is arguably a target for intervention.
Collapse
Affiliation(s)
- Nanon F. L. Heijnen
- Department of Intensive CareMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Laura A. Hagens
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marry R. Smit
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marcus J. Schultz
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A)Academic Medical CentersLocation Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Mahidol‐Oxford Tropical Medicine Research Unit (MORU)Mahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Tom van der Poll
- Center for Experimental and Molecular MedicineAmsterdam University Medical CentersLocation Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Division of Infectious DiseasesAmsterdam University Medical CentersLocation Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Ronny M. Schnabel
- Department of Intensive CareMaastricht University Medical Center+MaastrichtThe Netherlands
| | | | - Robert P. Dickson
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMIUSA
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareAnn ArborMIUSA
| | | | - Lieuwe D. J. Bos
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
| | | |
Collapse
|
21
|
Hagens LA, Heijnen NFL, Smit MR, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Systematic review of diagnostic methods for acute respiratory distress syndrome. ERJ Open Res 2021; 7:00504-2020. [PMID: 33532455 PMCID: PMC7836439 DOI: 10.1183/23120541.00504-2020] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/18/2020] [Indexed: 01/10/2023] Open
Abstract
Rationale Acute respiratory distress syndrome (ARDS) is currently diagnosed by the Berlin definition, which does not include a direct measure of pulmonary oedema, endothelial permeability or pulmonary inflammation. We hypothesised that biomarkers of these processes have good diagnostic accuracy for ARDS. Methods Medline and Scopus were searched for original diagnostic studies using minimally invasive testing. Primary outcome was the diagnostic accuracy per test and was categorised by control group. The methodological quality was assessed with QUADAS-2 tool. Biomarkers that had an area under the receiver operating characteristic curve (AUROCC) of >0.75 and were studied with minimal bias against an unselected control group were considered to be promising. Results Forty-four articles were included. The median AUROCC for all evaluated tests was 0.80 (25th to 75th percentile: 0.72–0.88). The type of control group influenced the diagnostic accuracy (p=0.0095). Higher risk of bias was associated with higher diagnostic accuracy (AUROCC 0.75 for low-bias, 0.77 for intermediate-bias and 0.84 for high-bias studies; p=0.0023). Club cell protein 16 and soluble receptor for advanced glycation end-products in plasma and two panels with biomarkers of oxidative stress in breath showed good diagnostic accuracy in low-bias studies that compared ARDS patients to an unselected intensive care unit (ICU) population. Conclusion This systematic review revealed only four diagnostic tests fulfilling stringent criteria for a promising biomarker in a low-bias setting. For implementation into the clinical setting, prospective studies in a general unselected ICU population with good methodological quality are needed. Accuracy of diagnosis of acute respiratory distress syndrome (ARDS) is associated with risk of bias. There is a lack of validated diagnostic tests in an unbiased setting, emphasising the need for quality driven diagnostic research in ARDS.https://bit.ly/2GfPAvf
Collapse
Affiliation(s)
- Laura A Hagens
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Dept of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Dept of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Lieuwe D J Bos
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
22
|
Driessen RGH, Latten BGH, Bergmans DCJJ, Hulsewe RPMG, Holtkamp JWM, van der Horst ICC, Kubat B, Schnabel RM. Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study. Virchows Arch 2020; 478:1173-1178. [PMID: 33306143 PMCID: PMC8203528 DOI: 10.1007/s00428-020-02984-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Abstract
Early death in sepsis occurs frequently; however, specific causes are largely unknown. An autopsy can contribute to ascertain causes of death. The objective of the study was to determine discrepancies in clinical diagnosis and postmortem findings in septic intensive care unit (ICU) patients deceased within 48 h after ICU admission. All septic ICU patients who deceased within 48 h after ICU admission were identified and included. Four intensivists determined the clinical cause of death by medical record review. An autopsy was performed within 24 h of death. Clinical diagnosis and postmortem findings were compared and classified as autopsy-identified missed clinical diagnoses and autopsy-refuted diagnoses. Class I and II missed major diagnoses using the Goldman criteria were scored. Between 2012 and 2017, 1107 septic patients were admitted to ICU. Of these, 344 patients (31%) died, of which 97 patients (28%) deceased within 48 h. In 32 (33%) early deceased patients, an autopsy was agreed. There were 26 autopsy-identified missed clinical diagnoses found, mostly myocardial infarction (n = 4) and pneumonia (n = 4). In four patients (13%), a class I discrepancy was found. In fourteen patients (42%), a class II discrepancy was found. In conclusion, an autopsy is an important diagnostic tool that can identify definite causes of death. These diagnoses deviate from diagnoses established during admission in early deceased sepsis patients.
Collapse
Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands. .,Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | | | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Riquette P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Johanna W M Holtkamp
- Department of Intensive Care Medicine, St. Jans Gasthuis, Weert, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bela Kubat
- Department of Pathology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
23
|
Smit MR, de Vos J, Pisani L, Hagens LA, Almondo C, Heijnen NFL, Schnabel RM, van der Horst ICC, Bergmans DCJJ, Schultz MJ, Bos LDJ. Comparison of Linear and Sector Array Probe for Handheld Lung Ultrasound in Invasively Ventilated ICU Patients. Ultrasound in Medicine & Biology 2020; 46:3249-3256. [PMID: 32962892 DOI: 10.1016/j.ultrasmedbio.2020.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 06/11/2023]
Abstract
International guidelines do not recommend a specific probe for assessment of lung aeration using lung ultrasound (LUS). The aim of this study was to assess the concordance between linear and sector array probes of a handheld ultrasound device in assessment of lung aeration in invasively ventilated intensive care unit patients. This study included intensive care unit patients who were expected to be ventilated for longer than 24 h. A 12-region LUS exam was performed with a linear and a sector array probe. In each image, the LUS aeration score and number of B-lines were determined. Adding the LUS aeration scores of all regions resulted in a global LUS aeration score. Agreement between the two probes was calculated using intra-class correlation coefficients (ICCs). A total of 30 LUS exams were performed in 19 patients, resulting in a total of 328 pairs of images. Twenty-nine pairs of images were excluded from analysis because the images from the linear probe could not be scored. ICCs calculated for the remaining images revealed good concordance the LUS aeration scores for individual images (ICC = 0.73, 95% confidence interval 0.67-0.78), number of B-lines (ICC = 0.79, 95% confidence interval 0.72-0.83) and global LUS aeration score (ICC = 0.74, 95% confidence interval 0.52-0.87). In conclusion, there is good concordance between linear and sector array probes of a handheld ultrasound device in assessment of lung aeration patterns in mechanically ventilated intensive care unit patients. However, in roughly 10% of the images acquired using the linear probe, the aeration pattern could not be scored.
