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de Grooth HJ, Parienti JJ. Surrogate Endpoints in Pandemic Preparedness. J Infect Dis 2024; 229:1244-1245. [PMID: 38323636 DOI: 10.1093/infdis/jiae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/08/2024] Open
Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care Medicine, University Medical Center Utrecht, The Netherlands
| | - Jean-Jacques Parienti
- Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University
- Inserm U1311 DYNAMICURE, Caen Normandy University, Caen, France
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2
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Zijlstra GJ, de Grooth HJ. ECMO and Prone Position in Patients With Severe ARDS. JAMA 2024; 331:1232-1233. [PMID: 38592394 DOI: 10.1001/jama.2024.1873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- G Jan Zijlstra
- Department of Intensive Care, Dijklander Hospital, Hoorn, the Netherlands
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Roggeveen LF, Hassouni AE, de Grooth HJ, Girbes ARJ, Hoogendoorn M, Elbers PWG. Reinforcement learning for intensive care medicine: actionable clinical insights from novel approaches to reward shaping and off-policy model evaluation. Intensive Care Med Exp 2024; 12:32. [PMID: 38526681 DOI: 10.1186/s40635-024-00614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Reinforcement learning (RL) holds great promise for intensive care medicine given the abundant availability of data and frequent sequential decision-making. But despite the emergence of promising algorithms, RL driven bedside clinical decision support is still far from reality. Major challenges include trust and safety. To help address these issues, we introduce cross off-policy evaluation and policy restriction and show how detailed policy analysis may increase clinical interpretability. As an example, we apply these in the setting of RL to optimise ventilator settings in intubated covid-19 patients. METHODS With data from the Dutch ICU Data Warehouse and using an exhaustive hyperparameter grid search, we identified an optimal set of Dueling Double-Deep Q Network RL models. The state space comprised ventilator, medication, and clinical data. The action space focused on positive end-expiratory pressure (peep) and fraction of inspired oxygen (FiO2) concentration. We used gas exchange indices as interim rewards, and mortality and state duration as final rewards. We designed a novel evaluation method called cross off-policy evaluation (OPE) to assess the efficacy of models under varying weightings between the interim and terminal reward components. In addition, we implemented policy restriction to prevent potentially hazardous model actions. We introduce delta-Q to compare physician versus policy action quality and in-depth policy inspection using visualisations. RESULTS We created trajectories for 1118 intensive care unit (ICU) admissions and trained 69,120 models using 8 model architectures with 128 hyperparameter combinations. For each model, policy restrictions were applied. In the first evaluation step, 17,182/138,240 policies had good performance, but cross-OPE revealed suboptimal performance for 44% of those by varying the reward function used for evaluation. Clinical policy inspection facilitated assessment of action decisions for individual patients, including identification of action space regions that may benefit most from optimisation. CONCLUSION Cross-OPE can serve as a robust evaluation framework for safe RL model implementation by identifying policies with good generalisability. Policy restriction helps prevent potentially unsafe model recommendations. Finally, the novel delta-Q metric can be used to operationalise RL models in clinical practice. Our findings offer a promising pathway towards application of RL in intensive care medicine and beyond.
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Affiliation(s)
- Luca F Roggeveen
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ali El Hassouni
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mark Hoogendoorn
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
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de Grooth HJ, Cremer OL. Bayes and the Evidence Base: Reanalyzing Trials Using Many Priors Does Not Contribute to Consensus. Am J Respir Crit Care Med 2024; 209:483-484. [PMID: 37922492 PMCID: PMC10919112 DOI: 10.1164/rccm.202308-1455vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 11/03/2023] [Indexed: 11/05/2023] Open
Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC – Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; and
| | - Olaf L. Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
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5
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Otten M, Jagesar AR, Dam TA, Biesheuvel LA, den Hengst F, Ziesemer KA, Thoral PJ, de Grooth HJ, Girbes ARJ, François-Lavet V, Hoogendoorn M, Elbers PWG. Does Reinforcement Learning Improve Outcomes for Critically Ill Patients? A Systematic Review and Level-of-Readiness Assessment. Crit Care Med 2024; 52:e79-e88. [PMID: 37938042 DOI: 10.1097/ccm.0000000000006100] [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] [Indexed: 11/09/2023]
Abstract
OBJECTIVE Reinforcement learning (RL) is a machine learning technique uniquely effective at sequential decision-making, which makes it potentially relevant to ICU treatment challenges. We set out to systematically review, assess level-of-readiness and meta-analyze the effect of RL on outcomes for critically ill patients. DATA SOURCES A systematic search was performed in PubMed, Embase.com, Clarivate Analytics/Web of Science Core Collection, Elsevier/SCOPUS and the Institute of Electrical and Electronics Engineers Xplore Digital Library from inception to March 25, 2022, with subsequent citation tracking. DATA EXTRACTION Journal articles that used an RL technique in an ICU population and reported on patient health-related outcomes were included for full analysis. Conference papers were included for level-of-readiness assessment only. Descriptive statistics, characteristics of the models, outcome compared with clinician's policy and level-of-readiness were collected. RL-health risk of bias and applicability assessment was performed. DATA SYNTHESIS A total of 1,033 articles were screened, of which 18 journal articles and 18 conference papers, were included. Thirty of those were prototyping or modeling articles and six were validation articles. All articles reported RL algorithms to outperform clinical decision-making by ICU professionals, but only in retrospective data. The modeling techniques for the state-space, action-space, reward function, RL model training, and evaluation varied widely. The risk of bias was high in all articles, mainly due to the evaluation procedure. CONCLUSION In this first systematic review on the application of RL in intensive care medicine we found no studies that demonstrated improved patient outcomes from RL-based technologies. All studies reported that RL-agent policies outperformed clinician policies, but such assessments were all based on retrospective off-policy evaluation.
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Affiliation(s)
- Martijn Otten
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ameet R Jagesar
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tariq A Dam
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Laurens A Biesheuvel
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Floris den Hengst
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Patrick J Thoral
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Vincent François-Lavet
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mark Hoogendoorn
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence, Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Raasveld SJ, de Bruin S, Reuland MC, van den Oord C, Schenk J, Aubron C, Bakker J, Cecconi M, Feldheiser A, Meier J, Müller MCA, Scheeren TWL, McQuilten Z, Flint A, Hamid T, Piagnerelli M, Tomić Mahečić T, Benes J, Russell L, Aguirre-Bermeo H, Triantafyllopoulou K, Chantziara V, Gurjar M, Myatra SN, Pota V, Elhadi M, Gawda R, Mourisco M, Lance M, Neskovic V, Podbregar M, Llau JV, Quintana-Diaz M, Cronhjort M, Pfortmueller CA, Yapici N, Nielsen ND, Shah A, de Grooth HJ, Vlaar APJ. Red Blood Cell Transfusion in the Intensive Care Unit. JAMA 2023; 330:1852-1861. [PMID: 37824112 PMCID: PMC10570913 DOI: 10.1001/jama.2023.20737] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice. Objective To evaluate and describe ICU RBC transfusion practices worldwide. Design, Setting, and Participants International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks. Exposure ICU stay. Main Outcomes and Measures The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused. Results Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL. Conclusions and Relevance RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sanne de Bruin
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Merijn C. Reuland
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Claudia van den Oord
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Amsterdam Public Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Cécile Aubron
- Médecine Intensive Réanimation, CHU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Jan Bakker
- Department of Pulmonary and Critical Care, New York University and Columbia University New York
- Department of Intensive Care Adults, Erasmus MC University Medical Centers, Rotterdam, the Netherlands
- Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Aarne Feldheiser
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, EvangKliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, Essen, Germany
| | - Jens Meier
- Department of Anesthesiology and Intensive Care, Kepler University Clinic, Kepler University, Linz, Austria
| | - Marcella C. A. Müller
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Thomas W. L. Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Zoe McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Flint
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tarikul Hamid
- Department of Critical Care, Asgar Ali Hospital, Dhaka, Bangladesh
| | - Michaël Piagnerelli
- Department of Intensive Care, CHU Charleroi Marie Curie, Université Libre de Brussels, Charleroi, Belgium
| | - Tina Tomić Mahečić
- Department of Anesthesiology and Intensive Care, University Clinical Hospital Center Zagreb, Croatia
| | - Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital and Faculty of Medicine in Plzen–Charles University, Plzen, Czech Republic
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care Medicine, Copenhagen University Hospital–Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Vasiliki Chantziara
- Intensive Care Unit, First Department of Respiratory Medicine, National and Kapodistrian University of Athens, Sotiria Chest Hospital, Athens, Greece
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vincenzo Pota
- Department of Child, General and Specialistic Surgery, University of Campania, Luigi Vanvitelli, Naples, Italy
| | | | - Ryszard Gawda
- Department of Anesthesiology and Intensive Care, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Mafalda Mourisco
- Department of Intensive Care, Centro Hospitalar de Entro o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Marcus Lance
- Department of Anesthesiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Vojislava Neskovic
- Department of Anesthesia and Intensive Care, Military Medical Academy Belgrade, Belgrade, Serbia
| | - Matej Podbregar
- Department for Internal Intensive Care, General Hospital Celje, Medical Faculty, University of Ljubljana, Slovenia
| | - Juan V. Llau
- Department of Anesthesiology and Post-surgical Critical Care, University Hospital Doctor Peset, Valencia, Spain
| | | | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Carmen A. Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nihan Yapici
- Department of Anesthesiology and Reanimation, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, University of Health Sciences, Istanbul, Turkey
| | - Nathan D. Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, and Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque
| | - Akshay Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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de Grooth HJ, Cremer OL. Beyond patterns: how to assign biological meaning to ARDS and sepsis phenotypes. Lancet Respir Med 2023; 11:946-947. [PMID: 37633305 DOI: 10.1016/s2213-2600(23)00266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, Netherlands.
