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Dujardin RWG, Kleinveld DJB, van den Brom CE, Geeraedts LMG, Beijer E, Gaarder C, Brohi K, Stanworth S, Johansson PI, Stensballe J, Maegele M, Juffermans NP. Older females have increased mortality after trauma as compared with younger females and males, associated with increased fibrinolysis. J Trauma Acute Care Surg 2024; 96:831-837. [PMID: 38079234 DOI: 10.1097/ta.0000000000004235] [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: 04/25/2024]
Abstract
INTRODUCTION Female sex may provide a survival benefit after trauma, possibly attributable to protective effects of estrogen. This study aimed to compare markers of coagulation between male and female trauma patients across different ages. METHODS Secondary analysis of a prospective cohort study that was conducted at six trauma centers. Trauma patients presenting with full trauma team activation were eligible for inclusion. Patients with a penetrating trauma or traumatic brain injury were excluded. Upon hospital arrival, blood was drawn for measurement of endothelial and coagulation markers and for rotational thromboelastometry measurement. Trauma patients were divided into four categories: males younger than 45 years, males 45 years or older, females younger than 45 years, and females 45 years or older. In a sensitivity analysis, patients between 45 and 55 years old were excluded to control for menopausal transitioning. Groups were compared with a Kruskal-Wallis test with Bonferroni correction. A logistic regression was performed to assess whether the independent effect of sex and age on mortality. RESULTS A total of 1,345 patients were available for analysis. Compared with the other groups, mortality was highest in females 45 years or older, albeit not independent from injury severity and shock. In the group of females 45 years or older, there was increased fibrinolysis, demonstrated by increased levels of plasmin-antiplasmin complexes with a concomitant decrease in α2-antiplasmin. Also, a modest decrease in coagulation factors II and X was observed. Fibrinogen levels were comparable between groups. The sensitivity analysis in 1,104 patients demonstrated an independent relationship between female sex, age 55 years or older, and mortality. Rotational thromboelastometry profiles did not reflect the changes in coagulation tests. CONCLUSION Female trauma patients past their reproductive age have an increased risk of mortality compared with younger females and males, associated with augmented fibrinolysis and clotting factor consumption. Rotational thromboelastometry parameters did not reflect coagulation differences between groups. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Romein W G Dujardin
- From the Laboratory of Experimental Intensive Care and Anesthesiology (R.W.G.D., D.J.B.K., C.E.v.d.B., E.B., N.P.J.), and Department of Intensive Care (R.W.G.D., C.E.v.d.B.), Amsterdam UMC, University of Amsterdam; OLVG Hospital, Department of Intensive Care Medicine (R.W.G.D., N.P.J.), Amsterdam; Erasmus MC, Department of Anesthesiology (D.J.B.K.), Rotterdam; Department of Anesthesiology (C.E.v.d.B., E.B.), Amsterdam UMC, Vrije Universiteit Amsterdam; Department of Surgery (L.M.G.G., E.B.), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Traumatology (C.G.), Oslo University Hospital, Oslo, Norway; Trauma Sciences (K.B.), Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom; NHS Blood and Transplant/Oxford University Hospital NHS Trust (S.S.), John Radcliffe Hospital, Oxford, United Kingdom; Radcliffe Department of Medicine (S.S.), University of Oxford, United Kingdom; Department of Anesthesiology and Trauma Center (P.I.J., J.S.), Center for Head and Orthopedics, and Section for Transfusion Medicine (P.I.J., J.S.), Capital Region Blood Bank, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; and Department of Traumatology and Orthopedic Surgery (M.M.), Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
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Slim MA, Lim EHT, van Vught LA, Boer AMTD, Rademaker E, Mulier JLGH, Engel JJ, Pickkers P, van de Veerdonk FL, Vlaar APJ, Derde LPG, Juffermans NP. The effect of immunosuppressive therapies on the endothelial host response in critically ill COVID-19 patients. Sci Rep 2024; 14:9113. [PMID: 38643179 PMCID: PMC11032323 DOI: 10.1038/s41598-024-59385-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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/10/2024] [Indexed: 04/22/2024] Open
Abstract
While several effective therapies for critically ill patients with COVID-19 have been identified in large, well-conducted trials, the mechanisms underlying these therapies have not been investigated in depth. Our aim is to investigate the association between various immunosuppressive therapies (corticosteroids, tocilizumab and anakinra) and the change in endothelial host response over time in critically ill COVID-19 patients. We conducted a pre-specified multicenter post-hoc analysis in a Dutch cohort of COVID-19 patients admitted to the ICU between March 2020 and September 2021 due to hypoxemic respiratory failure. A panel of 18 immune response biomarkers in the complement, coagulation and endothelial function domains were measured using ELISA or Luminex. Biomarkers were measured on day 0-1, day 2-4 and day 6-8 after start of COVID-19 treatment. Patients were categorized into four treatment groups: no immunomodulatory treatment, corticosteroids, anakinra plus corticosteroids, or tocilizumab plus corticosteroids. The association between treatment group and the change in concentrations of biomarkers was estimated with linear mixed-effects models, using no immunomodulatory treatment as reference group. 109 patients with a median age of 62 years [IQR 54-70] of whom 72% (n = 78) was male, were included in this analysis. Both anakinra plus corticosteroids (n = 22) and tocilizumab plus corticosteroids (n = 38) were associated with an increase in angiopoietin-1 compared to no immune modulator (n = 23) (beta of 0.033 [0.002-0.064] and 0.041 [0.013-0.070] per day, respectively). These treatments, as well as corticosteroids alone (n = 26), were further associated with a decrease in the ratio of angiopoietin-2/angiopoietin-1 (beta of 0.071 [0.034-0.107], 0.060 [0.030-0.091] and 0.043 [0.001-0.085] per day, respectively). Anakinra plus corticosteroids and tocilizumab plus corticosteroids were associated with a decrease in concentrations of complement complex 5b-9 compared to no immunomodulatory treatment (0.038 [0.006-0.071] and 0.023 [0.000-0.047], respectively). Currently established treatments for critically ill COVID-19 patients are associated with a change in biomarkers of the angiopoietin and complement pathways, possibly indicating a role for stability of the endothelium. These results increase the understanding of the mechanisms of interventions and are possibly useful for stratification of patients with other inflammatory conditions which may potentially benefit from these treatments.