Collapse
Affiliation(s)
- Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Juliette de Vos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Chiara Almondo
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | | | | | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
24
|
Schiffer VMMM, Janssen EBNJ, van Bussel BCT, Jorissen LLM, Tas J, Sels JWEM, Bergmans DCJJ, Dinh THT, van Kuijk SMJ, Hana A, Mehagnoul-Schipper J, Scheeren CIE, Mesotten D, Stessel B, Marx G, Hof AWJVT, Spaanderman MEA, van Mook WNKA, van der Horst ICC, Ghossein-Doha C. The "sex gap" in COVID-19 trials: a scoping review. EClinicalMedicine 2020; 29:100652. [PMID: 33283178 PMCID: PMC7701906 DOI: 10.1016/j.eclinm.2020.100652] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/22/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Many studies investigate the role of pharmacological treatments on disease course in Corona Virus Disease 2019 (COVID-19). Sex disparities in genetics, immunological responses, and hormonal mechanisms may underlie the substantially higher fatality rates reported in male COVID-19 patients. To optimise care for COVID-19 patients, prophylactic and therapeutic studies should include sex-specific design and analyses. Therefore, in this scoping review, we investigated whether studies on pharmacological treatment in COVID-19 were performed based on a priori sex-specific design or post-hoc sex-specific analyses. METHODS We systematically searched PubMed, EMBASE, UpToDate, clinical trial.org, and MedRxiv for studies on pharmacological treatment for COVID-19 until June 6th, 2020. We included case series, randomized controlled trials, and observational studies in humans (≥18 years) investigating antiviral, antimalarial, and immune system modulating drugs. Data were collected on 1) the proportion of included females, 2) whether sex stratification was performed (a priori by design or post-hoc), and 3) whether effect modification by sex was investigated. FINDINGS 30 studies were eligible for inclusion, investigating remdesivir (n = 2), lopinavir/ritonavir (n = 5), favipiravir (n = 1), umifenovir (n = 1), hydroxychloroquine/chloroquine (n = 8), convalescent plasma (n = 6), interleukin-6 (IL-6) pathway inhibitors (n = 5), interleukin-1 (IL-1) pathway inhibitors (n = 1) and corticosteroids (n = 3). Only one study stratified its data based on sex in a post-hoc analysis, whereas none did a priori by design. None of the studies investigated effect modification by sex. A quarter of the studies included twice as many males as females. INTERPRETATION Analyses assessing potential interference of sex with (side-)effects of pharmacological therapy for COVID-19 are rarely reported. Considering sex differences in case-fatality rates and genetic, immunological, and hormonal mechanisms, studies should include sex-specific analyses in their design to optimise COVID-19 care. FUNDING None.
Collapse
Affiliation(s)
- Veronique M M M Schiffer
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
- GROW, School for Oncology and Developmental Biology, Maastricht University, the Netherlands
| | - Emma B N J Janssen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care, MUMC+, Maastricht, the Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, the Netherlands
| | - Laura L M Jorissen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Jeanette Tas
- Department of Intensive Care, MUMC+, Maastricht, the Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care, MUMC+, Maastricht, the Netherlands
- Department of Cardiology, MUMC+, Maastricht, MD 6200, the Netherlands
| | | | - Trang H T Dinh
- Department of Cardiology, MUMC+, Maastricht, MD 6200, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, MUMC+, Maastricht, the Netherlands
| | - Anisa Hana
- Department of Intensive Care, Laurentius Ziekenhuis, Roermond, the Netherlands
| | | | | | - Dieter Mesotten
- Department of Intensive Care, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Bjorn Stessel
- Department of Intensive Care, Jessa Hospital, Hasselt, Belgium
| | - Gernot Marx
- Department of Intensive Care, Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Marc E A Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care, MUMC+, Maastricht, the Netherlands
- School of Health Professions Education, Academy for Postgraduate Medical Training, Maastricht University, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, MUMC+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
- Department of Intensive Care, MUMC+, Maastricht, the Netherlands
- Department of Cardiology, MUMC+, Maastricht, MD 6200, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| |
Collapse
|
25
|
Bels JLM, van Kuijk SMJ, Ghossein-Doha C, Tijssen FH, van Gassel RJJ, Tas J, Collaborators M, Schnabel RM, Aries MJH, van de Poll MCG, Bergmans DCJJ, Meex SJR, van Mook WNKA, van der Horst ICC, van Bussel BCT. Decreased serial scores of severe organ failure assessments are associated with survival in mechanically ventilated patients; the prospective Maastricht Intensive Care COVID cohort. J Crit Care 2020; 62:38-45. [PMID: 33246196 PMCID: PMC7669472 DOI: 10.1016/j.jcrc.2020.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 07/09/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 01/08/2023]
Abstract
Background The majority of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are admitted to the Intensive Care Unit (ICU) for mechanical ventilation. The role of multi-organ failure during ICU admission as driver for outcome remains to be investigated yet. Design and setting Prospective cohort of mechanically ventilated critically ill with SARS-CoV-2 infection. Participants and methods 94 participants of the MaastrICCht cohort (21% women) had a median length of stay of 16 days (maximum of 77). After division into survivors (n = 59) and non-survivors (n = 35), we analysed 1555 serial SOFA scores using linear mixed-effects models. Results Survivors improved one SOFA score point more per 5 days (95% CI: 4–8) than non-survivors. Adjustment for age, sex, and chronic lung, renal and liver disease, body-mass index, diabetes mellitus, cardiovascular risk factors, and Acute Physiology and Chronic Health Evaluation II score did not change this result. This association was stronger for women than men (P-interaction = 0.043). Conclusions The decrease in SOFA score associated with survival suggests multi-organ failure involvement during mechanical ventilation in patients with SARS-CoV-2. Surviving women appeared to improve faster than surviving men. Serial SOFA scores may unravel an unfavourable trajectory and guide decisions in mechanically ventilated patients with SARS-CoV-2.
Collapse
Affiliation(s)
- Julia L M Bels
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Chahinda Ghossein-Doha
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Department of Cardiology, Maastricht University Medical Centre+, Maastricht, the Netherlands; School for Oncology & Developmental Biology (GROW), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Fabian H Tijssen
- Department of Anaesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Rob J J van Gassel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - MaastrICCht Collaborators
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands.
| | - Marcel J H Aries
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands.
| | - Steven J R Meex
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands.
| | - Walther N K A van Mook
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School of Health Professions Education, Maastricht University, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands.
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands.
| | - Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| |
Collapse
|
26
|
Vreeswijk SJM, Mommers LPW, Bergmans DCJJ, van Wageningen B. Clamshell in a Heartbeat. Air Med J 2020; 39:509-511. [PMID: 33228905 DOI: 10.1016/j.amj.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 06/11/2023]
Abstract
There is a restrained attitude toward the implementation and performance of resuscitative thoracotomy as a last resort procedure in patients with cardiac arrest after penetrating thoracic trauma. We present a case with a remarkable recovery and hope to boost morality in the use of this procedure in the prehospital setting. A disoriented 25-year-old woman stabbed multiple times was found next to the highway. Her clinical situation deteriorated swiftly upon arrival of the helicopter emergency medical services. They were able to perform a clamshell thoracotomy and fly the patient out to the nearest trauma center. She awoke with good neurologic function. Her hospital admission was complicated by mediastinitis. A routine cardiac ultrasound showed mitral valve insufficiency due to combined perforation of the anterior leaflet and ventricular septum. Both lesions were in the trajectory of the primary stab wound. Successful outcome in our case was due to the following: little delay between clinical deterioration and the arrival of the helicopter emergency medical services physician (signs of life on arrival of paramedics are an independent predictor of survival), young age and penetrating injury are associated with a good neurologic outcome in case of traumatic cardiac arrest, and extensive follow-up cardiac ultrasound as part of tertiary survey after resuscitative emergency thoracotomy is advised.