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de Grooth HJ, Parienti JJ. Heterogeneity between studies can be explained more reliably with individual patient data. Intensive Care Med 2023; 49:1238-1241. [PMID: 37466672 PMCID: PMC10556177 DOI: 10.1007/s00134-023-07163-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
- Laboratory for Critical Care Computational Intelligence (LCCCI), Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
| | - Jean-Jacques Parienti
- Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France
- INSERM U1311 DYNAMICURE, Caen Normandy University, Caen, France
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Juschten J, Tuinman PR, de Grooth HJ. Harmonization of Reported Baseline Characteristics Is a Prerequisite for Progress in Acute Respiratory Distress Syndrome Research. Ann Am Thorac Soc 2023; 20:947-950. [PMID: 37166835 DOI: 10.1513/annalsats.202212-1038ip] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Affiliation(s)
- Jenny Juschten
- Department of Anesthesiology and
- Department of Intensive Care, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
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10
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Heldeweg MLA, Heldeweg TTR, Schober P, Tuinman PR, de Grooth HJ. Interrater Agreement for Lung Ultrasound Scoring: Practice and Methods, Make Perfect. J Ultrasound Med 2023; 42:951-952. [PMID: 36125246 DOI: 10.1002/jum.16094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
- Department of Anesthesia, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Tomas T R Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesia, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
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Blok SG, Mousa A, Brouwer MG, de Grooth HJ, Neto AS, Blans MJ, den Boer S, Dormans T, Endeman H, Roeleveld T, Scholten H, van Slobbe-Bijlsma ER, Scholten E, Touw H, van der Ven FSLIM, Wils EJ, van Westerloo DJ, Heunks LMA, Schultz MJ, Paulus F, Tuinman PR. Effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients (CONFIDENCE): protocol for a multicentre randomised controlled trial. Trials 2023; 24:226. [PMID: 36964614 PMCID: PMC10038369 DOI: 10.1186/s13063-023-07171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/14/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Fluid therapy is a common intervention in critically ill patients. It is increasingly recognised that deresuscitation is an essential part of fluid therapy and delayed deresuscitation is associated with longer invasive ventilation and length of intensive care unit (ICU) stay. However, optimal timing and rate of deresuscitation remain unclear. Lung ultrasound (LUS) may be used to identify fluid overload. We hypothesise that daily LUS-guided deresuscitation is superior to deresuscitation without LUS in critically ill patients expected to undergo invasive ventilation for more than 24 h in terms of ventilator free-days and being alive at day 28. METHODS The "effect of lung ultrasound-guided fluid deresuscitation on duration of ventilation in intensive care unit patients" (CONFIDENCE) is a national, multicentre, open-label, randomised controlled trial (RCT) in adult critically ill patients that are expected to be invasively ventilated for at least 24 h. Patients with conditions that preclude a negative fluid balance or LUS examination are excluded. CONFIDENCE will operate in 10 ICUs in the Netherlands and enrol 1000 patients. After hemodynamic stabilisation, patients assigned to the intervention will receive daily LUS with fluid balance recommendations. Subjects in the control arm are deresuscitated at the physician's discretion without the use of LUS. The primary endpoint is the number of ventilator-free days and being alive at day 28. Secondary endpoints include the duration of invasive ventilation; 28-day mortality; 90-day mortality; ICU, in hospital and total length of stay; cumulative fluid balance on days 1-7 after randomisation and on days 1-7 after start of LUS examination; mean serum lactate on days 1-7; the incidence of reintubations, chest drain placement, atrial fibrillation, kidney injury (KDIGO stadium ≥ 2) and hypernatremia; the use of invasive hemodynamic monitoring, and chest-X-ray; and quality of life at day 28. DISCUSSION The CONFIDENCE trial is the first RCT comparing the effect of LUS-guided deresuscitation to routine care in invasively ventilated ICU patients. If proven effective, LUS-guided deresuscitation could improve outcomes in some of the most vulnerable and resource-intensive patients in a manner that is non-invasive, easy to perform, and well-implementable. TRIAL REGISTRATION ClinicalTrials.gov NCT05188092. Registered since January 12, 2022.
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Affiliation(s)
- Siebe G Blok
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands.
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands.
| | - Amne Mousa
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Michelle G Brouwer
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michiel J Blans
- Department of Intensive Care, Rijnstate Hospital, Arnhem, Netherlands
| | - Sylvia den Boer
- Department of Intensive Care, Spaarne Gasthuis, Haarlem, Hoofddorp, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Centre, Heerlen, Netherlands
- Department of Intensive Care, Zuyderland Medical Centre, Sittard-Geleen, Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | - Timo Roeleveld
- Department of Intensive Care, Amstelland Hospital, Amstelveen, Netherlands
| | - Harm Scholten
- Department of Intensive Care, Catharina Hospital, Eindhoven, Netherlands
| | | | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, Utrecht, Netherlands
| | - Hugo Touw
- Department of Intensive Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fleur Stefanie L I M van der Ven
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Hospital, Beverwijk, Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | | | - Leo M A Heunks
- Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Amsterdam, The Netherlands
- Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com ), Leiden, The Netherlands
- Department of Intensive Care, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, 1117, Amsterdam, Netherlands
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12
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Heldeweg MLA, Lieveld AW, Walburgh-Schmidt RS, Smit JM, Haaksma ME, Veldhuis L, de Grooth HJ, Girbes AR, Heunks LM, Tuinman PR. Concise Versus Extended Lung Ultrasound Score to Monitor Critically Ill Patients With COVID-19. Respir Care 2023; 68:400-407. [PMID: 36649978 PMCID: PMC10027145 DOI: 10.4187/respcare.10406] [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] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lung ultrasound (LUS) can be used to monitor critically ill patients with COVID-19, but the optimal number of examined lung zones is disputed. METHODS This was a prospective observational study. The objective was to investigate whether concise (6 zones) and extended (12 zones) LUS scoring protocols are clinically equivalent in critically ill ICU subjects with COVID-19. The primary outcome of this study was (statistical) agreement between concise and extended LUS score index evaluated in both supine and prone position. Agreement was determined using correlation coefficients and Bland-Altman plots to detect systematic differences between protocols. Secondary outcomes were difference between LUS score index in supine and prone position using similar methods. RESULTS We included 130 LUS examinations in 40 subjects (mean age 69.0 ± 8.5y, 75% male). Agreement between concise and extended LUS score index had no clinically relevant constant or proportional bias and limits of agreement were below the smallest detectable change. Across position changes, supine LUS score index was 8% higher than prone LUS score index and had limits above the smallest detectable change, indicating true LUS score index differences between protocols may occur due to the position change itself. Lastly, inter-rater and intra-rater agreement were very good. CONCLUSIONS Concise LUS was equally informative as extended LUS for monitoring critically ill subjects with COVID-19 in supine or prone position. Clinicians can monitor patients undergoing position changes but must be wary that LUS score index alterations may result from the position change itself rather than disease progression or clinical improvement.
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Affiliation(s)
- Micah LA Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Leiden IC Focused Echography, Amsterdam, the Netherlands.
| | - Arthur We Lieveld
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Robin S Walburgh-Schmidt
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Leiden IC Focused Echography, Amsterdam, the Netherlands
| | - Lars Veldhuis
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Armand Rj Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Leo Ma Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands; and Amsterdam Leiden IC Focused Echography, Amsterdam, the Netherlands
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13
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Lijović L, Pelajić S, Hawchar F, Minev I, da Silva BHCS, Angelucci A, Ercole A, de Grooth HJ, Thoral P, Radočaj T, Elbers P. Diagnosing acute kidney injury ahead of time in critically ill septic patients using kinetic estimated glomerular filtration rate. J Crit Care 2023; 75:154276. [PMID: 36774818 DOI: 10.1016/j.jcrc.2023.154276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 01/10/2023] [Accepted: 02/02/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Accurate and actionable diagnosis of Acute Kidney Injury (AKI) ahead of time is important to prevent or mitigate renal insufficiency. The purpose of this study was to evaluate the performance of Kinetic estimated Glomerular Filtration Rate (KeGFR) in timely predicting AKI in critically ill septic patients. METHODS We conducted a retrospective analysis on septic ICU patients who developed AKI in AmsterdamUMCdb, the first freely available European ICU database. The reference standard for AKI was the Kidney Disease: Improving Global Outcomes (KDIGO) classification based on serum creatinine and urine output (UO). Prediction of AKI was based on stages defined by KeGFR and UO. Classifications were compared by length of ICU stay (LOS), need for renal replacement therapy and 28-day mortality. Predictive performance and time between prediction and diagnosis were calculated. RESULTS Of 2492 patients in the cohort, 1560 (62.0%) were diagnosed with AKI by KDIGO and 1706 (68.5%) by KeGFR criteria. Disease stages had agreement of kappa = 0.77, with KeGFR sensitivity 93.2%, specificity 73.0% and accuracy 85.7%. Median time to recognition of AKI Stage 1 was 13.2 h faster for KeGFR, and 7.5 h and 5.0 h for Stages 2 and 3. Outcomes revealed a slight difference in LOS and 28-day mortality for Stage 1. CONCLUSIONS Predictive performance of KeGFR combined with UO criteria for diagnosing AKI is excellent. Compared to KDIGO, deterioration of renal function was identified earlier, most prominently for lower stages of AKI. This may shift the actionable window for preventing and mitigating renal insufficiency.