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Affiliation(s)
- M A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Intensive Care, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, the Netherlands.
| | - E H T Lim
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers - Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - A M Tuip-de Boer
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers - Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - E Rademaker
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J L G Haitsma Mulier
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J J Engel
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers - Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L P G Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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Hilderink BN, Crane RF, van den Bogaard B, Pillay J, Juffermans NP. Hyperoxemia and hypoxemia impair cellular oxygenation: a study in healthy volunteers. Intensive Care Med Exp 2024; 12:37. [PMID: 38619625 PMCID: PMC11018572 DOI: 10.1186/s40635-024-00619-6] [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: 09/06/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Administration of oxygen therapy is common, yet there is a lack of knowledge on its ability to prevent cellular hypoxia as well as on its potential toxicity. Consequently, the optimal oxygenation targets in clinical practice remain unresolved. The novel PpIX technique measures the mitochondrial oxygen tension in the skin (mitoPO2) which allows for non-invasive investigation on the effect of hypoxemia and hyperoxemia on cellular oxygen availability. RESULTS During hypoxemia, SpO2 was 80 (77-83)% and PaO2 45(38-50) mmHg for 15 min. MitoPO2 decreased from 42(35-51) at baseline to 6(4.3-9)mmHg (p < 0.001), despite 16(12-16)% increase in cardiac output which maintained global oxygen delivery (DO2). During hyperoxic breathing, an FiO2 of 40% decreased mitoPO2 to 20 (9-27) mmHg. Cardiac output was unaltered during hyperoxia, but perfused De Backer density was reduced by one-third (p < 0.01). A PaO2 < 100 mmHg and > 200 mmHg were both associated with a reduction in mitoPO2. CONCLUSIONS Hypoxemia decreases mitoPO2 profoundly, despite complete compensation of global oxygen delivery. In addition, hyperoxemia also decreases mitoPO2, accompanied by a reduction in microcirculatory perfusion. These results suggest that mitoPO2 can be used to titrate oxygen support.
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Affiliation(s)
- Bashar N Hilderink
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands.
| | - Reinier F Crane
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Janesh Pillay
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Bolscher M, Koster SCE, Koopmans M, Haitsma Mulier JLG, Derde LPG, Juffermans NP. Anti-inflammatory therapies are associated with delayed onset of anemia and reduction in transfusion requirements in critically ill patients: results from two studies. Crit Care 2024; 28:114. [PMID: 38594746 PMCID: PMC11003051 DOI: 10.1186/s13054-024-04898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Anemia is a hallmark of critical illness, which is largely inflammatory driven. We hypothesized that the use of anti-inflammatory agents limits the development of anemia and reduces the need for red blood cell (RBC) transfusions in patients with a hyper-inflammatory condition due to COVID-19. METHODS An observational cohort (n = 772) and a validation cohort (a subset of REMAP-CAP, n = 119) of critically ill patients with hypoxemic respiratory failure due to COVID-19 were analyzed, who either received no treatment, received steroids or received steroids plus IL-6 blocking agents. The trajectory of hemoglobin (Hb) decline and the need for RBC transfusions were compared using descriptive statistics as well as multivariate modeling. RESULTS In both cohorts, Hb level was higher in the treated groups compared to the untreated group at all time points. In the observational cohort, incidence and number of transfused patients were lower in the group receiving the combination treatment compared to the untreated groups. In a multivariate analysis controlling for baseline Hb imbalance and mechanical ventilation, receipt of steroids remained associated with a slower decline in Hb level and the combination treatment remained associated with a slower decline of Hb and with less transfusions. Results remained the same in the validation cohort. CONCLUSION Immunomodulatory treatment was associated with a slower decline in Hb level in critically ill patients with COVID-19 and with less transfusion. Findings point toward inflammation as an important cause for the occurrence of anemia in the critically ill.
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Affiliation(s)
- Madelief Bolscher
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, Amsterdam, The Netherlands
| | | | - Matty Koopmans
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, Amsterdam, The Netherlands
| | | | - Lennie P G Derde
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Molewaterplein 40, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Molewaterplein 40, Rotterdam, The Netherlands.