Collapse
Affiliation(s)
- Sebastiaan J M Vreeswijk
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Lars P W Mommers
- Department of Anesthesiology, Maastricht University Medical Centre+, Maastricht, The Netherlands; Helicopter Emergency Medical Service, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Bas van Wageningen
- Helicopter Emergency Medical Service, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
27
|
Bosveld MH, van Doorn DPC, Stassen PM, Westerman D, Bergmans DCJJ, van der Horst ICC, van Mook WNKA. Lessons learned: Contribution to healthcare by medical students during COVID-19. J Crit Care 2020; 63:113-116. [PMID: 32980234 PMCID: PMC7501515 DOI: 10.1016/j.jcrc.2020.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/27/2020] [Accepted: 09/16/2020] [Indexed: 11/30/2022]
Abstract
An overview of the experiences with deployment of undergraduate medical students in a Dutch university center during the COVID-19 pandemic is provided from organisational and educational perspectives. Medical students' and specialists' experiences during the first peak of COVID-19 underscore the preliminary suggestion that students can be given more enhanced (yet supervised) responsibility for patient care early in their practicums.
Collapse
Affiliation(s)
- Matthijs H Bosveld
- Faculty of Health, Medicine and Life Sciences Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands
| | - Daan P C van Doorn
- Faculty of Health, Medicine and Life Sciences Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands
| | - Patricia M Stassen
- Department of Internal Medicine, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands; Caphri School for Public Health and Primary Care, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands
| | - Dewa Westerman
- Department of Internal Medicine, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands; Academy for Postgraduate Medical Training, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands; School of Health Professions Education, Maastricht University Medical Centre+ and Maastricht University, Maastricht, the Netherlands.
| |
Collapse
|
28
|
Driessen RGH, Heijnen NFL, Hulsewe RPMG, Holtkamp JWM, Winkens B, van de Poll MCG, van der Horst ICC, Bergmans DCJJ, Schnabel RM. Early ICU-mortality in sepsis - causes, influencing factors and variability in clinical judgement: a retrospective cohort study. Infect Dis (Lond) 2020; 53:61-68. [PMID: 32930619 DOI: 10.1080/23744235.2020.1821912] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sepsis is a global health care problem with a high mortality. Early death seems common; however, data are sparse. The objective of the present study was to report causes and influencing factors of early death in sepsis and septic shock. METHODS All septic ICU patients were included from 2012 to 2017. Early death was predefined as occurring within 48 h. Causes and factors leading up to death were reported by a panel of four intensivists, independently reviewing the medical files. Following factors were assessed: (1) delay in ICU admission; (2) futile ICU treatment; (3) missed diagnosis or inadequate treatment on the ICU. Fleiss kappa was used to assess inter-observer agreement. RESULTS 1107 septic patients (APACHE II score 25 ± 8) were included. 344 patients died of which 97 (28%) within 48 h. In 33% an autopsy was performed. Primary causes of early death were multiple organ failure, mesenteric ischaemia and death after cardio-pulmonary resuscitation (CPR). Delay in ICU admission was scored in 32% of early deaths with slight agreement (κ = 0.180), futile ICU treatment in 29% with moderate agreement (κ = 0.415) and missed diagnosis or treatment in 7% of cases with slight agreement (κ = 0.122). CONCLUSIONS Early death after ICU admission in sepsis is common and primarily caused by multiple organ failure, mesenteric ischaemia and death after unsuccessful CPR. Influencing factors were delay in ICU admission and futile ICU admission. Fleiss kappa indicates substantial variability in clinical judgement between intensivists, strengthening the necessity for shared decision making.
Collapse
Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Riquette P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Johanna W M Holtkamp
- Department of Intensive Care Medicine, St. Jans Gasthuis, Weert, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| |
Collapse
|
29
|
Grim CCA, Cornet AD, Kroner A, Meiners AJ, Brouwers AJBW, Reidinga AC, van Westerloo DJ, Bergmans DCJJ, Gommers D, Versluis D, Weller D, Christiaan Boerma E, van Driel E, de Jonge E, Schoonderbeek FJ, Helmerhorst HJF, Jongsma-van Netten HG, Weenink J, Woittiez KJ, Simons KS, van Ewelie L, Petjak M, Sigtermans MJ, van der Woude M, Cremer OL, Bijlstra P, van der Heiden P, So RKL, Vink R, Jansen T, de Ruijter W. Attitudes of Dutch intensive care unit clinicians towards oxygen therapy. Neth J Med 2020; 78:167-174. [PMID: 32641541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Over the last decade, there has been an increasing awareness for the potential harm of the administration of too much oxygen. We aimed to describe self-reported attitudes towards oxygen therapy by clinicians from a large representative sample of intensive care units (ICUs) in the Netherlands. METHODS In April 2019, 36 ICUs in the Netherlands were approached and asked to send out a questionnaire (59 questions) to their nursing and medical staff (ICU clinicians) eliciting self-reported behaviour and attitudes towards oxygen therapy in general and in specific ICU case scenarios. RESULTS In total, 1361 ICU clinicians (71% nurses, 24% physicians) from 28 ICUs returned the questionnaire. Of responding ICU clinicians, 64% considered oxygen-induced lung injury to be a major concern. The majority of respondents considered a partial pressure of oxygen (PaO2) of 6-10 kPa (45-75 mmHg) and an arterial saturation (SaO2) of 85-90% as acceptable for 15 minutes, and a PaO2 7-10 kPa (53-75 mmHg) and SaO2 90-95% as acceptable for 24-48 hours in an acute respiratory distress syndrome (ARDS) patient. In most case scenarios, respondents reported not to change the fraction of inspired oxygen (FiO2) if SaO2 was 90-95% or PaO2 was 12 kPa (90 mmHg). CONCLUSION A representative sample of ICU clinicians from the Netherlands were concerned about oxygen-induced lung injury, and reported that they preferred PaO2 and SaO2 targets in the lower physiological range and would adjust ventilation settings accordingly.