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Affiliation(s)
- Lada Lijović
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands; Department of Anesthesiology, Intensive Care and Pain Management, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia.
| | - Stipe Pelajić
- Department of Anesthesiology, Intensive Care and Pain Management, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Fatime Hawchar
- Department of Anesthesiology and Intensive Care, Albert Szent-Györgyi Health Center, University of Szeged, Hungary
| | - Ivaylo Minev
- Department of Anaesthesiology, Emergency and Intensive care medicine, Medical University of Plovdiv, University hospital St. George, Bulgaria
| | - Beatriz Helena Cermaria Soares da Silva
- Diretoria de Ciencias Medicas, Universidade Nove de Julho - Campus Guarulhos, Sao Paulo, Brazil; Departamento de Anesthesiologia, Dor e Terapia Intensiva, Universidade Federal de Sao Paolo, Sao Paolo, Brazil
| | - Alessandra Angelucci
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Patrick Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Tomislav Radočaj
- Department of Anesthesiology, Intensive Care and Pain Management, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Paul Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Public Health, Amsterdam Cardiovascular Science, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
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14
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Iachkine J, Buetti N, de Grooth HJ, Briant AR, Mimoz O, Mégarbane B, Mira JP, Valette X, Daubin C, du Cheyron D, Mermel LA, Timsit JF, Parienti JJ. Development and validation of a multivariable model predicting the required catheter dwell time among mechanically ventilated critically ill patients in three randomized trials. Ann Intensive Care 2023; 13:5. [PMID: 36645531 PMCID: PMC9842826 DOI: 10.1186/s13613-023-01099-9] [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: 10/19/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The anatomic site for central venous catheter insertion influences the risk of central venous catheter-related intravascular complications. We developed and validated a predictive score of required catheter dwell time to identify critically ill patients at higher risk of intravascular complications. METHODS We retrospectively conducted a cohort study from three multicenter randomized controlled trials enrolling consecutive patients requiring central venous catheterization. The primary outcome was the required catheter dwell time, defined as the period between the first catheter insertion and removal of the last catheter for absence of utility. Predictors were identified in the training cohort (3SITES trial; 2336 patients) through multivariable analyses based on the subdistribution hazard function accounting for death as a competing event. Internal validation was performed in the training cohort by 500 bootstraps to derive the CVC-IN score from robust risk factors. External validation of the CVC-IN score were performed in the testing cohort (CLEAN, and DRESSING2; 2371 patients). RESULTS The analysis was restricted to patients requiring mechanical ventilation to comply with model assumptions. Immunosuppression (2 points), high creatinine > 100 micromol/L (2 points), use of vasopressor (1 point), obesity (1 point) and older age (40-59, 1 point; ≥ 60, 2 points) were independently associated with the required catheter dwell time. At day 28, area under the ROC curve for the CVC-IN score was 0.69, 95% confidence interval (CI) [0.66-0.72] in the training cohort and 0.64, 95% CI [0.61-0.66] in the testing cohort. Patients with a CVC-IN score ≥ 4 in the overall cohort had a median required catheter dwell time of 24 days (versus 11 days for CVC-IN score < 4 points). The positive predictive value of a CVC-IN score ≥ 4 was 76.9% for > 7 days required catheter dwell time in the testing cohort. CONCLUSION The CVC-IN score, which can be used for the first catheter, had a modest ability to discriminate required catheter dwell time. Nevertheless, preference of the subclavian site may contribute to limit the risk of intravascular complications, in particular among ventilated patients with high CVC-IN score. Trials Registration NCT01479153, NCT01629550, NCT01189682.
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Affiliation(s)
- Jeanne Iachkine
- grid.411149.80000 0004 0472 0160Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France ,grid.460771.30000 0004 1785 9671INSERM U1311 DYNAMICURE, Caen Normandy University, Caen, France
| | - Niccolò Buetti
- grid.8591.50000 0001 2322 4988Infection Control Program and World Health Organization Collaborating Center on Patient Safety, Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Harm-Jan de Grooth
- grid.12380.380000 0004 1754 9227Department of Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Anaïs R. Briant
- grid.411149.80000 0004 0472 0160Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France
| | - Olivier Mimoz
- grid.11166.310000 0001 2160 6368Inserm U1070, Poitiers University, Poitiers, France ,grid.411162.10000 0000 9336 4276Poitiers University Hospital, 86021 Poitiers, France
| | - Bruno Mégarbane
- Medical and Toxicological Intensive Care Unit, Lariboisière Hospital, AP-HP, INSERM, UMRS-1144, Paris University, Paris, France
| | - Jean-Paul Mira
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Xavier Valette
- grid.411149.80000 0004 0472 0160Department of Medical Intensive Care, Caen University Hospital, 14000 Caen, France
| | - Cédric Daubin
- grid.411149.80000 0004 0472 0160Department of Medical Intensive Care, Caen University Hospital, 14000 Caen, France
| | - Damien du Cheyron
- grid.411149.80000 0004 0472 0160Department of Medical Intensive Care, Caen University Hospital, 14000 Caen, France
| | - Leonard A. Mermel
- grid.411024.20000 0001 2175 4264Department of Epidemiology and Infection Prevention, Lifespan Hospital System, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI USA
| | - Jean-François Timsit
- grid.411119.d0000 0000 8588 831XMedical and Infectious Diseases ICU (MI2), Bichat Hospital, AP-HP, University of Paris, IAME, INSERM U1137, Paris, France
| | - Jean-Jacques Parienti
- grid.411149.80000 0004 0472 0160Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France ,grid.460771.30000 0004 1785 9671INSERM U1311 DYNAMICURE, Caen Normandy University, Caen, France
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15
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Iachkine J, Buetti N, de Grooth HJ, Briant AR, Mimoz O, Mégarbane B, Mira JP, Ruckly S, Souweine B, du Cheyron D, Mermel LA, Timsit JF, Parienti JJ. Development and validation of a multivariable prediction model of central venous catheter-tip colonization in a cohort of five randomized trials. Crit Care 2022; 26:205. [PMID: 35799302 PMCID: PMC9261073 DOI: 10.1186/s13054-022-04078-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The majority of central venous catheters (CVC) removed in the ICU are not colonized, including when a catheter-related infection (CRI) is suspected. We developed and validated a predictive score to reduce unnecessary CVC removal.
Methods
We conducted a retrospective cohort study from five multicenter randomized controlled trials with systematic catheter-tip culture of consecutive CVCs. Colonization was defined as growth of ≥103 colony-forming units per mL. Risk factors for colonization were identified in the training cohort (CATHEDIA and 3SITES trials; 3899 CVCs of which 575 (15%) were colonized) through multivariable analyses. After internal validation in 500 bootstrapped samples, the CVC-OUT score was computed by attaching points to the robust (> 50% of the bootstraps) risk factors. External validation was performed in the testing cohort (CLEAN, DRESSING2 and ELVIS trials; 6848 CVCs, of which 588 (9%) were colonized).
Results
In the training cohort, obesity (1 point), diabetes (1 point), type of CVC (dialysis catheter, 1 point), anatomical insertion site (jugular, 4 points; femoral 5 points), rank of the catheter (second or subsequent, 1 point) and catheterization duration (≥ 5 days, 2 points) were significantly and independently associated with colonization . Area under the ROC curve (AUC) for the CVC-OUT score was 0.69, 95% confidence interval (CI) [0.67–0.72]. In the testing cohort, AUC for the CVC-OUT score was 0.60, 95% CI [0.58–0.62]. Among 1,469 CVCs removed for suspected CRI in the overall population, 1200 (82%) were not colonized. The negative predictive value (NPV) of a CVC-OUT score < 6 points was 94%, 95% CI [93%–95%].
Conclusion
The CVC-OUT score had a moderate ability to discriminate catheter-tip colonization, but the high NPV may contribute to reduce unnecessary CVCs removal. Preference of the subclavian site is the strongest and only modifiable risk factor that reduces the likelihood of catheter-tip colonization and consequently the risk of CRI.
Clinical Trials Registration: NCT00277888, NCT01479153, NCT01629550, NCT01189682, NCT00875069.
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16
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Ahuja S, de Grooth HJ, Paulus F, van der Ven FL, Serpa Neto A, Schultz MJ, Tuinman PR, Ahuja S, van Akkeren JP, Algera AG, Algoe CK, van Amstel RB, Artigas A, Baur OL, van de Berg P, van den Berg AE, Bergmans DCJJ, van den Bersselaar DI, Bertens FA, Bindels AJGH, de Boer MM, den Boer S, Boers LS, Bogerd M, Bos LDJ, Botta M, Breel JS, de Bruin H, de Bruin S, Bruna CL, Buiteman-Kruizinga LA, Cremer OL, Determann RM, Dieperink W, Dongelmans DA, Franke HS, Galek-Aldridge MS, de Graaff MJ, Hagens LA, Haringman JJ, van der Heide ST, van der Heiden PLJ, Heijnen NFL, Hiel SJP, Hoeijmakers LL, Hol L, Hollmann MW, Hoogendoorn ME, Horn J, van der Horst R, Ie ELK, Ivanov D, Juffermans NP, Kho E, de Klerk ES, Koopman-van Gemert AWMM, Koopmans M, Kucukcelebi S, Kuiper MA, de Lange DW, van Mourik N, Nijbroek SG, Onrust M, Oostdijk EAN, Paulus F, Pennartz CJ, Pillay J, Pisani L, Purmer IM, Rettig TCD, Roozeman JP, Schuijt MTU, Schultz MJ, Serpa Neto A, Sleeswijk ME, Smit MR, Spronk PE, Stilma W, Strang AC, Tsonas AM, Tuinman PR, Valk CMA, Veen-Schra FL, Veldhuis LI, van Velzen P, van der Ven WH, Vlaar APJ, van Vliet P, van der Voort PHJ, van Welie L, Wesselink HJFT, van der Wier-Lubbers HH, van Wijk B, Winters T, Wong WY, van Zanten ARH. Association between early cumulative fluid balance and successful liberation from invasive ventilation in COVID-19 ARDS patients — insights from the PRoVENT-COVID study: a national, multicenter, observational cohort analysis. Crit Care 2022; 26:157. [PMID: 35650616 PMCID: PMC9157033 DOI: 10.1186/s13054-022-04023-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Increasing evidence indicates the potential benefits of restricted fluid management in critically ill patients. Evidence lacks on the optimal fluid management strategy for invasively ventilated COVID-19 patients. We hypothesized that the cumulative fluid balance would affect the successful liberation of invasive ventilation in COVID-19 patients with acute respiratory distress syndrome (ARDS).
Methods
We analyzed data from the multicenter observational ‘PRactice of VENTilation in COVID-19 patients’ study. Patients with confirmed COVID-19 and ARDS who required invasive ventilation during the first 3 months of the international outbreak (March 1, 2020, to June 2020) across 22 hospitals in the Netherlands were included. The primary outcome was successful liberation of invasive ventilation, modeled as a function of day 3 cumulative fluid balance using Cox proportional hazards models, using the crude and the adjusted association. Sensitivity analyses without missing data and modeling ARDS severity were performed.