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Correction: Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:490. [PMID: 38285053 DOI: 10.1007/s00134-024-07323-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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Juffermans NP, Gözden T, Brohi K, Davenport R, Acker JP, Reade MC, Maegele M, Neal MD, Spinella PC. Transforming research to improve therapies for trauma in the twenty-first century. Crit Care 2024; 28:45. [PMID: 38350971 PMCID: PMC10865682 DOI: 10.1186/s13054-024-04805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Improvements have been made in optimizing initial care of trauma patients, both in prehospital systems as well as in the emergency department, and these have also favorably affected longer term outcomes. However, as specific treatments for bleeding are largely lacking, many patients continue to die from hemorrhage. Also, major knowledge gaps remain on the impact of tissue injury on the host immune and coagulation response, which hampers the development of interventions to treat or prevent organ failure, thrombosis, infections or other complications of trauma. Thereby, trauma remains a challenge for intensivists. This review describes the most pressing research questions in trauma, as well as new approaches to trauma research, with the aim to bring improved therapies to the bedside within the twenty-first century.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Tarik Gözden
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jason P Acker
- Canadian Blood Services, Innovation and Portfolio Management, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Michael C Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery Cologne-Merheim Medical Center Institute of Research, Operative Medicine University Witten-Herdecke, Cologne, Germany
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Rozemeijer S, Hamer HM, Heijboer AC, de Jonge R, Jimenez CR, Juffermans NP, Dujardin RWG, Girbes ARJ, de Man AME. Micronutrient Status of Critically Ill Patients with COVID-19 Pneumonia. Nutrients 2024; 16:385. [PMID: 38337670 PMCID: PMC10856879 DOI: 10.3390/nu16030385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Micronutrient deficiencies can develop in critically ill patients, arising from factors such as decreased intake, increased losses, drug interactions, and hypermetabolism. These deficiencies may compromise important immune functions, with potential implications for patient outcomes. Alternatively, micronutrient blood levels may become low due to inflammation-driven redistribution rather than consumption. This explorative pilot study investigates blood micronutrient concentrations during the first three weeks of ICU stay in critically ill COVID-19 patients and evaluates the impact of additional micronutrient administration. Moreover, associations between inflammation, disease severity, and micronutrient status were explored. We measured weekly concentrations of vitamins A, B6, D, and E; iron; zinc; copper; selenium; and CRP as a marker of inflammation state and the SOFA score indicating disease severity in 20 critically ill COVID-19 patients during three weeks of ICU stay. Half of the patients received additional (intravenous) micronutrient administration. Data were analyzed with linear mixed models and Pearson's correlation coefficient. High deficiency rates of vitamins A, B6, and D; zinc; and selenium (50-100%) were found at ICU admission, along with low iron status. After three weeks, vitamins B6 and D deficiencies persisted, and iron status remained low. Plasma levels of vitamins A and E, zinc, and selenium improved. No significant differences in micronutrient levels were found between patient groups. Negative correlations were identified between the CRP level and levels of vitamins A and E, iron, transferrin, zinc, and selenium. SOFA scores negatively correlated with vitamin D and selenium levels. Our findings reveal high micronutrient deficiency rates at ICU admission. Additional micronutrient administration did not enhance levels or expedite their increase. Spontaneous increases in vitamins A and E, zinc, and selenium levels were associated with inflammation resolution, suggesting that observed low levels may be attributed, at least in part, to redistribution rather than true deficiencies.
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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; (A.R.J.G.); (A.M.E.d.M.)
- Department of Anesthesiology, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Henrike M. Hamer
- Department of Laboratory Medicine, Laboratory Specialized Techniques and Research, Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands;
| | - Annemieke C. Heijboer
- Department of Laboratory Medicine, Endocrine Laboratory, Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands;
| | - Robert de Jonge
- Department of Laboratory Medicine, Amsterdam Gastroenterology Endocrinology and Metabolism, 1105 AZ Amsterdam, The Netherlands;
| | - Connie R. Jimenez
- OncoProteomics Laboratory, Department Laboratory Medical Oncology, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands;
| | - Nicole P. Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Romein W. G. Dujardin
- Department of Anesthesiology, 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; (A.R.J.G.); (A.M.E.d.M.)
| | - 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; (A.R.J.G.); (A.M.E.d.M.)
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Alshalani A, de Wissel MB, Tuip-de Boer AM, Roelofs JJTH, van Bruggen R, Acker JP, Juffermans NP. Transfusion of female blood in a rat model is associated with red blood cells entrapment in organs. PLoS One 2023; 18:e0288308. [PMID: 37992035 PMCID: PMC10664878 DOI: 10.1371/journal.pone.0288308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/25/2023] [Indexed: 11/24/2023] Open
Abstract
Transfusion of red blood cells (RBCs) has been associated with adverse outcomes. Mechanisms may be related to donor sex and biological age of RBC. This study hypothesized that receipt of female blood is associated with decreased post-transfusion recovery (PTR) and a concomitant increased organ entrapment in rats, related to young age of donor RBCs. Donor rats underwent bloodletting to stimulate production of new, young RBCs, followed by Percoll fractionation for further enrichment of young RBCs based on their low density. Control donors did not undergo these procedures. Male rats received either a (biotinylated) standard RBC product or a product enriched for young RBCs, derived from either male or female donors. Controls received saline. Organs and blood samples were harvested after 24 hours. This study found no difference in PTR between groups, although only the group receiving young RBCs from females failed to reach a PTR of 75%. Receipt of both standard RBCs and young RBCs from females was associated with increased entrapment of donor RBCs in the lung, liver, and spleen compared to receiving blood from male donors. Soluble ICAM-1 and markers of hemolysis were higher in recipients of female blood compared to control. In conclusion, transfusing RBCs from female donors, but not from male donors, is associated with trapping of donor RBCs in organs, accompanied by endothelial activation and hemolysis.