Collapse
Affiliation(s)
- C C A Grim
- Leiden University Medical Centre, Leiden, the Netherlands
| | - A D Cornet
- Leiden University Medical Centre, Leiden, the Netherlands
| | - A Kroner
- Leiden University Medical Centre, Leiden, the Netherlands
| | - A J Meiners
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - A C Reidinga
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | - D Gommers
- Leiden University Medical Centre, Leiden, the Netherlands
| | - D Versluis
- Leiden University Medical Centre, Leiden, the Netherlands
| | - D Weller
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - E van Driel
- Leiden University Medical Centre, Leiden, the Netherlands
| | - E de Jonge
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | | | | | - J Weenink
- Leiden University Medical Centre, Leiden, the Netherlands
| | - K J Woittiez
- Leiden University Medical Centre, Leiden, the Netherlands
| | - K S Simons
- Leiden University Medical Centre, Leiden, the Netherlands
| | - L van Ewelie
- Leiden University Medical Centre, Leiden, the Netherlands
| | - M Petjak
- Leiden University Medical Centre, Leiden, the Netherlands
| | - M J Sigtermans
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - O L Cremer
- Leiden University Medical Centre, Leiden, the Netherlands
| | - P Bijlstra
- Leiden University Medical Centre, Leiden, the Netherlands
| | | | - R K L So
- Leiden University Medical Centre, Leiden, the Netherlands
| | - R Vink
- Leiden University Medical Centre, Leiden, the Netherlands
| | - T Jansen
- Leiden University Medical Centre, Leiden, the Netherlands
| | - W de Ruijter
- Leiden University Medical Centre, Leiden, the Netherlands
| |
Collapse
|
30
|
Bauer PR, Chevret S, Yadav H, Mehta S, Pickkers P, Bukan RB, Rello J, van de Louw A, Klouche K, Meert AP, Martin-Loeches I, Marsh B, Socias Crespi L, Moreno-Gonzalez G, Buchtele N, Amrein K, Balik M, Antonelli M, Nyunga M, Barratt-Due A, Bergmans DCJJ, Spoelstra-de Man AME, Kuitunen A, Wallet F, Seguin A, Metaxa V, Lemiale V, Burghi G, Demoule A, Karvunidis T, Cotoia A, Klepstad P, Møller AM, Mokart D, Azoulay E. Diagnosis and outcome of acute respiratory failure in immunocompromised patients after bronchoscopy. Eur Respir J 2019; 54:13993003.02442-2018. [PMID: 31109985 DOI: 10.1183/13993003.02442-2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 04/21/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We wished to explore the use, diagnostic capability and outcomes of bronchoscopy added to noninvasive testing in immunocompromised patients. In this setting, an inability to identify the cause of acute hypoxaemic respiratory failure is associated with worse outcome. Every effort should be made to obtain a diagnosis, either with noninvasive testing alone or combined with bronchoscopy. However, our understanding of the risks and benefits of bronchoscopy remains uncertain. PATIENTS AND METHODS This was a pre-planned secondary analysis of Efraim, a prospective, multinational, observational study of 1611 immunocompromised patients with acute respiratory failure admitted to the intensive care unit (ICU). We compared patients with noninvasive testing only to those who had also received bronchoscopy by bivariate analysis and after propensity score matching. RESULTS Bronchoscopy was performed in 618 (39%) patients who were more likely to have haematological malignancy and a higher severity of illness score. Bronchoscopy alone achieved a diagnosis in 165 patients (27% adjusted diagnostic yield). Bronchoscopy resulted in a management change in 236 patients (38% therapeutic yield). Bronchoscopy was associated with worsening of respiratory status in 69 (11%) patients. Bronchoscopy was associated with higher ICU (40% versus 28%; p<0.0001) and hospital mortality (49% versus 41%; p=0.003). The overall rate of undiagnosed causes was 13%. After propensity score matching, bronchoscopy remained associated with increased risk of hospital mortality (OR 1.41, 95% CI 1.08-1.81). CONCLUSIONS Bronchoscopy was associated with improved diagnosis and changes in management, but also increased hospital mortality. Balancing risk and benefit in individualised cases should be investigated further.
Collapse
Affiliation(s)
- Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sylvie Chevret
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153, INSERM, Paris Diderot Sorbonne University and Service de Biostatistique et Information Médicale, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Hemang Yadav
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sangeeta Mehta
- Dept of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Peter Pickkers
- Dept of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ramin B Bukan
- Dept of Anesthesiology I, Herlev University Hospital, Herlev, Denmark
| | - Jordi Rello
- CIBERES, Instituto Salud Carlos III and Vall d'Hebron Institut of Research Barcelona, Barcelona, Spain
| | - Andry van de Louw
- Division of Pulmonary and Critical Care, Penn State University College of Medicine, Hershey, PA, USA
| | - Kada Klouche
- Dept of Intensive Care Medicine, Lapeyronie University Hospital, Montpellier, France
| | - Anne-Pascale Meert
- Service de Médecine Interne, Unité de Soins Intensifs et Urgences Oncologiques, Université de Libre de Bruxelles, Institut Jules Bordet, Brussels, Belgium
| | - Ignacio Martin-Loeches
- Dept of Intensive Care Medicine, Universidad de Barcelona IDIBAPS, Barcelona, Spain.,Dept of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland
| | - Brian Marsh
- Dept of Critical Care, Mater Misericordiae, Dublin, Ireland
| | | | | | - Nina Buchtele
- Dept of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Karin Amrein
- Dept of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz and Thyroid Endocrinology Osteoporosis Institute Dobnig, Graz, Austria
| | - Martin Balik
- Dept of Anesthesiology and Intensive Care Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Massimo Antonelli
- Dept of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Martine Nyunga
- Medical Intensive Care Unit, CHG Victor Provo, Roubaix, France
| | - Andreas Barratt-Due
- Dept of Emergencies and Critical Care, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dennis C J J Bergmans
- Dept of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Anne Kuitunen
- Dept of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Florent Wallet
- Dept of Critical Care, University Hospital Lyon Sud, Pierre Benite, France
| | | | - Victoria Metaxa
- Dept of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Virginie Lemiale
- Medical Intensive Care Unit, AP-HP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Gaston Burghi
- Terapia Intensiva, Hospital Maciel, Montevideo, Uruguay
| | - Alexandre Demoule
- Service de Pneumologie et Réanimation, CHU Pitié-Salpétrière, Paris, France
| | - Thomas Karvunidis
- Medical ICU, First Dept of Internal Medicine, Teaching Hospital, Faculty of Medicine and Biomedical Center in Pilsen, Charles University, Pilsen, Czech Republic
| | - Antonella Cotoia
- Dept of Anesthesia, Intensive Care, and Pain Therapy, University of Foggia, Policlinico "OO Riuniti", Foggia, Italy
| | - Pål Klepstad
- Dept of Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway
| | - Ann M Møller
- Dept of Anesthesiology, Herlev University Hospital, UCPH, Herlev, Denmark
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
| | | |
Collapse
|
31
|
Heijnen NFL, Bergmans DCJJ, Schnabel RM, Bos LDJ. Targeted treatment of acute respiratory distress syndrome with statins-a commentary on two phenotype stratified re-analysis of randomized controlled trials. J Thorac Dis 2019; 11:S296-S299. [PMID: 30997202 DOI: 10.21037/jtd.2019.01.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nanon F L Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Ronny M Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, UMC Amsterdam, Location AMC, Amsterdam, The Netherlands
| |
Collapse
|
32
|
Schauwvlieghe AFAD, Rijnders BJA, Philips N, Verwijs R, Vanderbeke L, Van Tienen C, Lagrou K, Verweij PE, Van de Veerdonk FL, Gommers D, Spronk P, Bergmans DCJJ, Hoedemaekers A, Andrinopoulou ER, van den Berg CHSB, Juffermans NP, Hodiamont CJ, Vonk AG, Depuydt P, Boelens J, Wauters J. Invasive aspergillosis in patients admitted to the intensive care unit with severe influenza: a retrospective cohort study. The Lancet Respiratory Medicine 2018; 6:782-792. [DOI: 10.1016/s2213-2600(18)30274-1] [Citation(s) in RCA: 468] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/11/2018] [Accepted: 06/15/2018] [Indexed: 12/11/2022]
|
33
|
Heines SJH, Strauch U, van de Poll MCG, Roekaerts PMHJ, Bergmans DCJJ. Clinical implementation of electric impedance tomography in the treatment of ARDS: a single centre experience. J Clin Monit Comput 2018; 33:291-300. [PMID: 29845479 PMCID: PMC6420412 DOI: 10.1007/s10877-018-0164-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 01/12/2018] [Accepted: 05/27/2018] [Indexed: 11/24/2022]
Abstract
To report on our clinical experience using EIT in individualized PEEP titration in ARDS. Using EIT assessment, we optimized PEEP settings in 39 ARDS patients. The EIT PEEP settings were compared with the physicians' PEEP settings and the PEEP settings according to the ARDS network. We defined a PEEP difference equal to or greater than 4 cm H2O as clinically relevant. Changes in lung compliance and PaO2/FiO2-ratio were compared in patients with EIT-based PEEP adjustments and in patients with unaltered PEEP. In 28% of the patients, the difference in EIT-based PEEP and physician-PEEP was clinically relevant; in 36%, EIT-based PEEP and physician-PEEP were equal. The EIT-based PEEP disagreed with the PEEP settings according to the ARDS network. Adjusting PEEP based upon EIT led to a rapid increase in lung compliance and PaO2/FiO2-ratio. However, this increase was also observed in the group where the PEEP difference was less than 4 cm H2O. We hypothesize that this can be attributed to the alveolar recruitment during the PEEP trial. EIT based individual PEEP setting appears to be a promising method to optimize PEEP in ARDS patients. The clinical impact, however, remains to be established.