Results
Among 650 patients, three groups were identified. Patients in the higher, intermediate, and lower groups had a median cumulative fluid balance of 1.98 L (1.27–7.72 L), 0.78 L (0.26–1.27 L), and − 0.35 L (− 6.52–0.26 L), respectively. Higher day 3 cumulative fluid balance was significantly associated with a lower probability of successful ventilation liberation (adjusted hazard ratio 0.86, 95% CI 0.77–0.95, P = 0.0047). Sensitivity analyses showed similar results.
Conclusions
In a cohort of invasively ventilated patients with COVID-19 and ARDS, a higher cumulative fluid balance was associated with a longer ventilation duration, indicating that restricted fluid management in these patients may be beneficial.
Trial registration Clinicaltrials.gov (NCT04346342); Date of registration: April 15, 2020.
Graphical abstract
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17
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Dam TA, Roggeveen LF, van Diggelen F, Fleuren LM, Jagesar AR, Otten M, de Vries HJ, Gommers D, Cremer OL, Bosman RJ, Rigter S, Wils EJ, Frenzel T, Dongelmans DA, de Jong R, Peters MAA, Kamps MJA, Ramnarain D, Nowitzky R, Nooteboom FGCA, de Ruijter W, Urlings-Strop LC, Smit EGM, Mehagnoul-Schipper DJ, Dormans T, de Jager CPC, Hendriks SHA, Achterberg S, Oostdijk E, Reidinga AC, Festen-Spanjer B, Brunnekreef GB, Cornet AD, van den Tempel W, Boelens AD, Koetsier P, Lens J, Faber HJ, Karakus A, Entjes R, de Jong P, Rettig TCD, Arbous S, Vonk SJJ, Machado T, Herter WE, de Grooth HJ, Thoral PJ, Girbes ARJ, Hoogendoorn M, Elbers PWG. Predicting responders to prone positioning in mechanically ventilated patients with COVID-19 using machine learning. Ann Intensive Care 2022; 12:99. [PMID: 36264358 PMCID: PMC9583049 DOI: 10.1186/s13613-022-01070-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background For mechanically ventilated critically ill COVID-19 patients, prone positioning has quickly become an important treatment strategy, however, prone positioning is labor intensive and comes with potential adverse effects. Therefore, identifying which critically ill intubated COVID-19 patients will benefit may help allocate labor resources. Methods From the multi-center Dutch Data Warehouse of COVID-19 ICU patients from 25 hospitals, we selected all 3619 episodes of prone positioning in 1142 invasively mechanically ventilated patients. We excluded episodes longer than 24 h. Berlin ARDS criteria were not formally documented. We used supervised machine learning algorithms Logistic Regression, Random Forest, Naive Bayes, K-Nearest Neighbors, Support Vector Machine and Extreme Gradient Boosting on readily available and clinically relevant features to predict success of prone positioning after 4 h (window of 1 to 7 h) based on various possible outcomes. These outcomes were defined as improvements of at least 10% in PaO2/FiO2 ratio, ventilatory ratio, respiratory system compliance, or mechanical power. Separate models were created for each of these outcomes. Re-supination within 4 h after pronation was labeled as failure. We also developed models using a 20 mmHg improvement cut-off for PaO2/FiO2 ratio and using a combined outcome parameter. For all models, we evaluated feature importance expressed as contribution to predictive performance based on their relative ranking. Results The median duration of prone episodes was 17 h (11–20, median and IQR, N = 2632). Despite extensive modeling using a plethora of machine learning techniques and a large number of potentially clinically relevant features, discrimination between responders and non-responders remained poor with an area under the receiver operator characteristic curve of 0.62 for PaO2/FiO2 ratio using Logistic Regression, Random Forest and XGBoost. Feature importance was inconsistent between models for different outcomes. Notably, not even being a previous responder to prone positioning, or PEEP-levels before prone positioning, provided any meaningful contribution to predicting a successful next proning episode. Conclusions In mechanically ventilated COVID-19 patients, predicting the success of prone positioning using clinically relevant and readily available parameters from electronic health records is currently not feasible. Given the current evidence base, a liberal approach to proning in all patients with severe COVID-19 ARDS is therefore justified and in particular regardless of previous results of proning. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01070-0.
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Affiliation(s)
- Tariq A Dam
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Luca F Roggeveen
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Fuda van Diggelen
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, VU University, Amsterdam, The Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ameet R Jagesar
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martijn Otten
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Heder J de Vries
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olaf L Cremer
- Intensive Care, UMC Utrecht, Utrecht, The Netherlands
| | | | - Sander Rigter
- Department of Anesthesiology and Intensive Care, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Tim Frenzel
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Remko de Jong
- Intensive Care, Bovenij Ziekenhuis, Amsterdam, The Netherlands
| | - Marco A A Peters
- Intensive Care, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Marlijn J A Kamps
- Intensive Care, Catharina Ziekenhuis Eindhoven, Eindhoven, The Netherlands
| | | | - Ralph Nowitzky
- Intensive Care, HagaZiekenhuis, Den Haag, The Netherlands
| | | | - Wouter de Ruijter
- Department of Intensive Care Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | | | - Ellen G M Smit
- Intensive Care, Spaarne Gasthuis, Haarlem en Hoofddorp, The Netherlands
| | | | - Tom Dormans
- Intensive Care, Zuyderland MC, Heerlen, The Netherlands
| | | | | | | | | | - Auke C Reidinga
- ICU, SEH, BWC, Martiniziekenhuis, Groningen, The Netherlands
| | | | - Gert B Brunnekreef
- Department of Intensive Care, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | - Alexander D Cornet
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Walter van den Tempel
- Department of Intensive Care, Ikazia Ziekenhuis Rotterdam, Rotterdam, The Netherlands
| | | | - Peter Koetsier
- Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Judith Lens
- ICU, IJsselland Ziekenhuis, Capelle aan den IJssel, The Netherlands
| | | | - A Karakus
- Department of Intensive Care, Diakonessenhuis Hospital, Utrecht, The Netherlands
| | - Robert Entjes
- Department of Intensive Care, Adrz, Goes, The Netherlands
| | - Paul de Jong
- Department of Anesthesia and Intensive Care, Slingeland Ziekenhuis, Doetinchem, The Netherlands
| | - Thijs C D Rettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Ziekenhuis, Breda, The Netherlands
| | | | | | | | | | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Patrick J Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mark Hoogendoorn
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, VU University, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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Roggeveen LF, Guo T, Fleuren LM, Driessen R, Thoral P, van Hest RM, Mathot RAA, Swart EL, de Grooth HJ, van den Bogaard B, Girbes ARJ, Bosman RJ, Elbers PWG. Right dose, right now: bedside, real-time, data-driven, and personalised antibiotic dosing in critically ill patients with sepsis or septic shock—a two-centre randomised clinical trial. Crit Care 2022; 26:265. [PMID: 36064438 PMCID: PMC9443636 DOI: 10.1186/s13054-022-04098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Adequate antibiotic dosing may improve outcomes in critically ill patients but is challenging due to altered and variable pharmacokinetics. To address this challenge, AutoKinetics was developed, a decision support system for bedside, real-time, data-driven and personalised antibiotic dosing. This study evaluates the feasibility, safety and efficacy of its clinical implementation. Methods In this two-centre randomised clinical trial, critically ill patients with sepsis or septic shock were randomised to AutoKinetics dosing or standard dosing for four antibiotics: vancomycin, ciprofloxacin, meropenem, and ceftriaxone. Adult patients with a confirmed or suspected infection and either lactate > 2 mmol/L or vasopressor requirement were eligible for inclusion. The primary outcome was pharmacokinetic target attainment in the first 24 h after randomisation. Clinical endpoints included mortality, ICU length of stay and incidence of acute kidney injury. Results After inclusion of 252 patients, the study was stopped early due to the COVID-19 pandemic. In the ciprofloxacin intervention group, the primary outcome was obtained in 69% compared to 3% in the control group (OR 62.5, CI 11.4–1173.78, p < 0.001). Furthermore, target attainment was faster (26 h, CI 18–42 h, p < 0.001) and better (65% increase, CI 49–84%, p < 0.001). For the other antibiotics, AutoKinetics dosing did not improve target attainment. Clinical endpoints were not significantly different. Importantly, higher dosing did not lead to increased mortality or renal failure. Conclusions In critically ill patients, personalised dosing was feasible, safe and significantly improved target attainment for ciprofloxacin. Trial registration: The trial was prospectively registered at Netherlands Trial Register (NTR), NL6501/NTR6689 on 25 August 2017 and at the European Clinical Trials Database (EudraCT), 2017-002478-37 on 6 November 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04098-7.
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van Oers JAH, Pouwels S, Ramnarain D, Kluiters Y, Bons JAP, de Lange DW, de Grooth HJ, Girbes ARJ. Mid-regional proadrenomedullin, C-terminal proendothelin-1 values, and disease course are not different in critically ill SARS-CoV-2 pneumonia patients with obesity. Int J Obes (Lond) 2022; 46:1801-1807. [PMID: 35840771 PMCID: PMC9283850 DOI: 10.1038/s41366-022-01184-2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 01/08/2023]
Abstract
Background/objectives Patients affected by obesity and Coronavirus disease 2019, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), appear to have a higher risk for intensive care (ICU) admission. A state of low-grade chronic inflammation in obesity has been suggested as one of the underlying mechanisms. We investigated whether obesity is associated with differences in new inflammatory biomarkers mid-regional proadrenomedullin (MR-proADM), C-terminal proendothelin-1 (CT-proET-1), and clinical outcomes in critically ill patients with SARS-CoV-2 pneumonia. Subjects/methods A total of 105 critically ill patients with SARS-CoV-2 pneumonia were divided in patients with obesity (body mass index (BMI) ≥ 30 kg/m2, n = 42) and patients without obesity (BMI < 30 kg/m2, n = 63) and studied in a retrospective observational cohort study. MR-proADM, CT-proET-1 concentrations, and conventional markers of white blood count (WBC), C-reactive protein (CRP), and procalcitonin (PCT) were collected during the first 7 days. Results BMI was 33.5 (32–36.1) and 26.2 (24.7–27.8) kg/m2 in the group with and without obesity. There were no significant differences in concentrations MR-proADM, CT-proET-1, WBC, CRP, and PCT at baseline and the next 6 days between patients with and without obesity. Only MR-proADM changed significantly over time (p = 0.039). Also, BMI did not correlate with inflammatory biomarkers (MR-proADM rho = 0.150, p = 0.125, CT-proET-1 rho = 0.179, p = 0.067, WBC rho = −0.044, p = 0.654, CRP rho = 0.057, p = 0.564, PCT rho = 0.022, p = 0.842). Finally, no significant differences in time on a ventilator, ICU length of stay, and 28-day mortality between patients with or without obesity were observed. Conclusions In critically ill patients with confirmed SARS-CoV-2 pneumonia, obesity was not associated with differences in MR-proADM, and CT-proET-1, or impaired outcome. Trial registration Netherlands Trial Register, NL8460.