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Affiliation(s)
- Abdulrahman Alshalani
- Chair of Medical and Molecular Genetics Research, Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marit B. de Wissel
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita M. Tuip-de Boer
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris J. T. H. Roelofs
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jason P. Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Innovation and Portfolio Management, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
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10
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Bulle EB, Blanken B, Klanderman RB, van Manen L, Juffermans NP, Vlaar APJ. Exploring NT-proBNP, syndecan-1, and cytokines as biomarkers for transfusion-associated circulatory overload in a critically ill patient population receiving a single-unit red blood cell transfusion. Transfusion 2023; 63:2052-2060. [PMID: 37797228 DOI: 10.1111/trf.17561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Transfusion-associated circulatory overload (TACO) is an often underdiagnosed pulmonary transfusion complication. A biomarker could aid with the diagnosis. To date, B-type natriuretic peptide (BNP) and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) seem the most promising biomarkers in the general hospital population. The aim was to evaluate NT-proBNP as a biomarker for TACO in a critically ill patient population and explore syndecan-1 and cytokines as other potential biomarkers. STUDY DESIGN AND METHODS A retrospective study was performed using samples and clinical data collected during a prospective observational study. Adult patients admitted to the intensive care and transfused with a single red blood cell unit were included. TACO cases were retrospectively identified using a case definition based on the current TACO definition. The primary biomarker was NT-proBNP, also we measured syndecan-1 IL-6, IL-8, and IL-10. All markers were measured directly before transfusion, 1 and 24 h after transfusion. RESULTS Our cohort included 64 patients, 12 of which were identified as TACO patients. TACO patients had a lower PaO2 /FiO2 ratio and were more often ventilated following transfusion compared to non-TACO patients. There was no significant difference in NT-proBNP between pre- and post-transfusion levels nor between TACO and non-TACO patients. Syndecan-1 was significantly elevated in TACO patients both pre- and post-transfusion compared to non-TACO patients. DISCUSSION NT-proBNP was not associated with TACO in this critically ill patient population. Interestingly, levels of syndecan-1 were increased in TACO patients at baseline. More research is needed to clarify this association and its possibilities as a biomarker to predict patients at risk for TACO.
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Affiliation(s)
- Esther B Bulle
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Britt Blanken
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert B Klanderman
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lisa van Manen
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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11
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van den Brink DP, Kleinveld DJB, Bongers A, Vos J, Roelofs JTH, Weber NC, van Buul JD, Juffermans NP. The Effects of Heparan Sulfate Infusion on Endothelial and Organ Injury in a Rat Pneumosepsis Model. J Clin Med 2023; 12:6438. [PMID: 37892576 PMCID: PMC10607557 DOI: 10.3390/jcm12206438] [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: 05/04/2023] [Revised: 09/15/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
Septic shock is characterized by endothelial dysfunction, leading to tissue edema and organ failure. Heparan sulfate (HS) is essential for vascular barrier integrity, possibly via albumin as a carrier. We hypothesized that supplementing fluid resuscitation with HS would improve endothelial barrier function, thereby reducing organ edema and injury in a rat pneumosepsis model. Following intratracheal inoculation with Streptococcus pneumoniae, Sprague Dawley rats were randomized to resuscitation with a fixed volume of either Ringer's Lactate (RL, standard of care), RL supplemented with 7 mg/kg HS, 5% human albumin, or 5% human albumin supplemented with 7 mg/kg HS (n = 11 per group). Controls were sham inoculated animals. Five hours after the start of resuscitation, animals were sacrificed. To assess endothelial permeability, 70 kD FITC-labelled dextran was administered before sacrifice. Blood samples were taken to assess markers of endothelial and organ injury. Organs were harvested to quantify pulmonary FITC-dextran leakage, organ edema, and for histology. Inoculation resulted in sepsis, with increased lactate levels, pulmonary FITC-dextran leakage, pulmonary edema, and pulmonary histologic injury scores compared to healthy controls. RL supplemented with HS did not reduce median pulmonary FITC-dextran leakage compared to RL alone (95.1 CI [62.0-105.3] vs. 87.1 CI [68.9-139.3] µg/mL, p = 0.76). Similarly, albumin supplemented with HS did not reduce pulmonary FITC-dextran leakage compared to albumin (120.0 [93.8-141.2] vs. 116.2 [61.7 vs. 160.8] µg/mL, p = 0.86). No differences were found in organ injury between groups. Heparan sulfate, as an add-on therapy to RL or albumin resuscitation, did not reduce organ or endothelial injury in a rat pneumosepsis model. Higher doses of heparan sulfate may decrease organ and endothelial injury induced by shock.
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Affiliation(s)
- Daan P. van den Brink
- Amsterdam UMC, Department of Intensive Care Medicine, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam UMC, Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands (N.C.W.); (N.P.J.)
| | - Derek J. B. Kleinveld
- Amsterdam UMC, Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands (N.C.W.); (N.P.J.)
- Erasmus MC, Department Anesthesiology, Erasmus University of Rotterdam, 3015 GD Rotterdam, The Netherlands
| | - Annabel Bongers
- Amsterdam UMC, Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands (N.C.W.); (N.P.J.)
| | - Jaël Vos
- Amsterdam UMC, Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands (N.C.W.); (N.P.J.)
| | - Joris T. H. Roelofs
- Amsterdam UMC, Department of Pathology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam UMC, Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands
| | - Nina C. Weber
- Amsterdam UMC, Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands (N.C.W.); (N.P.J.)
- Amsterdam UMC, Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands
| | - Jaap D. van Buul
- Sanquin Research and Landsteiner Laboratory, Molecular Cell Biology Laboratory, Department Molecular Hematology, 1066 CX Amsterdam, The Netherlands
- Leeuwenhoek Centre for Advanced Microscopy (LCAM), Section Molecular Cytology at Swammerdam Institute for Life Sciences (SILS), University of Amsterdam, 1066 CX Amsterdam, The Netherlands
| | - Nicole P. Juffermans
- Amsterdam UMC, Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands (N.C.W.); (N.P.J.)