Collapse
Affiliation(s)
- Serge J H Heines
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands.
| | - Ulrich Strauch
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Medicine (NUTRIM), Maastricht University, P.O. Box 616, 6200MD, Maastricht, The Netherlands
| | - Paul M H J Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, P.O. Box 616, 6200MD, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229HX, Maastricht, The Netherlands
| |
Collapse
|
34
|
van Oort PM, Povoa P, Schnabel R, Dark P, Artigas A, Bergmans DCJJ, Felton T, Coelho L, Schultz MJ, Fowler SJ, Bos LD. The potential role of exhaled breath analysis in the diagnostic process of pneumonia-a systematic review. J Breath Res 2018; 12:024001. [PMID: 29292698 DOI: 10.1088/1752-7163/aaa499] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Diagnostic strategies currently used for pneumonia are time-consuming, lack accuracy and suffer from large inter-observer variability. Exhaled breath contains thousands of volatile organic compounds (VOCs), which include products of host and pathogen metabolism. In this systematic review we investigated the use of so-called 'breathomics' for diagnosing pneumonia. A Medline search yielded 18 manuscripts reporting on animal and human studies using organic and inorganic molecules in exhaled breath, that all could be used to answer whether analysis of VOC profiles could potentially improve the diagnostic process of pneumonia. Papers were categorised based on their specific aims; the exclusion of pneumonia; the detection of specific respiratory pathogens; and whether targeted or untargeted VOC analysis was used. Ten studies reported on the association between VOCs and presence of pneumonia. Eight studies demonstrated a difference in exhaled VOCs between pneumonia and controls; in the individual studies this discrimination was based on unique sets of VOCs. Eight studies reported on the accuracy of a breath test for a specific respiratory pathogen: five of these concerned pre-clinical studies in animals. All studies were valued as having a high risk of bias, except for one study that used an external validation cohort. The findings in the identified studies are promising. However, as yet no breath test has been shown to have sufficient diagnostic accuracy for pneumonia. We are in need of studies that further translate the knowledge from discovery studies to clinical practice.
Collapse
Affiliation(s)
- Pouline M van Oort
- Department of Intensive Care, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
van de Veerdonk FL, Kolwijck E, Lestrade PPA, Hodiamont CJ, Rijnders BJA, van Paassen J, Haas PJ, Oliveira dos Santos C, Kampinga GA, Bergmans DCJJ, van Dijk K, de Haan AFJ, van Dissel J, van der Hoeven HG, Verweij PE, Rahamat-Langendoen JC, Kullberg BJ, Netea MG, Brüggeman RJ, Hoedemaekers AW, Melchers WJG, Freudenburg W, Roescher N, Wiersinga WJ, van den Berg CHSB, Vonk AG, Tienen CV, Hoven BVD, van der Beek MT, Derde LP, Leer CV, Aardema H, Lashof AO, Ang CW. Influenza-associated Aspergillosis in Critically Ill Patients. Am J Respir Crit Care Med 2017; 196:524-527. [DOI: 10.1164/rccm.201612-2540le] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Eva Kolwijck
- Radboud University Medical CentreNijmegen, the Netherlands
| | | | | | | | | | | | | | | | | | - Karin van Dijk
- VU University Medical CentreAmsterdam, the Netherlandsand
| | | | - Jaap van Dissel
- National Institute of Public Health and the EnvironmentBilthoven, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Strauch U, Bergmans DCJJ, Habers J, Jansen J, Winkens B, Veldman DJ, Roekaerts PMHJ, Beckers SK. QUIT EMR trial: a prospective, observational, multicentre study to evaluate quality and 24 hours post-transport morbidity of interhospital transportation of critically ill patients: study protocol. BMJ Open 2017; 7:e012861. [PMID: 28283485 PMCID: PMC5353331 DOI: 10.1136/bmjopen-2016-012861] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION It is widely accepted that transportation of critically ill patients is high risk. Unfortunately, however, there are currently no evidence-based criteria with which to determine the quality of various interhospital transport systems and their impact on the outcomes for patients. We aim to rectify this by assessing 2 scores which were developed in our hospital in a prospective, observational study. Primarily, we will be examining the Quality of interhospital critical care transportation in the Euregion Meuse-Rhine (QUIT EMR) score, which focuses on the quality of the transport system, and secondarily the SEMROS (Simplified EMR outcome score) which detects changes in the patient's clinical condition in the 24 hours following their transportation. METHODS AND ANALYSIS A web-based application will be used to document around 150 pretransport, intratransport and post-transport items of each patient case.To be included, patients must be at least 18-years of age and should have been supervised by a physician during an interhospital transport which was started in the study region.The quality of the QUIT EMR score will be assessed by comparing 3 predefined levels of transport facilities: the high, medium and low standards. Subsequently, SEMROS will be used to determine the effect of transport quality on the morbidity 24 hours after transportation.It is estimated that there will be roughly 3000 appropriate cases suitable for inclusion in this study per year. Cases shall be collected from 1 April 2015 until 31 December 2017. ETHICS AND DISSEMINATION This trial was approved by the Ethics committees of the university hospitals of Maastricht (Netherlands) and Aachen (Germany). The study results will be published in a peer reviewed journal. Results of this study will determine if a prospective randomised trial involving patients of various categories being randomly assigned to different levels of transportation system shall be conducted. TRIAL REGISTRATION NUMBER NTR4937.
Collapse
Affiliation(s)
- Ulrich Strauch
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim Habers
- Emergency Medical Service district of Aachen, Aachen, Germany
| | - Jochen Jansen
- Emergency Medical Service South Limburg, Geleen, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - Dirk J Veldman
- Maastricht University, MEMIC Center for Data and Information Management, Maastricht, The Netherlands
| | - Paul M H J Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | |
Collapse
|
37
|
van Bussel BCT, van de Poll MCG, Schalkwijk CG, Bergmans DCJJ. Increased Dicarbonyl Stress as a Novel Mechanism of Multi-Organ Failure in Critical Illness. Int J Mol Sci 2017; 18:ijms18020346. [PMID: 28178202 PMCID: PMC5343881 DOI: 10.3390/ijms18020346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 01/16/2017] [Accepted: 02/03/2017] [Indexed: 01/09/2023] Open
Abstract
Molecular pathological pathways leading to multi-organ failure in critical illness are progressively being unravelled. However, attempts to modulate these pathways have not yet improved the clinical outcome. Therefore, new targetable mechanisms should be investigated. We hypothesize that increased dicarbonyl stress is such a mechanism. Dicarbonyl stress is the accumulation of dicarbonyl metabolites (i.e., methylglyoxal, glyoxal, and 3-deoxyglucosone) that damages intracellular proteins, modifies extracellular matrix proteins, and alters plasma proteins. Increased dicarbonyl stress has been shown to impair the renal, cardiovascular, and central nervous system function, and possibly also the hepatic and respiratory function. In addition to hyperglycaemia, hypoxia and inflammation can cause increased dicarbonyl stress, and these conditions are prevalent in critical illness. Hypoxia and inflammation have been shown to drive the rapid intracellular accumulation of reactive dicarbonyls, i.e., through reduced glyoxalase-1 activity, which is the key enzyme in the dicarbonyl detoxification enzyme system. In critical illness, hypoxia and inflammation, with or without hyperglycaemia, could thus increase dicarbonyl stress in a way that might contribute to multi-organ failure. Thus, we hypothesize that increased dicarbonyl stress in critical illness, such as sepsis and major trauma, contributes to the development of multi-organ failure. This mechanism has the potential for new therapeutic intervention in critical care.