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Affiliation(s)
- Jos A H van Oers
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands.
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Yvette Kluiters
- Department of Clinical Chemistry, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Judith A P Bons
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care Medicine, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Medical Centres, VU University Medical Centre, Amsterdam, The Netherlands
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20
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van Oers JAH, Ramnarain D, Oldenbeuving A, Vos P, Roks G, Kluiters Y, Beishuizen A, de Lange DW, de Grooth HJ, Girbes ARJ. C-Terminal Proarginine Vasopressin is Associated with Disease Outcome and Mortality, but not with Delayed Cerebral Ischemia in Critically Ill Patients with an Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study. Neurocrit Care 2022; 37:678-688. [PMID: 35750931 DOI: 10.1007/s12028-022-01540-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is an important indication for intensive care unit admission and may lead to significant morbidity and mortality. We assessed the ability of C-terminal proarginine vasopressin (CT-proAVP) to predict disease outcome, mortality, and delayed cerebral ischemia (DCI) in critically ill patients with aSAH compared with the World Federation of Neurological Surgeons (WFNS) score and Acute Physiological and Chronic Health Evaluation IV (APACHE IV) model. METHODS C-terminal proarginine vasopressin was collected on admission in this single-center, prospective, observational cohort study. The primary aim was to investigate the relationship between CT-proAVP and poor functional outcome at 1 year (Glasgow Outcome Scale score 1-3) in a multivariable logistic regression model adjusted for WFNS and APACHE IV scores. Secondary aims were mortality and DCI. The multivariable logistic regression model for DCI was also adjusted for the modified Fisher scale. RESULTS In 100 patients, the median CT-proAVP level was 24.9 pmol/L (interquartile range 11.5-53.8); 45 patients had a poor 1-year functional outcome, 19 patients died within 30 days, 25 patients died within 1 year, and DCI occurred in 28 patients. Receiver operating characteristics curves revealed high accuracy for CT-proAVP to identify patients with poor 1-year functional outcome (area under the curve [AUC] 0.84, 95% confidence interval [CI] 0.77-0.92, p < 0.001), 30-day mortality (AUC 0.84, 95% CI 0.76-0.93, p < 0.001), and 1-year mortality (AUC 0.79, 95% CI 0.69-0.89, p < 0.001). CT-proAVP had a low AUC for identifying patients with DCI (AUC 0.67, 95% CI 0.55-0.79, p 0.008). CT-proAVP ≥ 24.9 pmo/L proved to be a significant predictor for poor 1-year functional outcome (odds ratio [OR] 8.04, 95% CI 2.97-21.75, p < 0.001), and CT-proAVP ≥ 29.1 pmol/L and ≥ 27.7 pmol/L were significant predictors for 30-day and 1-year mortality (OR 9.31, 95% CI 1.55-56.07, p 0.015 and OR 5.15, 95% CI 1.48-17.93, p 0.010) in multivariable models with WFNS and APACHE IV scores. CT-proAVP ≥ 29.5 pmol/L was not a significant predictor for DCI in a multivariable model adjusted for the modified Fisher scale (p = 0.061). CONCLUSIONS C-terminal proarginine vasopressin was able to predict poor functional outcome and mortality in critically ill patients with aSAH. Its prognostic ability to predict DCI was low. TRIAL REGISTRATION Nederlands Trial Register: NTR4118.
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Affiliation(s)
- Jos A H van Oers
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands.
| | - Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Annemarie Oldenbeuving
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Piet Vos
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Gerwin Roks
- Department of Neurology, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Yvette Kluiters
- Department of Clinical Chemistry, Elisabeth Tweesteden Ziekenhuis, Tilburg, The Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care Medicine, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
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21
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Fujarski M, Porschen C, Plagwitz L, Brenner A, Ghoreishi N, Thoral P, de Grooth HJ, Elbers P, Weiss R, Meersch M, Zarbock A, von Groote TC, Varghese J. Prediction of Acute Kidney Injury in the Intensive Care Unit: Preliminary Findings in a European Open Access Database. Stud Health Technol Inform 2022; 294:139-140. [PMID: 35612039 DOI: 10.3233/shti220419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Indexed: 06/15/2023]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with long-term complications and an increased mortality. This work presents preliminary findings from the first freely available European intensive care database released by Amsterdam UMC. A machine learning (ML) model was developed to predict AKI in the intensive care unit 12 hours before the actual event. Main features of the model included medications and hemodynamic parameters. Our models perform with an accuracy of 81.8% on moderate to severe AKI and 79.8% on all AKI patients. Those results can compete with models reported in the literature and introduce an ML model for AKI based on European patient data.
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Affiliation(s)
- Michael Fujarski
- Institute of Medical Informatics, University of Münster, Germany
| | - Christian Porschen
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Lucas Plagwitz
- Institute of Medical Informatics, University of Münster, Germany
| | | | | | - Patrick Thoral
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence. Vrije Universiteit, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence. Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence. Vrije Universiteit, Amsterdam, The Netherlands
| | - Raphael Weiss
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Thilo Caspar von Groote
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Julian Varghese
- Institute of Medical Informatics, University of Münster, Germany
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Juschten J, Bos LDJ, de Grooth HJ, Beuers U, Girbes ARJ, Juffermans NP, Loer SA, van der Poll T, Cremer OL, Bonten MJM, Schultz MJ, Tuinman PR. Incidence, Clinical Characteristics and Outcomes of Early Hyperbilirubinemia in Critically Ill Patients: Insights From the MARS Study. Shock 2022; 57:161-167. [PMID: 34238904 PMCID: PMC8757589 DOI: 10.1097/shk.0000000000001836] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/19/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients. DESIGN AND SETTING This is a post hoc analysis of a prospective multicenter cohort study. PATIENTS Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded. ENDPOINTS The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 μmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30. RESULTS Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%-confidence interval 1.06-1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%-confidence interval 2.08-3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%-confidence interval 0.75-1.55]; P = 0.655). CONCLUSIONS Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.
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Affiliation(s)
- Jenny Juschten
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Department of Pulmonology, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Armand R. J. Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
| | - Stephan A. Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Division of Infectious Diseases, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Olaf L. Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc J. M. Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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van Oers JAH, de Grooth HJ, de Lange DW, Girbes ARJ. Response to: MR-proADM has a good ability to predict mortality in critically ill patients with SARS-CoV-2 pneumonia: Beware of some potential confounders! J Crit Care 2021; 67:214-215. [PMID: 34688526 PMCID: PMC8548649 DOI: 10.1016/j.jcrc.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 10/07/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Jos A H van Oers
- Department of Intensive Care Medicine, Elisabeth Tweesteden Ziekenhuis, Tilburg, the Netherlands.
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Medical Centres, VU University Medical Centre, Amsterdam, the Netherlands
| | - Dylan W de Lange
- Department of Intensive Care Medicine, University Medical Centre Utrecht, University Utrecht, Utrecht, the Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Medical Centres, VU University Medical Centre, Amsterdam, the Netherlands
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Gelissen H, de Grooth HJ, Smulders Y, Wils EJ, de Ruijter W, Vink R, Smit B, Röttgering J, Atmowihardjo L, Girbes A, Elbers P, Tuinman PR, Oudemans-van Straaten H, de Man A. Effect of Low-Normal vs High-Normal Oxygenation Targets on Organ Dysfunction in Critically Ill Patients: A Randomized Clinical Trial. JAMA 2021; 326:940-948. [PMID: 34463696 PMCID: PMC8408761 DOI: 10.1001/jama.2021.13011] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Hyperoxemia may increase organ dysfunction in critically ill patients, but optimal oxygenation targets are unknown. OBJECTIVE To determine whether a low-normal Pao2 target compared with a high-normal target reduces organ dysfunction in critically ill patients with systemic inflammatory response syndrome (SIRS). DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial in 4 intensive care units in the Netherlands. Enrollment was from February 2015 to October 2018, with end of follow-up to January 2019, and included adult patients admitted with 2 or more SIRS criteria and expected stay of longer than 48 hours. A total of 9925 patients were screened for eligibility, of whom 574 fulfilled the enrollment criteria and were randomized. INTERVENTIONS Target Pao2 ranges were 8 to 12 kPa (low-normal, n = 205) and 14 to 18 kPa (high-normal, n = 195). An inspired oxygen fraction greater than 0.60 was applied only when clinically indicated. MAIN OUTCOMES AND MEASURES Primary end point was SOFARANK, a ranked outcome of nonrespiratory organ failure quantified by the nonrespiratory components of the Sequential Organ Failure Assessment (SOFA) score, summed over the first 14 study days. Participants were ranked from fastest organ failure improvement (lowest scores) to worsening organ failure or death (highest scores). Secondary end points were duration of mechanical ventilation, in-hospital mortality, and hypoxemic measurements. RESULTS Among the 574 patients who were randomized, 400 (70%) were enrolled within 24 hours (median age, 68 years; 140 women [35%]), all of whom completed the trial. The median Pao2 difference between the groups was -1.93 kPa (95% CI, -2.12 to -1.74; P < .001). The median SOFARANK score was -35 points in the low-normal Pao2 group vs -40 in the high-normal Pao2 group (median difference, 10 [95% CI, 0 to 21]; P = .06). There was no significant difference in median duration of mechanical ventilation (3.4 vs 3.1 days; median difference, -0.15 [95% CI, -0.88 to 0.47]; P = .59) and in-hospital mortality (32% vs 31%; odds ratio, 1.04 [95% CI, 0.67 to 1.63]; P = .91). Mild hypoxemic measurements occurred more often in the low-normal group (1.9% vs 1.2%; median difference, 0.73 [95% CI, 0.30 to 1.20]; P < .001). Acute kidney failure developed in 20 patients (10%) in the low-normal Pao2 group and 21 patients (11%) in the high-normal Pao2 group, and acute myocardial infarction in 6 patients (2.9%) in the low-normal Pao2 group and 7 patients (3.6%) in the high-normal Pao2 group. CONCLUSIONS AND RELEVANCE Among critically ill patients with 2 or more SIRS criteria, treatment with a low-normal Pao2 target compared with a high-normal Pao2 target did not result in a statistically significant reduction in organ dysfunction. However, the study may have had limited power to detect a smaller treatment effect than was hypothesized. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02321072.