- Erasmus MC, Department of Intensive Care, Erasmus University of Rotterdam, 3015 GD Rotterdam, The Netherlands
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12
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Atmowihardjo LN, Schippers JR, Haaksma ME, Smit MR, Bogaard HJ, Heunks L, Juffermans NP, Schultz MJ, Endeman H, van Velzen P, Tuinman PR, Aman J, Bos LDJ. The diagnostic accuracy of lung ultrasound to determine PiCCO-derived extravascular lung water in invasively ventilated patients with COVID-19 ARDS. Ultrasound J 2023; 15:40. [PMID: 37782370 PMCID: PMC10545605 DOI: 10.1186/s13089-023-00340-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Lung ultrasound (LUS) can detect pulmonary edema and it is under consideration to be added to updated acute respiratory distress syndrome (ARDS) criteria. However, it remains uncertain whether different LUS scores can be used to quantify pulmonary edema in patient with ARDS. OBJECTIVES This study examined the diagnostic accuracy of four LUS scores with the extravascular lung water index (EVLWi) assessed by transpulmonary thermodilution in patients with moderate-to-severe COVID-19 ARDS. METHODS In this predefined secondary analysis of a multicenter randomized-controlled trial (InventCOVID), patients were enrolled within 48 hours after intubation and underwent LUS and EVLWi measurement on the first and fourth day after enrolment. EVLWi and ∆EVLWi were used as reference standards. Two 12-region scores (global LUS and LUS-ARDS), an 8-region anterior-lateral score and a 4-region B-line score were used as index tests. Pearson correlation was performed and the area under the receiver operating characteristics curve (AUROCC) for severe pulmonary edema (EVLWi > 15 mL/kg) was calculated. RESULTS 26 out of 30 patients (87%) had complete LUS and EVLWi measurements at time point 1 and 24 out of 29 patients (83%) at time point 2. The global LUS (r = 0.54), LUS-ARDS (r = 0.58) and anterior-lateral score (r = 0.54) correlated significantly with EVLWi, while the B-line score did not (r = 0.32). ∆global LUS (r = 0.49) and ∆anterior-lateral LUS (r = 0.52) correlated significantly with ∆EVLWi. AUROCC for EVLWi > 15 ml/kg was 0.73 for the global LUS, 0.79 for the anterior-lateral and 0.85 for the LUS-ARDS score. CONCLUSIONS Overall, LUS demonstrated an acceptable diagnostic accuracy for detection of pulmonary edema in moderate-to-severe COVID-19 ARDS when compared with PICCO. For identifying patients at risk of severe pulmonary edema, an extended score considering pleural morphology may be of added value. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04794088, registered on 11 March 2021. European Clinical Trials Database number 2020-005447-23.
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Affiliation(s)
- Leila N Atmowihardjo
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands.
| | - Job R Schippers
- Department of Pulmonology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Mark E Haaksma
- Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Marry R Smit
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Harm J Bogaard
- Department of Pulmonology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole P Juffermans
- Intensive Care, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus University, Rotterdam, the Netherlands
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Henrik Endeman
- Intensive Care, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, The Netherlands
| | - Patricia van Velzen
- Dijklander Hospital Location Purmerend, Intensive Care, Waterlandlaan 250, Purmerend, The Netherlands
| | - Pieter R Tuinman
- Intensive Care, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography, Amsterdam, The Netherlands
| | - Jurjan Aman
- Department of Pulmonology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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13
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Bouzat P, Hunt BJ, Juffermans NP. Four-factor prothrombin complex concentrate in trauma patients. Intensive Care Med 2023; 49:1242-1244. [PMID: 37486378 DOI: 10.1007/s00134-023-07170-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Pierre Bouzat
- CHU Grenoble Alpes, Grenoble Institute Neurosciences, Université Grenoble Alpes, Inserm, U1216, 38000, Grenoble, France.
- Pôle d'Anesthésie-Réanimation, Hôpital Albert Michallon, BP 217, 38043, Grenoble, France.
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nicole P Juffermans
- Department Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
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14
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van den Brink DP, Kleinveld DJB, Bongers A, Vos J, Roelofs JJTH, Weber NC, van Buul JD, Juffermans NP. The effects of resuscitation with different plasma products on endothelial permeability and organ injury in a rat pneumosepsis model. Intensive Care Med Exp 2023; 11:62. [PMID: 37728777 PMCID: PMC10511387 DOI: 10.1186/s40635-023-00549-9] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Endothelial injury and permeability are a hallmark of sepsis. Initial resuscitation of septic patients with crystalloids is associated with aggravation of endothelial permeability, which may be related either to low protein content or to volume. We investigated whether initial resuscitation with different types of plasma or albumin decreases endothelial dysfunction and organ injury in a pneumosepsis rat model compared to the same volume of crystalloids. STUDY DESIGN AND METHODS Sprague-Dawley rats were intratracheally inoculated with Streptococcus pneumoniae. Twenty-four hours after inoculation, animals were randomized to 2 control groups and 5 intervention groups (n = 11 per group) to receive resuscitation with a fixed volume (8 mL/kg for 1 h) of either Ringer's Lactate, 5% human albumin, fresh frozen plasma derived from syngeneic donor rats (rFFP), human-derived plasma (hFFP) or human-derived solvent detergent plasma (SDP). Controls were non-resuscitated (n = 11) and healthy animals. Animals were sacrificed 5 h after start of resuscitation (T = 5). Pulmonary FITC-dextran leakage as a reflection of endothelial permeability was used as the primary outcome. RESULTS Inoculation with S. Pneumoniae resulted in sepsis, increased median lactate levels (1.6-2.8 mM, p < 0.01), pulmonary FITC-dextran leakage (52-134 µg mL-1, p < 0.05) and lung injury scores (0.7-6.9, p < 0.001) compared to healthy controls. Compared to animals receiving no resuscitation, animals resuscitated with rFFP had reduced pulmonary FITC leakage (134 vs 58 µg/mL, p = 0.011). However, there were no differences in any other markers of organ or endothelial injury. Resuscitation using different human plasma products or 5% albumin showed no differences in any outcome. CONCLUSIONS Resuscitation with plasma did not reduce endothelial and organ injury when compared to an equal resuscitation volume of crystalloids. Rat-derived FFP may decrease pulmonary leakage induced by shock.