Collapse
Affiliation(s)
- Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Centre +, Maastricht 6229 HX, The Netherlands.
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre +, Maastricht 6229 HX, The Netherlands.
- Department of Surgery, and NUTRIM School for Nutrition and Translational Research, Maastricht University Medical Centre +, Maastricht 6229 HX, The Netherlands.
| | - Casper G Schalkwijk
- Department of Internal Medicine, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre +, Maastricht 6229 HX, The Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre +, Maastricht 6229 HX, The Netherlands.
| |
Collapse
|
38
|
Scholte JBJ, van der Velde JIM, Linssen CFM, van Dessel HA, Bergmans DCJJ, Savelkoul PHM, Roekaerts PMHJ, van Mook WNKA. Erratum to: ‘Ventilator-associated Pneumonia caused by commensal oropharyngeal a retrospective Analysis of a prospectively collected Database’. BMC Pulm Med 2015; 15:104. [PMID: 26381863 PMCID: PMC4574459 DOI: 10.1186/s12890-015-0098-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
39
|
Schnabel RM, Boumans MLL, Smolinska A, Stobberingh EE, Kaufmann R, Roekaerts PMHJ, Bergmans DCJJ. Electronic nose analysis of exhaled breath to diagnose ventilator-associated pneumonia. Respir Med 2015; 109:1454-9. [PMID: 26440675 DOI: 10.1016/j.rmed.2015.09.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 09/21/2015] [Accepted: 09/25/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Exhaled breath analysis is an emerging technology in respiratory disease and infection. Electronic nose devices (e-nose) are small and portable with a potential for point of care application. Ventilator-associated pneumonia (VAP) is a common nosocomial infection occurring in the intensive care unit (ICU). The current best diagnostic approach is based on clinical criteria combined with bronchoalveolar lavage (BAL) and subsequent bacterial culture analysis. BAL is invasive, laborious and time consuming. Exhaled breath analysis by e-nose is non-invasive, easy to perform and could reduce diagnostic time. Aim of this study was to explore whether an e-nose can be used as a non-invasive in vivo diagnostic tool for VAP. METHODS Seventy-two patients met the clinical diagnostic criteria of VAP and underwent BAL. In thirty-three patients BAL analysis confirmed the diagnosis of VAP [BAL+(VAP+)], in thirty-nine patients the diagnosis was rejected [BAL-]. Before BAL was performed, exhaled breath was sampled from the expiratory limb of the ventilator into sterile Tedlar bags and subsequently analysed by an e-nose with metal oxide sensors (DiagNose, C-it, Zutphen, The Netherlands). From further fifty-three patients without clinical suspicion of VAP or signs of respiratory disease exhaled breath was collected to serve as a control group [control(VAP-]). The e-nose data from exhaled breath were analysed using logistic regression. RESULTS The ROC curve comparing [BAL+(VAP+)] and [control(VAP-)] patients had an area under the curve (AUC) of 0.82 (95% CI 0.73-0.9). The sensitivity was 88% with a specificity of 66%. The comparison of [BAL+(VAP+)] and [BAL-] patients revealed an AUC of 0.69; 95% CI 0.57-0.81) with a sensitivity of 76% with a specificity of 56%. CONCLUSION E-nose lacked sensitivity and specificity in the diagnosis of VAP in the present study for current clinical application. Further investigation into this field is warranted to explore the diagnostic possibilities of this promising new technique.
Collapse
Affiliation(s)
- R M Schnabel
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands.
| | - M L L Boumans
- Medical Microbiology, Maastricht University Medical Centre, The Netherlands
| | - A Smolinska
- Department of Pharmacology and Toxicology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, The Netherlands
| | - E E Stobberingh
- Medical Microbiology, Maastricht University Medical Centre, The Netherlands
| | - R Kaufmann
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - P M H J Roekaerts
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - D C J J Bergmans
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| |
Collapse
|
40
|
Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PMHJ, Bergmans DCJJ. Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients. BMC Pulm Med 2015; 15:107. [PMID: 26420333 PMCID: PMC4588466 DOI: 10.1186/s12890-015-0104-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 09/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h. Methods Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression. Results Clinical course: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 – 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death. Discussion Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.
Collapse
Affiliation(s)
- R M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - K van der Velden
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - A Osinski
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - G Rohde
- Department of Respiratory Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - P M H J Roekaerts
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - D C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| |
Collapse
|
41
|
Scholte JBJ, van der Velde JIM, Linssen CFM, van Dessel HA, Bergmans DCJJ, Savelkoul PHM, Roekaerts PMHJ, van Mook WNKA. Ventilator-associated Pneumonia caused by commensal oropharyngeal Flora; [corrected] a retrospective Analysis of a prospectively collected Database. BMC Pulm Med 2015; 15:86. [PMID: 26264828 PMCID: PMC4531521 DOI: 10.1186/s12890-015-0087-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 07/30/2015] [Indexed: 12/13/2022] Open
Abstract
Background The significance of commensal oropharyngeal flora (COF) as a potential cause of ventilator-associated pneumonia (VAP) is scarcely investigated and consequently unknown. Therefore, the aim of this study was to explore whether COF may cause VAP. Methods Retrospective clinical, microbiological and radiographic analysis of all prospectively collected suspected VAP cases in which bronchoalveolar lavage fluid exclusively yielded ≥ 104 cfu/ml COF during a 9.5-year period. Characteristics of 899 recent intensive care unit (ICU) admissions were used as a reference population. Results Out of the prospectively collected database containing 159 VAP cases, 23 patients were included. In these patients, VAP developed after a median of 8 days of mechanical ventilation. The patients faced a prolonged total ICU length of stay (35 days [P < .001]), hospital length of stay (45 days [P = .001]), and a trend to higher mortality (39 % vs. 26 %, [P = .158]; standardized mortality ratio 1.26 vs. 0.77, [P = .137]) compared to the reference population. After clinical, microbiological and radiographic analysis, COF was the most likely cause of respiratory deterioration in 15 patients (9.4 % of all VAP cases) and a possible cause in 2 patients. Conclusion Commensal oropharyngeal flora appears to be a potential cause of VAP in limited numbers of ICU patients as is probably associated with an increased length of stay in both ICU and hospital. As COF-VAP develops late in the course of ICU admission, it is possibly associated with the immunocompromised status of ICU patients.