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Affiliation(s)
- Harry Gelissen
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Department of Anesthesiology, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Yvo Smulders
- Department of Internal Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Wouter de Ruijter
- Department of Intensive Care, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Roel Vink
- Department of Intensive Care, Tergooiziekenhuizen, Hilversum, the Netherlands
| | - Bob Smit
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Department of Clinical Chemistry, HAGA Ziekenhuis, Den Haag, the Netherlands
| | - Jantine Röttgering
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Leila Atmowihardjo
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Armand Girbes
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Pieter-Roel Tuinman
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Heleen Oudemans-van Straaten
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Angelique de Man
- Department of Intensive Care Medicine, Research VUmc Intensive Care, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam Medical Data Science, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
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Zaal EA, de Grooth HJ, Oudaert I, Langerhorst P, Levantovsky S, van Slobbe GJJ, Jansen JWA, Menu E, Wu W, Berkers CR. Targeting coenzyme Q10 synthesis overcomes bortezomib resistance in multiple myeloma. Mol Omics 2021; 18:19-30. [PMID: 34879122 DOI: 10.1039/d1mo00106j] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
During the development of drug resistance, multiple myeloma (MM) cells undergo changes to their metabolism. However, how these metabolic changes can be exploited to improve treatment efficacy is not known. Here we demonstrate that targeting coenzyme Q10 (CoQ) biosynthesis through the mevalonate pathway works in synergy with the proteasome inhibitor bortezomib (BTZ) in MM. We show that gene expression signatures relating to the mitochondrial tricarboxylic acid (TCA) cycle and electron transport chain (ETC) predispose to clinical BTZ resistance and poor prognosis in MM patients. Mechanistically, BTZ-resistant cells show increased activity of glutamine-driven TCA cycle and oxidative phosphorylation, together with an increased vulnerability towards ETC inhibition. Moreover, BTZ resistance is accompanied by high levels of the mitochondrial electron carrier CoQ, while the mevalonate pathway inhibitor simvastatin increases cell death and decreases CoQ levels, specifically in BTZ-resistant cells. Both in vitro and in vivo, simvastatin enhances the effect of bortezomib treatment. Our study links CoQ synthesis to drug resistance in MM and provides a novel avenue for improving BTZ responses through statin-induced inhibition of mitochondrial metabolism.
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Affiliation(s)
- Esther A Zaal
- Biomolecular Mass Spectrometry and Proteomics, Bijvoet Centre for Biomolecular Research and Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Division of Cell Biology, Metabolism & Cancer, Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
| | - Harm-Jan de Grooth
- Department of Intensive Care & Department of Anesthesiology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Inge Oudaert
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pieter Langerhorst
- Biomolecular Mass Spectrometry and Proteomics, Bijvoet Centre for Biomolecular Research and Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Sophie Levantovsky
- Division of Cell Biology, Metabolism & Cancer, Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
| | - Gijs J J van Slobbe
- Division of Cell Biology, Metabolism & Cancer, Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
| | - Jeroen W A Jansen
- Division of Cell Biology, Metabolism & Cancer, Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
| | - Eline Menu
- Department of Hematology and Immunology, Myeloma Center Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Wei Wu
- Biomolecular Mass Spectrometry and Proteomics, Bijvoet Centre for Biomolecular Research and Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Netherlands Proteomics Centre, Utrecht, The Netherlands
| | - Celia R Berkers
- Biomolecular Mass Spectrometry and Proteomics, Bijvoet Centre for Biomolecular Research and Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Division of Cell Biology, Metabolism & Cancer, Department Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands.
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26
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Rozemeijer S, de Grooth HJ, Elbers PWG, Girbes ARJ, den Uil CA, Dubois EA, Wils EJ, Rettig TCD, van Zanten ARH, Vink R, van den Bogaard B, Bosman RJ, Oudemans-van Straaten HM, de Man AME. Early high-dose vitamin C in post-cardiac arrest syndrome (VITaCCA): study protocol for a randomized, double-blind, multi-center, placebo-controlled trial. Trials 2021; 22:546. [PMID: 34407846 PMCID: PMC8371424 DOI: 10.1186/s13063-021-05483-3] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND High-dose intravenous vitamin C directly scavenges and decreases the production of harmful reactive oxygen species (ROS) generated during ischemia/reperfusion after a cardiac arrest. The aim of this study is to investigate whether short-term treatment with a supplementary or very high-dose intravenous vitamin C reduces organ failure in post-cardiac arrest patients. METHODS This is a double-blind, multi-center, randomized placebo-controlled trial conducted in 7 intensive care units (ICUs) in The Netherlands. A total of 270 patients with cardiac arrest and return of spontaneous circulation will be randomly assigned to three groups of 90 patients (1:1:1 ratio, stratified by site and age). Patients will intravenously receive a placebo, a supplementation dose of 3 g of vitamin C or a pharmacological dose of 10 g of vitamin C per day for 96 h. The primary endpoint is organ failure at 96 h as measured by the Resuscitation-Sequential Organ Failure Assessment (R-SOFA) score at 96 h minus the baseline score (delta R-SOFA). Secondary endpoints are a neurological outcome, mortality, length of ICU and hospital stay, myocardial injury, vasopressor support, lung injury score, ventilator-free days, renal function, ICU-acquired weakness, delirium, oxidative stress parameters, and plasma vitamin C concentrations. DISCUSSION Vitamin C supplementation is safe and preclinical studies have shown beneficial effects of high-dose IV vitamin C in cardiac arrest models. This is the first RCT to assess the clinical effect of intravenous vitamin C on organ dysfunction in critically ill patients after cardiac arrest. TRIAL REGISTRATION ClinicalTrials.gov NCT03509662. Registered on April 26, 2018. https://clinicaltrials.gov/ct2/show/NCT03509662 European Clinical Trials Database (EudraCT): 2017-004318-25. Registered on June 8, 2018. https://www.clinicaltrialsregister.eu/ctr-search/trial/2017-004318-25/NL.
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Affiliation(s)
- Sander Rozemeijer
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Paul W. G. Elbers
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Armand R. J. Girbes
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Corstiaan A. den Uil
- Department of Intensive Care Medicine, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands
| | - Eric A. Dubois
- Department of Cardiology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care Medicine, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care Medicine, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
| | - Thijs C. D. Rettig
- Department of Anesthesiology, Intensive Care and Pain Medicine, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Arthur R. H. van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, HELIX (Building 124), Stippeneng 4, 6708 WE Wageningen, The Netherlands
| | - Roel Vink
- Department of Intensive Care Medicine, Tergooi Hospital, Van Riebeeckweg 212, 1213 XZ Hilversum, The Netherlands
| | - Bas van den Bogaard
- Department of Intensive Care Medicine, OLVG, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Rob J. Bosman
- Department of Intensive Care Medicine, OLVG, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Heleen M. Oudemans-van Straaten
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Angélique M. E. de Man
- Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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27
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van den Bosch OFC, Alvarez-Jimenez R, de Grooth HJ, Girbes ARJ, Loer SA. Breathing variability-implications for anaesthesiology and intensive care. Crit Care 2021; 25:280. [PMID: 34353348 PMCID: PMC8339683 DOI: 10.1186/s13054-021-03716-0] [Citation(s) in RCA: 13] [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: 06/16/2021] [Accepted: 07/29/2021] [Indexed: 12/04/2022] Open
Abstract
The respiratory system reacts instantaneously to intrinsic and extrinsic inputs. This adaptability results in significant fluctuations in breathing parameters, such as respiratory rate, tidal volume, and inspiratory flow profiles. Breathing variability is influenced by several conditions, including sleep, various pulmonary diseases, hypoxia, and anxiety disorders. Recent studies have suggested that weaning failure during mechanical ventilation may be predicted by low respiratory variability. This review describes methods for quantifying breathing variability, summarises the conditions and comorbidities that affect breathing variability, and discusses the potential implications of breathing variability for anaesthesia and intensive care.
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Affiliation(s)
- Oscar F C van den Bosch
- Departments of Anesthesiology and Intensive Care, Amsterdam UMC, VUMC, ZH 6F 003, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Ricardo Alvarez-Jimenez
- Departments of Anesthesiology and Intensive Care, Amsterdam UMC, VUMC, ZH 6F 003, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Departments of Anesthesiology and Intensive Care, Amsterdam UMC, VUMC, ZH 6F 003, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Departments of Anesthesiology and Intensive Care, Amsterdam UMC, VUMC, ZH 6F 003, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Stephan A Loer
- Departments of Anesthesiology and Intensive Care, Amsterdam UMC, VUMC, ZH 6F 003, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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28
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van der Ven F, de Grooth HJ. Independent associations in observational studies: Biased beyond confounding. J Crit Care 2021; 65:124-125. [PMID: 34126366 DOI: 10.1016/j.jcrc.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Fleur van der Ven
- Department of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, location VUmc, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, Amsterdam, the Netherlands.