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Affiliation(s)
- Daan P van den Brink
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Derek J B Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Erasmus MC, Erasmus University of Rotterdam, Rotterdam, The Netherlands
| | - Annabel Bongers
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaël Vos
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cardiovascular Sciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Nina C Weber
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap D van Buul
- Molecular Cell Biology Lab at Department Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
- Leeuwenhoek Centre for Advanced Microscopy (LCAM), Section Molecular Cytology at Swammerdam Institute for Life Sciences (SILS) at University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
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15
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Grasselli G, Calfee CS, Camporota L, Poole D, Amato MBP, Antonelli M, Arabi YM, Baroncelli F, Beitler JR, Bellani G, Bellingan G, Blackwood B, Bos LDJ, Brochard L, Brodie D, Burns KEA, Combes A, D'Arrigo S, De Backer D, Demoule A, Einav S, Fan E, Ferguson ND, Frat JP, Gattinoni L, Guérin C, Herridge MS, Hodgson C, Hough CL, Jaber S, Juffermans NP, Karagiannidis C, Kesecioglu J, Kwizera A, Laffey JG, Mancebo J, Matthay MA, McAuley DF, Mercat A, Meyer NJ, Moss M, Munshi L, Myatra SN, Ng Gong M, Papazian L, Patel BK, Pellegrini M, Perner A, Pesenti A, Piquilloud L, Qiu H, Ranieri MV, Riviello E, Slutsky AS, Stapleton RD, Summers C, Thompson TB, Valente Barbas CS, Villar J, Ware LB, Weiss B, Zampieri FG, Azoulay E, Cecconi M. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med 2023; 49:727-759. [PMID: 37326646 PMCID: PMC10354163 DOI: 10.1007/s00134-023-07050-7] [Citation(s) in RCA: 97] [Impact Index Per Article: 97.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/24/2023] [Indexed: 06/17/2023]
Abstract
The aim of these guidelines is to update the 2017 clinical practice guideline (CPG) of the European Society of Intensive Care Medicine (ESICM). The scope of this CPG is limited to adult patients and to non-pharmacological respiratory support strategies across different aspects of acute respiratory distress syndrome (ARDS), including ARDS due to coronavirus disease 2019 (COVID-19). These guidelines were formulated by an international panel of clinical experts, one methodologist and patients' representatives on behalf of the ESICM. The review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and grade recommendations and the quality of reporting of each study based on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network guidelines. The CPG addressed 21 questions and formulates 21 recommendations on the following domains: (1) definition; (2) phenotyping, and respiratory support strategies including (3) high-flow nasal cannula oxygen (HFNO); (4) non-invasive ventilation (NIV); (5) tidal volume setting; (6) positive end-expiratory pressure (PEEP) and recruitment maneuvers (RM); (7) prone positioning; (8) neuromuscular blockade, and (9) extracorporeal life support (ECLS). In addition, the CPG includes expert opinion on clinical practice and identifies the areas of future research.