Collapse
Affiliation(s)
- Johannes B J Scholte
- Department of Intensive Care Medicine, Luzerner Kantonspital, 6000, Luzern 16, Switzerland.
| | - Johan I M van der Velde
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Catharina F M Linssen
- Department of Medical Microbiology, Atrium Medical Centre, P.O. box 4446, 6401 CX, Heerlen, The Netherlands.
| | - Helke A van Dessel
- Department of Medical Microbiology, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Paul H M Savelkoul
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Paul M H J Roekaerts
- Department of Medical Microbiology, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P.O. box 5800, 6202 AZ, Maastricht, The Netherlands.
| |
Collapse
|
42
|
Strauch U, Bergmans DCJJ, Winkens B, Roekaerts PMHJ. Short-term outcomes and mortality after interhospital intensive care transportation: an observational prospective cohort study of 368 consecutive transports with a mobile intensive care unit. BMJ Open 2015; 5:e006801. [PMID: 25922097 PMCID: PMC4420937 DOI: 10.1136/bmjopen-2014-006801] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To evaluate short-term outcomes and mortality after interhospital transportation of intensive care patients performed by a mobile intensive care unit (MICU). SETTING This study was performed in the tertiary care process of interhospital transportation using the local MICU system in the South East of the Netherlands. PARTICIPANTS Between March 2009 and December 2011, all transports of adult patients being performed by the local MICU centre have been documented; data on 42 variables, including a 24 h follow-up Sequential Organ Failure Assessment (SOFA) score of 368 consecutive interhospital transports of intensive care patients, were recorded. In 24 cases, the follow-up SOFA score was missing, so 344 data sets were included. INTERVENTIONS No interventions have been done. PRIMARY/SECONDARY OUTCOME MEASURES Primary outcome measures were the mean SOFA score before and 24 h after transport, and the 24 h post-transport mortality. Moreover, the differences between the groups of 24 h post-transport survivors and non-survivors have been analysed. RESULTS The mean SOFA score before transport was 8.8 for the whole population and 8.6 for those patients who were alive 24 h after transport, with a mean SOFA score of 8.4 after transport. The adverse events rate was 6.4%. Fourteen patients (4.1%) died within 24 h after transport. Patients in this group had a higher SOFA score, lower pH, higher age and more additional medical support devices than those patients in the survivor group. CONCLUSIONS The non-significant decrease in the post-transport SOFA score and the lack of an association between transport and 24 h post-transport mortality indicates that in the study setting, interhospital transportation of intensive care patients performed by a MICU system was not associated with a clinically relevant deterioration of the patient.
Collapse
Affiliation(s)
- Ulrich Strauch
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - Paul M H J Roekaerts
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
43
|
Schnabel RM, Scholte JBJ, Van Der Velden KEHM, Roekaerts PMHJ, Bergmans DCJJ. Ventilator-associated pneumonia rates after introducing selective digestive tract decontamination. Infect Dis (Lond) 2015; 47:650-3. [PMID: 25851244 DOI: 10.3109/23744235.2015.1031172] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The incidence of ventilator-associated pneumonia (VAP) before and after the introduction of selective oral decontamination (SOD) only and selective digestive tract decontamination (SDD) in a general intensive care population was examined. SOD as standard of care was introduced in December 2010 and SDD, including SOD, in January 2012 for all patients with an expected length of intensive care unit (ICU) stay of at least 48 h. The diagnosis of VAP was based on clinical criteria and quantitative cultures of bronchoalveolar lavage fluid. A total of 4945 mechanically ventilated patients accounting for 37 554 ventilator days in the period from 2005 to 2013 were analyzed. The incidence of VAP per 1000 ventilator days declined significantly from 4.38 ± 1.64 before to 1.64 ± 0.43 after introduction of SOD/SDD (p = 0.007). Implementation of SOD/SDD as standard of care in ICUs may thus be effective in preventing VAP.
Collapse
Affiliation(s)
- Ronny M Schnabel
- From the Department of Intensive Care Medicine, Maastricht University Medical Centre+ , The Netherlands
| | | | | | | | | |
Collapse
|
44
|
Hoogveld LMT, Bergmans DCJJ, de Vries S, van Proemeren H, van den Beuken-van Everdingen MHJ, Zijlstra JG, van Mook WNKA. [Intensive care patients who want to die at home: how can we fulfil this last wish?]. Ned Tijdschr Geneeskd 2015; 159:A8711. [PMID: 25873224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To make an inventory of the number of intensive care (ICU) patients per year in the Netherlands who have been discharged home to die, and the conditions under which this does or should take place. DESIGN Descriptive, survey study. METHOD A survey was conducted across all ICU departments in the Netherlands in the spring of 2012. They were approached in writing and requested to answer a few questions about the possibility of immediate discharge home for ICU patients with a short life expectancy and receiving palliative care. RESULTS A total of 46 surveys (52%) was returned from the 89 ICUs approached. Of these, 21 (46%) had discharged patients home at the request of the patient or their family so that the anticipated death could take place at home. Of the respondents, 39 (85%), supported discharge home for these patients, and 7 (15%) were opposed to it. These opinions were equally divided across all three ICU levels in the Netherlands. Higher-level ICUs had discharged patients home more often in comparison with lower-level ICUs (19%, 43% and 75% for levels 1, 2 and 3, respectively). The preconditions for transfer can be subdivided into patient conditions, care conditions and general conditions. CONCLUSION ICU patients do sometimes want to die at home. It does not happen every day, but the wish is often granted in the Netherlands. There are certain general and patient-related conditions that have to be fulfilled. This article suggests a national guideline that could provide support on this subject.
Collapse
|
45
|
Schoemakers RJ, Schnabel R, Oudhuis GJ, Linssen CFM, van Mook WNKA, Verbon A, Bergmans DCJJ. Alternative diagnosis in the putative ventilator-associated pneumonia patient not meeting lavage-based diagnostic criteria. ACTA ACUST UNITED AC 2014; 46:868-74. [PMID: 25238607 DOI: 10.3109/00365548.2014.953576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The clinical picture of ventilator-associated pneumonia (VAP) can be mimicked by other infectious and non-infectious diseases. The aim of this study was to determine the alternative diagnoses and to develop a diagnostic flow chart for patients suspected of having VAP not meeting the diagnostic broncho-alveolar lavage (BAL) criteria. METHODS Adult intensive care patients with a clinical suspicion of VAP and negative BAL results were included. The clinical suspicion of VAP was based on the combination of clinical, radiological, and microbiological criteria. BAL was considered positive if cell differentiation revealed ≥ 2% cells with intracellular organisms and/or quantitative culture results of ≥ 10(4) cfu/ml. The most likely alternative diagnosis of fever and pulmonary densities was retrospectively determined by two authors independently. RESULTS In all, 110 of 207 patients with suspected VAP did not meet the diagnostic BAL criteria and required further diagnostic evaluation. In 67 patients an alternative diagnosis for fever could be found. In 51 patients an alternative diagnosis of both fever and pulmonary densities could be established. In almost 40% of patients no alternative diagnosis could be provided. Non-bacterial pneumonia was diagnosed in 10 patients with Herpes simplex virus 1 (HSV-1) as the most common pathogen. In eight patients non-infectious pneumonitis was diagnosed. CONCLUSION Due to the wide range of alternative diagnoses and applied tests the diagnostic work-up proved to be necessarily individualized and guided by repeated clinical assessment. The most frequently found alternative diagnoses were viral pneumonia and non-infectious pneumonitis.