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29
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Heldeweg MLA, Lopez Matta JE, Haaksma ME, Smit JM, Elzo Kraemer CV, de Grooth HJ, de Jonge E, Meijboom LJ, Heunks LMA, van Westerloo DJ, Tuinman PR. Lung ultrasound and computed tomography to monitor COVID-19 pneumonia in critically ill patients: a two-center prospective cohort study. Intensive Care Med Exp 2021; 9:1. [PMID: 33491147 PMCID: PMC7829056 DOI: 10.1186/s40635-020-00367-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/21/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Lung ultrasound can adequately monitor disease severity in pneumonia and acute respiratory distress syndrome. We hypothesize lung ultrasound can adequately monitor COVID-19 pneumonia in critically ill patients. METHODS Adult patients with COVID-19 pneumonia admitted to the intensive care unit of two academic hospitals who underwent a 12-zone lung ultrasound and a chest CT examination were included. Baseline characteristics, and outcomes including composite endpoint death or ICU stay > 30 days were recorded. Lung ultrasound and CT images were quantified as a lung ultrasound score involvement index (LUSI) and CT severity involvement index (CTSI). Primary outcome was the correlation, agreement, and concordance between LUSI and CTSI. Secondary outcome was the association of LUSI and CTSI with the composite endpoints. RESULTS We included 55 ultrasound examinations in 34 patients, which were 88% were male, with a mean age of 63 years and mean P/F ratio of 151. The correlation between LUSI and CTSI was strong (r = 0.795), with an overall 15% bias, and limits of agreement ranging - 40 to 9.7. Concordance between changes in sequentially measured LUSI and CTSI was 81%. In the univariate model, high involvement on LUSI and CTSI were associated with a composite endpoint. In the multivariate model, LUSI was the only remaining independent predictor. CONCLUSIONS Lung ultrasound can be used as an alternative for chest CT in monitoring COVID-19 pneumonia in critically ill patients as it can quantify pulmonary involvement, register changes over the course of the disease, and predict death or ICU stay > 30 days. TRIAL REGISTRATION NTR, NL8584. Registered 01 May 2020-retrospectively registered, https://www.trialregister.nl/trial/8584.
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Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands.
- VU University Medical Center Amsterdam, Postbox 7507, 1007 MB, Amsterdam, The Netherlands.
| | - Jorge E Lopez Matta
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Evert de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
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30
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Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Department of Anesthesiology, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, Amsterdam, The Netherlands.
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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31
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Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Paul W G Elbers
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
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32
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Girbes ARJ, de Grooth HJ. Time to stop randomized and large pragmatic trials for intensive care medicine syndromes: the case of sepsis and acute respiratory distress syndrome. J Thorac Dis 2020; 12:S101-S109. [PMID: 32148932 DOI: 10.21037/jtd.2019.10.36] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In this paper we discuss the limitations of large randomized controlled trials with mortality endpoints in patients with critical illness associated diagnoses such as sepsis. When patients with the same syndrome diagnosis do not share the pathways that lead to death (the attributable risk), any therapy can only lead to small effects in these populations. Using Monte Carlo simulations, we show how the syndrome-attributable risks of critical illness-associated diagnoses are likely overestimated using common statistical methods. This overestimation of syndrome-attributable risks leads to a corresponding overestimation of attainable treatment effects and an underestimation of required sample sizes. We demonstrate that larger and more 'pragmatic' randomized trials are not the solution because they decrease therapeutic and diagnostic precision, the therapeutic effect size and the probability of finding a beneficial effect. Finally, we argue that the most logical solution is a renewed focus on mechanistic research into the complexities of critical illness syndromes.
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Affiliation(s)
- Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
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33
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Zwager CL, Tuinman PR, de Grooth HJ, Kooter J, Ket H, Fleuren LM, Elbers PWG. Why physiology will continue to guide the choice between balanced crystalloids and normal saline: a systematic review and meta-analysis. Crit Care 2019; 23:366. [PMID: 31752973 PMCID: PMC6868741 DOI: 10.1186/s13054-019-2658-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Crystalloids are the most frequently prescribed drugs in intensive care medicine and emergency medicine. Thus, even small differences in outcome may have major implications, and therefore, the choice between balanced crystalloids versus normal saline continues to be debated. We examined to what extent the currently accrued information size from completed and ongoing trials on the subject allow intensivists and emergency physicians to choose the right fluid for their patients. METHODS Systematic review and meta-analysis with random effects inverse variance model. Published randomized controlled trials enrolling adult patients to compare balanced crystalloids versus normal saline in the setting of intensive care medicine or emergency medicine were included. The main outcome was mortality at the longest follow-up, and secondary outcomes were moderate to severe acute kidney injury (AKI) and initiation of renal replacement therapy (RRT). Trial sequential analyses (TSA) were performed, and risk of bias and overall quality of evidence were assessed. Additionally, previously published meta-analyses, trial sequential analyses and ongoing large trials were analysed for included studies, required information size calculations and the assumptions underlying those calculations. RESULTS Nine studies (n = 32,777) were included. Of those, eight had data available on mortality, seven on AKI and six on RRT. Meta-analysis showed no significant differences between balanced crystalloids versus normal saline for mortality (P = 0.33), the incidence of moderate to severe AKI (P = 0.37) or initiation of RRT (P = 0.29). Quality of evidence was low to very low. Analysis of previous meta-analyses and ongoing trials showed large differences in calculated required versus accrued information sizes and assumptions underlying those. TSA revealed the need for extremely large trials based on our realistic and clinically relevant assumptions on relative risk reduction and baseline mortality. CONCLUSIONS Our meta-analysis could not find significant differences between balanced crystalloids and normal saline on mortality at the longest follow-up, moderate to severe AKI or new RRT. Currently accrued information size is smaller, and the required information size is larger than previously anticipated. Therefore, completed and ongoing trials on the topic may fail to provide adequate guidance for choosing the right crystalloid. Thus, physiology will continue to play an important role for individualizing this choice.
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Affiliation(s)
- Charlotte L Zwager
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jos Kooter
- Department of Internal Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Hans Ket
- University Library, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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34
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Girbes ARJ, de Grooth HJ, Zijlstra JG, Hein L. Invalid methods lead to inappropriate conclusions. Int J Qual Health Care 2019; 31:72. [PMID: 30124854 DOI: 10.1093/intqhc/mzy165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Lars Hein
- Department of Anesthesiology and Intensive Care, Hillerød Hospital, Aarhus University, Aarhus, Denmark
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35
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Rozemeijer S, Spoelstra-de Man AME, Coenen S, Smit B, Elbers PWG, de Grooth HJ, Girbes ARJ, Oudemans-van Straaten HM. Estimating Vitamin C Status in Critically Ill Patients with a Novel Point-of-Care Oxidation-Reduction Potential Measurement. Nutrients 2019; 11:nu11051031. [PMID: 31071996 PMCID: PMC6566553 DOI: 10.3390/nu11051031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/22/2022] Open
Abstract
Vitamin C deficiency is common in critically ill patients. Vitamin C, the most important antioxidant, is likely consumed during oxidative stress and deficiency is associated with organ dysfunction and mortality. Assessment of vitamin C status may be important to identify patients who might benefit from vitamin C administration. Up to now, vitamin C concentrations are not available in daily clinical practice. Recently, a point-of-care device has been developed that measures the static oxidation-reduction potential (sORP), reflecting oxidative stress, and antioxidant capacity (AOC). The aim of this study was to determine whether plasma vitamin C concentrations were associated with plasma sORP and AOC. Plasma vitamin C concentration, sORP and AOC were measured in three groups: healthy volunteers, critically ill patients, and critically ill patients receiving 2- or 10-g vitamin C infusion. Its association was analyzed using regression models and by assessment of concordance. We measured 211 samples obtained from 103 subjects. Vitamin C concentrations were negatively associated with sORP (R2 = 0.816) and positively associated with AOC (R2 = 0.842). A high concordance of 94–100% was found between vitamin C concentration and sORP/AOC. Thus, plasma vitamin C concentrations are strongly associated with plasma sORP and AOC, as measured with a novel point-of-care device. Therefore, measuring sORP and AOC at the bedside has the potential to identify and monitor patients with oxidative stress and vitamin C deficiency.
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Affiliation(s)
- Sander Rozemeijer
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Angélique M E Spoelstra-de Man
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Sophie Coenen
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Bob Smit
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
| | - Heleen M Oudemans-van Straaten
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
- Research VUmc Intensive Care (REVIVE), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Science (ACS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Medical Data Science (AMDS), 1081 HV Amsterdam, The Netherlands.
- Amsterdam Infection and Immunity Institute (AI&II), 1081 HV Amsterdam, The Netherlands.