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Affiliation(s)
- Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | | | - Massimo Antonelli
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Trento, Italy
| | - Geoff Bellingan
- Intensive Care Medicine, University College London, NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lieuwe D J Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurent Brochard
- Keenan Research Center, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Critical Care, Unity Health Toronto - Saint Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013, Paris, France
| | - Sonia D'Arrigo
- Department of Anesthesiology Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département R3S), Paris, France
| | - Sharon Einav
- Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology and Critical Care, Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Departments of Medicine and Physiology, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jean-Pierre Frat
- CHU De Poitiers, Médecine Intensive Réanimation, Poitiers, France
- INSERM, CIC-1402, IS-ALIVE, Université de Poitiers, Faculté de Médecine et de Pharmacie, Poitiers, France
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Claude Guérin
- University of Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, INSERM 955 CNRS 7200, Créteil, France
| | - Margaret S Herridge
- Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Carol Hodgson
- The Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Catherine L Hough
- Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Samir Jaber
- Anesthesia and Critical Care Department (DAR-B), Saint Eloi Teaching Hospital, University of Montpellier, Research Unit: PhyMedExp, INSERM U-1046, CNRS, 34295, Montpellier, France
| | - Nicole P Juffermans
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken Der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arthur Kwizera
- Makerere University College of Health Sciences, School of Medicine, Department of Anesthesia and Intensive Care, Kampala, Uganda
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, College of Medicine Nursing and Health Sciences, University of Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospitals Groups, Galway, Ireland
| | - Jordi Mancebo
- Intensive Care Department, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Alain Mercat
- Département de Médecine Intensive Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - Nuala J Meyer
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, Canada
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Michelle Ng Gong
- Division of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Bronx, New York, NY, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Laurent Papazian
- Bastia General Hospital Intensive Care Unit, Bastia, France
- Aix-Marseille University, Faculté de Médecine, Marseille, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mariangela Pellegrini
- Anesthesia and Intensive Care Medicine, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - Marco V Ranieri
- Alma Mater Studiorum - Università di Bologna, Bologna, Italy
- Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Elisabeth Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Renee D Stapleton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charlotte Summers
- Department of Medicine, University of Cambridge Medical School, Cambridge, UK
| | - Taylor B Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carmen S Valente Barbas
- University of São Paulo Medical School, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jesús Villar
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Lorraine B Ware
- Departments of Medicine and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Björn Weiss
- Department of Anesthesiology and Intensive Care Medicine (CCM CVK), Charitè - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Fernando G Zampieri
- Academic Research Organization, Albert Einstein Hospital, São Paulo, Brazil
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Elie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris Cité University, Paris, France
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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16
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Daenen K, Huijben JA, Boyd A, Bos LDJ, Stoof SCM, van Willigen H, Gommers DAMPJ, Moeniralam HS, den Uil CA, Juffermans NP, Kant M, Valkenburg AJ, Pillay J, van Meenen DMP, Paulus F, Schultz MJ, Dalm VASH, van Gorp ECM, Schinkel J, Endeman H. Optimal Dosing and Timing of High-Dose Corticosteroid Therapy in Hospitalized Patients With COVID-19: Study Protocol for a Retrospective Observational Multicenter Study (SELECT). JMIR Res Protoc 2023; 12:e48183. [PMID: 37266993 DOI: 10.2196/48183] [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: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND In hospitalized patients with COVID-19, the dosing and timing of corticosteroids vary widely. Low-dose dexamethasone therapy reduces mortality in patients requiring respiratory support, but it remains unclear how to treat patients when this therapy fails. In critically ill patients, high-dose corticosteroids are often administered as salvage late in the disease course, whereas earlier administration may be more beneficial in preventing disease progression. Previous research has revealed that increased levels of various biomarkers are associated with mortality, and whole blood transcriptome sequencing has the ability to identify host factors predisposing to critical illness in patients with COVID-19. OBJECTIVE Our goal is to determine the most optimal dosing and timing of corticosteroid therapy and to provide a basis for personalized corticosteroid treatment regimens to reduce morbidity and mortality in hospitalized patients with COVID-19. METHODS This is a retrospective, observational, multicenter study that includes adult patients who were hospitalized due to COVID-19 in the Netherlands. We will use the differences in therapeutic strategies between hospitals (per protocol high-dose corticosteroids or not) over time to determine whether high-dose corticosteroids have an effect on the following outcome measures: mechanical ventilation or high-flow nasal cannula therapy, in-hospital mortality, and 28-day survival. We will also explore biomarker profiles in serum and bronchoalveolar lavage fluid and use whole blood transcriptome analysis to determine factors that influence the relationship between high-dose corticosteroids and outcome. Existing databases that contain routinely collected electronic data during ward and intensive care admissions, as well as existing biobanks, will be used. We will apply longitudinal modeling appropriate for each data structure to answer the research questions at hand. RESULTS As of April 2023, data have been collected for a total of 1500 patients, with data collection anticipated to be completed by December 2023. We expect the first results to be available in early 2024. CONCLUSIONS This study protocol presents a strategy to investigate the effect of high-dose corticosteroids throughout the entire clinical course of hospitalized patients with COVID-19, from hospital admission to the ward or intensive care unit until hospital discharge. Moreover, our exploration of biomarker and gene expression profiles for targeted corticosteroid therapy represents a first step towards personalized COVID-19 corticosteroid treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05403359; https://clinicaltrials.gov/ct2/show/NCT05403359. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48183.
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Affiliation(s)
- Katrijn Daenen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jilske A Huijben
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands
- HIV Monitoring Foundation, Amsterdam, Netherlands
- Infectious Diseases, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Sara C M Stoof
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hugo van Willigen
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, Netherlands
| | | | - Hazra S Moeniralam
- Department of Internal Medicine and Intensive Care, St Antonius Hospital, Nieuwegein, Netherlands