Collapse
Affiliation(s)
- Rik J Schoemakers
- From the Department of Intensive Care, Maastricht University Medical Centre+ , Maastricht , The Netherlands
| | | | | | | | | | | | | |
Collapse
|
46
|
Delnoij TSR, Veldhuijzen G, Strauch U, Van Mook WNKA, Bergmans DCJJ, Bouman EA, Lance MD, Smets M, Breedveld P, Ganushchak YM, Weerwind P, Kats S, Roekaerts PM, Maessen J, Donker DW. Mobile respiratory rescue support by off-centre initiation of extracorporeal membrane oxygenation. Perfusion 2014; 30:255-9. [PMID: 24965912 DOI: 10.1177/0267659114540735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- T S R Delnoij
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - G Veldhuijzen
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - U Strauch
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - W N K A Van Mook
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - D C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - E A Bouman
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M D Lance
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M Smets
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P Breedveld
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Trauma Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Y M Ganushchak
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S Kats
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P M Roekaerts
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - D W Donker
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| |
Collapse
|
47
|
Scholte JBJ, van Mook WNKA, Linssen CFM, van Dessel HA, Bergmans DCJJ, Savelkoul PHM, Roekaerts PMHJ. Surveillance cultures in intensive care units: a nationwide survey on current practice providing future perspectives. J Crit Care 2014; 29:885.e7-12. [PMID: 24974050 DOI: 10.1016/j.jcrc.2014.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/07/2013] [Revised: 04/21/2014] [Accepted: 05/05/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE To explore the extent of surveillance culture (SC) implementation underlying motives for obtaining SC and decision making based on the results. MATERIALS AND METHODS A questionnaire was distributed to Heads of Department (HODs) and microbiologists within all intensive care departments in the Netherlands. RESULTS Response was provided by 75 (79%) of 95 HODs and 38 (64%) of 59 laboratories allied to an intensive care unit (ICU). Surveillance cultures were routinely obtained according to 55 (73%) of 75 HODs and 33 (87%) of 38 microbiologists. Surveillance cultures were obtained in more than 80% of higher-level ICUs and in 58% of lower-level ICUs (P < .05). Surveillance cultures were obtained twice weekly (88%) and sampled from trachea (87%), pharynx (74%), and rectum (68%). Thirty (58%) of 52 HODs obtained SC to optimize individual patient treatment. On suspicion of infection from an unknown source, microorganisms identified by SC were targeted according to 87%. One third of HODs targeted microorganisms identified by SC in the case of an infection not at the location where the SC was obtained. This was significantly more often than microbiologists in case of no infection (P = .02) or infection of unknown origin (P < .05). CONCLUSIONS Surveillance culture implementation is common in Dutch ICUs to optimize individual patients' treatment. Consensus is lacking on how to deal with SC results when the focus of infection is not at the sampled site.
Collapse
Affiliation(s)
- Johannes B J Scholte
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | | | | | - Helke A van Dessel
- Department of Microbiology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht UMC+, Maastricht, the Netherlands.
| | - Paul H M Savelkoul
- Department of Microbiology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Paul M H J Roekaerts
- Department of Intensive Care Medicine, Maastricht UMC+, Maastricht, the Netherlands.
| |
Collapse
|
48
|
Vanspauwen MJ, Schnabel RM, Bruggeman CA, Drent M, van Mook WNKA, Bergmans DCJJ, Linssen CFM. Mimivirus is not a frequent cause of ventilator-associated pneumonia in critically ill patients. J Med Virol 2013; 85:1836-41. [PMID: 23861144 PMCID: PMC7166740 DOI: 10.1002/jmv.23655] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 12/27/2022]
Abstract
Acanthamoeba polyphaga mimivirus (APMV) belongs to the amoebae‐associated microorganisms. Antibodies to APMV have been found in patients with pneumonia suggesting a potential role as a respiratory pathogen. In addition, positive serology for APMV was associated with an increased duration of mechanical ventilation and intensive care unit stay in patients with ventilator‐associated pneumonia. The aim of the present study was to assess the presence of APMV in bronchoalveolar lavage fluid samples of critically ill patients suspected of ventilator‐associated pneumonia. The study was conducted in the intensive care unit of the Maastricht University Medical Centre. All consecutive bronchoalveolar lavage fluid samples obtained between January 2005 and October 2009 from patients suspected of ventilator‐associated pneumonia were eligible for inclusion. All samples were analyzed by real‐time PCR targeting the APMV. A total of 260 bronchoalveolar lavage fluid samples from 214 patients (139 male, 75 female) were included. Bacterial ventilator‐associated pneumonia was confirmed microbiologically in 105 out of 260 (40%) suspected episodes of ventilator‐associated pneumonia (86 patients). The presence of APMV DNA could not be demonstrated in the bacterial ventilator‐associated pneumonia positive or in the bacterial ventilator‐associated pneumonia negative bronchoalveolar lavage fluid samples. Although suspected, APMV appeared not to be present in critically ill patients suspected of ventilator‐associated pneumonia, and APMV does not seem to be a frequent cause of ventilator‐associated pneumonia. J Med. Virol. 85:1836–1841, 2013. © 2013 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- M J Vanspauwen
- Department of Medical Microbiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
49
|
Wittekamp BH, Chalabi M, van Mook WNKA, Winkens B, Verbon A, Bergmans DCJJ. Catheter-related bloodstream infections: a prospective observational study of central venous and arterial catheters. ACTA ACUST UNITED AC 2013; 45:738-45. [DOI: 10.3109/00365548.2013.804632] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
50
|
Heines SJH, Strauch U, Roekaerts PMHJ, Winkens B, Bergmans DCJJ. Accuracy of end-tidal CO2 capnometers in post-cardiac surgery patients during controlled mechanical ventilation. J Emerg Med 2013; 45:130-5. [PMID: 23375221 DOI: 10.1016/j.jemermed.2012.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 06/14/2012] [Accepted: 11/05/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The determination of end-tidal carbon dioxide (etCO2) is very helpful in cardiac resuscitation for confirmation and monitoring of endotracheal tube placement and as an indicator of return of circulation and effectiveness of chest compressions. There is now also widespread use of capnometry on-site at emergency and trauma fields. OBJECTIVE We studied the accuracy and correlation of three capnometers (EMMA, Medtronic, and Evita) with partial pressure of arterial CO2 (PaCO2) measurements. METHODS The three capnometers were placed in-line in the ventilator tubing of the patient. Forty sedated and mechanically ventilated post-cardiac surgery patients were studied. Twenty consecutive etCO2 values were collected simultaneously from all three monitors while drawing an arterial blood sample. Paired sample t-test and Pearson correlation were used to compare the capnometers and their correlation with PaCO2. RESULTS The correlation of etCO2 measurements between all three capnometers was good (Emma vs. Evita: 0.874, Emma vs. Medtronic: 0.949, Evita vs. Medtronic: 0.878). The correlation of PaCO2 with the Evita is the lowest (0.671) as compared to the EMMA (0.693) and the Medtronic (0.727). The lowest dispersion of the difference between etCO2 and PaCO2 was seen in EMMA (3.30), the highest in Evita (3.98). CONCLUSIONS A good correlation between etCO2 and PaCO2 was shown with the three capnometers in the present study. However, etCO2 measurements were not valid to estimate PaCO2 in these patients. Therefore, capnometry cannot be used to replace serial blood gas analyses completely, but may be a good cardiopulmonary trend monitor and alerting system in catastrophic events.
Collapse
Affiliation(s)
- Serge J H Heines
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | | | | |
Collapse
|