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Spoelstra-de Man AME, de Grooth HJ, Elbers PWG, Oudemans-van Straaten HM. Response to "Adjuvant vitamin C in cardiac arrest patients undergoing renal replacement therapy: an appeal for a higher high-dose". Crit Care 2018; 22:350. [PMID: 30567557 PMCID: PMC6299916 DOI: 10.1186/s13054-018-2200-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 09/24/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Angelique M E Spoelstra-de Man
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Heleen M Oudemans-van Straaten
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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de Grooth HJ, Parienti JJ, Postema J, Loer SA, Oudemans-van Straaten HM, Girbes AR. Positive outcomes, mortality rates, and publication bias in septic shock trials. Intensive Care Med 2018; 44:1584-1585. [PMID: 29922845 DOI: 10.1007/s00134-018-5258-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 05/30/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Harm-Jan de Grooth
- Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands.
| | - Jean-Jacques Parienti
- Unité de Biostatistique et de Recherche Clinique, Centre Hospitalier Universitaire de Caen, Caen, France.,EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Université Caen Normandie, Caen, France
| | - Jonne Postema
- Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | | | - Armand R Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
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de Grooth HJ, Postema J, Loer SA, Parienti JJ, Oudemans-van Straaten HM, Girbes AR. Unexplained mortality differences between septic shock trials: a systematic analysis of population characteristics and control-group mortality rates. Intensive Care Med 2018; 44:311-322. [PMID: 29546535 PMCID: PMC5861172 DOI: 10.1007/s00134-018-5134-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/17/2018] [Indexed: 12/21/2022]
Abstract
Purpose Although the definition of septic shock has been standardized, some variation in mortality rates among clinical trials is expected. Insights into the sources of heterogeneity may influence the design and interpretation of septic shock studies. We set out to identify inclusion criteria and baseline characteristics associated with between-trial differences in control group mortality rates. Methods We conducted a systematic review of RCTs published between 2006 and 2018 that included patients with septic shock. The percentage of variance in control-group mortality attributable to study heterogeneity rather than chance was measured by I2. The association between control-group mortality and population characteristics was estimated using linear mixed models and a recursive partitioning algorithm. Results Sixty-five septic shock RCTs were included. Overall control-group mortality was 38.6%, with significant heterogeneity (I2 = 93%, P < 0.0001) and a 95% prediction interval of 13.5–71.7%. The mean mortality rate did not differ between trials with different definitions of hypotension, infection or vasopressor or mechanical ventilation inclusion criteria. Population characteristics univariately associated with mortality rates were mean Sequential Organ Failure Assessment score (standardized regression coefficient (β) = 0.57, P = 0.007), mean serum creatinine (β = 0.48, P = 0.007), the proportion of patients on mechanical ventilation (β = 0.61, P < 0.001), and the proportion with vasopressors (β = 0.57, P = 0.002). Combinations of population characteristics selected with a linear model and recursive partitioning explained 41 and 42%, respectively, of the heterogeneity in mortality rates. Conclusions Among 65 septic shock trials, there was a clinically relevant amount of heterogeneity in control group mortality rates which was explained only partly by differences in inclusion criteria and reported baseline characteristics. Electronic supplementary material The online version of this article (10.1007/s00134-018-5134-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Jonne Postema
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Stephan A Loer
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Jean-Jacques Parienti
- Unité de Biostatistique et de Recherche Clinique, Centre Hospitalier Universitaire de Caen, Caen, France
- EA2656 Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Université Caen Normandie, Caen, France
| | | | - Armand R Girbes
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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de Grooth HJ, Manubulu-Choo WP, Zandvliet AS, Spoelstra-de Man AME, Girbes AR, Swart EL, Oudemans-van Straaten HM. Vitamin C Pharmacokinetics in Critically Ill Patients: A Randomized Trial of Four IV Regimens. Chest 2018. [PMID: 29522710 DOI: 10.1016/j.chest.2018.02.025] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [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] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Early high-dose IV vitamin C is being investigated as adjuvant therapy in patients who are critically ill, but the optimal dose and infusion method are unclear. The primary aim of this study was to describe the dose-plasma concentration relationship and safety of four different dosing regimens. METHODS This was a four-group randomized pharmacokinetic trial. Patients who were critically ill with multiple organ dysfunction were randomized to receive 2 or 10 g/d vitamin C as a twice daily bolus infusion or continuous infusion for 48 h. End points were plasma vitamin C concentrations during 96 h, 12-h urine excretion of vitamin C, and oxalate excretion and base excess. A population pharmacokinetic model was developed using NONMEM. RESULTS Twenty patients were included. A two-compartment pharmacokinetic model with creatinine clearance and weight as independent covariates described all four regimens best. With 2 g/d bolus, plasma vitamin C concentrations at 1 h were 29 to 50 mg/L and trough concentrations were 5.6 to 16 mg/L. With 2 g/d continuous, steady-state concentrations were 7 to 37 mg/L at 48 h. With 10 g/d bolus, 1-h concentrations were 186 to 244 mg/L and trough concentrations were 14 to 55 mg/L. With 10 g/d continuous, steady-state concentrations were 40 to 295 mg/L at 48 h. Oxalate excretion and base excess were increased in the 10 g/d dose. Forty-eight hours after discontinuation, plasma concentrations declined to hypovitaminosis levels in 15% of patients. CONCLUSIONS The 2 g/d dose was associated with normal plasma concentrations, and the 10 g/d dose was associated with supranormal plasma concentrations, increased oxalate excretion, and metabolic alkalosis. Sustained therapy is needed to prevent hypovitaminosis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02455180; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands; Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Wai-Ping Manubulu-Choo
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands; Department of Pharmacy, Westfriesgasthuis, Hoorn, The Netherlands
| | - Anthe S Zandvliet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Armand R Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Eleonora L Swart
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Amsterdam, The Netherlands
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de Grooth HJ, Geenen IL, Girbes AR, Vincent JL, Parienti JJ, Oudemans-van Straaten HM. SOFA and mortality endpoints in randomized controlled trials: a systematic review and meta-regression analysis. Crit Care 2017; 21:38. [PMID: 28231816 PMCID: PMC5324238 DOI: 10.1186/s13054-017-1609-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [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: 08/25/2016] [Accepted: 01/17/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The sequential organ failure assessment score (SOFA) is increasingly used as an endpoint in intensive care randomized controlled trials (RCTs). Although serially measured SOFA is independently associated with mortality in observational cohorts, the association between treatment effects on SOFA vs. effects on mortality has not yet been quantified in RCTs. The aim of this study was to quantify the relationship between SOFA and mortality in RCTs and to identify which SOFA derivative best reflects between-group mortality differences. METHODS The review protocol was prospectively registered (Prospero CRD42016034014). We performed a literature search (up to May 1, 2016) for RCTs reporting both SOFA and mortality, and analyzed between-group differences in these outcomes. Treatment effects on SOFA and mortality were calculated as the between-group SOFA standardized difference and log odds ratio (OR), respectively. We used random-effects meta-regression to (1) quantify the linear relationship between RCT treatment effects on mortality (logOR) and SOFA (i.e. responsiveness) and (2) quantify residual heterogeneity (i.e. consistency, expressed as I 2). RESULTS Of 110 eligible RCTs, 87 qualified for analysis. Using all RCTs, SOFA was significantly associated with mortality (slope = 0.49 (95% CI 0.17; 0.82), p = 0.006, I 2 = 5%); the overall mortality effect explained by SOFA score (R 2) was 9%. Fifty-eight RCTs used Fixed-day SOFA as an endpoint (i.e. the score on a fixed day after randomization), 25 studies used Delta SOFA as an endpoint (i.e. the trajectory from baseline score) and 15 studies used other SOFA derivatives as an endpoint. Fixed-day SOFA was not significantly associated with mortality (slope = 0.35 (95% CI -0.04; 0.75), p = 0.08, I 2 = 12%) and explained 3% of the overall mortality effect (R 2). Delta SOFA was significantly associated with mortality (slope = 0.70 (95% CI 0.26; 1.14), p = 0.004, I 2 = 0%) and explained 32% of the overall mortality effect (R 2). CONCLUSIONS Treatment effects on Delta SOFA appear to be reliably and consistently associated with mortality in RCTs. Fixed-day SOFA was the most frequently reported outcome among the reviewed RCTs, but was not significantly associated with mortality. Based on this study, we recommend using Delta SOFA rather than Fixed-day SOFA as an endpoint in future RCTs.
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Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Irma L Geenen
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Armand R Girbes
- Department of Intensive Care, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Parienti
- Unité de Biostatistique et de Recherche Clinique, Centre Hospitalier Universitaire de Caen, Caen, France.,EA4655 « Risques microbiens », Faculté de Médecine, Université de Caen Normandie, Caen, France
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Panka BA, de Grooth HJ, Spoelstra-de Man AME, Looney MR, Tuinman PR. Prevention or Treatment of Ards With Aspirin: A Review of Preclinical Models and Meta-Analysis of Clinical Studies. Shock 2017; 47:13-21. [PMID: 27984533 PMCID: PMC5175412 DOI: 10.1097/shk.0000000000000745] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) is a life-threating disorder that contributes significantly to critical illness. No specific pharmacological interventions directed at lung injury itself have proven effective in improving outcome of patients with ARDS. Platelet activation was identified as a key component in ARDS pathophysiology and may provide an opportunity for preventive and therapeutic strategies. We hypothesize that use of acetyl salicylic acid (ASA) may prevent and/or attenuate lung injury. METHODS We conducted a systematic review of preclinical studies and meta-analysis of clinical studies investigating the efficacy of ASA in the setting of lung injury. Medline, embase, and cochrane databases were searched. RESULTS The literature search yielded 1,314 unique articles. Fifteen preclinical studies and eight clinical studies fulfilled the in- and exclusion criteria. In the animal studies, the overall effect of ASA was positive, e.g., ASA improved survival and attenuated inflammation and pulmonary edema. Mechanisms of actions involved, among others, are interference with the neutrophil-platelets interaction, reduction of leukotrienes, neutrophil extracellular traps, and prostaglandins. High-dose ASA may be the drug of choice. A meta-analysis of three clinical studies showed an association between ASA use and a reduced incidence of ARDS (OR 0.59, 95% CI 0.36-0.98), albeit with substantial between-study heterogeneity. All studies had their own shortcomings in methodological quality. CONCLUSION This systematic review of preclinical studies and meta-analysis of clinical studies suggests a beneficial role for ASA in ARDS prevention and treatment. However, the currently available data is insufficient to justify an indication for ASA in ARDS. The body of literature does support further studies in humans. We suggest clinical trials in which the mechanisms of action of ASA in lung injury models are being evaluated to guide optimal timing and dose, before prospective randomized trials.
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Affiliation(s)
- Bernardo Amisa Panka
- *Department of Intensive Care Medicine, VU University Medical Centre, Amsterdam, The Netherlands †Department of Intensive Care Medicine, s' Lands Hospitaal Paramaribo, Paramaribo, Suriname ‡Research VUmc Intensive Care (REVIVE) and Institute for Cardiovascular Research (ICAR-VU), Amsterdam, The Netherlands §Department of Medicine, University of California, San Francisco; San Francisco, California
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