| | | | - Nicole P Juffermans
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, Netherlands
- Laboratory of Translational Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Merijn Kant
- Department of Pulmonology, Amphia Hospital, Breda, Netherlands
- Department of Intensive Care, Amphia Hospital, Breda, Netherlands
| | - Abraham J Valkenburg
- Department of Anesthesiology and Intensive Care, Isala Clinics, Zwolle, Netherlands
| | - Janesh Pillay
- Department of Intensive Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, Groningen Research Institute for Asthma and Chronic Obstructive Pulmonary Disease, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centers, location Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Virgil A S H Dalm
- Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
- Division of Allergy & Clinical Immunology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Internal Medicine, Erasmus University Medical Center, Erasmus, Netherlands
| | - Janke Schinkel
- Department of Medical Microbiology & Infection Prevention, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands
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17
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Sloos PH, Maas MAW, Meijers JCM, Nieuwland R, Roelofs JJTH, Juffermans NP, Kleinveld DJB. Anti-high-mobility group box-1 treatment strategies improve trauma-induced coagulopathy in a mouse model of trauma and shock. Br J Anaesth 2023; 130:687-697. [PMID: 36967283 DOI: 10.1016/j.bja.2023.01.026] [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: 08/19/2022] [Revised: 01/09/2023] [Accepted: 01/30/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Trauma-induced coagulopathy is associated with platelet dysfunction and contributes to early mortality after traumatic injury. Plasma concentrations of the damage molecule high-mobility group box-1 (HMGB-1) increase after trauma, which may contribute to platelet dysfunction. We hypothesised that inhibition of HMGB-1 with a monoclonal antibody (mAb) or with recombinant thrombomodulin (rTM) improves trauma-induced coagulopathy in a murine model of trauma and shock. METHODS Male 129S2/SvPasOrlRJ mice were anaesthetised, mechanically ventilated, and randomised into five groups: (i) ventilation control (VENT), (ii) trauma/shock (TS), (iii) TS+anti-HMGB-1 mAb (TS+AB), (iv) TS+rTM (TS+TM), and (v) TS+anti-HMGB-1 mAb+rTM (TS+COMBI). Primary outcome was rotational thromboelastometry EXTEM. Secondary outcomes included tail bleeding time, platelet count, plasma HMGB-1 concentration, and platelet activation. RESULTS Trauma and shock resulted in a hypocoagulable thromboelastometry profile, increased plasma HMGB-1, and increased platelet activation markers. TS+AB was associated with improved clot firmness after 5 min compared with TS (34 [33-37] vs 32 [29-34] mm; P=0.043). TS+COMBI was associated with decreased clot formation time (98 [92-125] vs 122 [111-148] s; P=0.018) and increased alpha angle (77 [72-78] vs 69 [64-71] degrees; P=0.003) compared with TS. TS+COMBI also reduced tail bleeding time compared with TS (P=0.007). The TS+TM and TS+COMBI groups had higher platelet counts compared with TS (P=0.044 and P=0.041, respectively). CONCLUSIONS Inhibition of HMGB-1 early after trauma in a mouse model improves clot formation and strength, preserves platelet count, and decreases bleeding time.
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Affiliation(s)
- Pieter H Sloos
- Amsterdam UMC Location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands
| | - M Adrie W Maas
- Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands
| | - Joost C M Meijers
- Amsterdam UMC Location University of Amsterdam, Department of Experimental Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Sanquin Research, Department of Molecular Hematology, Amsterdam, the Netherlands
| | - Rienk Nieuwland
- Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Clinical Chemistry, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Vesicle Observation Center, Amsterdam, the Netherlands
| | - Joris J T H Roelofs
- Amsterdam UMC Location University of Amsterdam, Department of Pathology, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Amsterdam UMC Location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands; Onze Lieve Vrouwe Gasthuis, Department of Intensive Care Medicine, Amsterdam, the Netherlands
| | - Derek J B Kleinveld
- Amsterdam UMC Location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam, the Netherlands; Erasmus MC, Department of Anesthesiology, Rotterdam, the Netherlands.
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18
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David S, Russell L, Castro P, van de Louw A, Zafrani L, Pirani T, Nielsen ND, Mariotte E, Ferreyro BL, Kielstein JT, Montini L, Brignier AC, Kochanek M, Cid J, Robba C, Martin-Loeches I, Ostermann M, Juffermans NP. Research priorities for therapeutic plasma exchange in critically ill patients. Intensive Care Med Exp 2023; 11:26. [PMID: 37150798 PMCID: PMC10164453 DOI: 10.1186/s40635-023-00510-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
Therapeutic plasma exchange (TPE) is a therapeutic intervention that separates plasma from blood cells to remove pathological factors or to replenish deficient factors. The use of TPE is increasing over the last decades. However, despite a good theoretical rationale and biological plausibility for TPE as a therapy for numerous diseases or syndromes associated with critical illness, TPE in the intensive care unit (ICU) setting has not been studied extensively. A group of eighteen experts around the globe from different clinical backgrounds used a modified Delphi method to phrase key research questions related to "TPE in the critically ill patient". These questions focused on: (1) the pathophysiological role of the removal and replacement process, (2) optimal timing of treatment, (3) dosing and treatment regimes, (4) risk-benefit assumptions and (5) novel indications in need of exploration. For all five topics, the current understanding as well as gaps in knowledge and future directions were assessed. The content should stimulate future research in the field and novel clinical applications.
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Affiliation(s)
- Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany.
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Andry van de Louw
- Medical Intensive Care Unit, Penn State Health Hershey Medical Center, Hershey, PA, USA
| | - Lara Zafrani
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Tasneem Pirani
- King's College Hospital, General and Liver Intensive Care, London, UK
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Eric Mariotte
- Medical Intensive Care Unit, Saint-Louis Hospital, AP-HP, University of Paris Cité, Paris, France
| | - Bruno L Ferreyro
- Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Brunswick, Germany
| | - Luca Montini
- Department of Intensive Care Medicine and Anesthesiology, "Fondazione Policlinico Universitario Agostino Gemelli IRCCS" Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anne C Brignier
- Apheresis Unit, Saint-Louis Hospital, AP-HP, University of Paris Cite, Paris, France
| | - Matthias Kochanek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO), University of Cologne, Cologne, Germany
| | - Joan Cid
- Apheresis and Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Chiara Robba
- IRCCS per Oncologia e Neuroscienze, Genoa, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Universita' di Genova, Genoa, Italy
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, D08 NHY1, Ireland
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, D02 PN91, Ireland
- Institut D'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - Marlies Ostermann
- Department of Intensive Care, Guy's & St Thomas' Hospital, King's College London, London, UK
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, Rotterdam, The Netherlands
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19
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Itenov TS, Kromann ME, Ostrowski SR, Bestle MH, Mohr T, Gyldensted L, Lindhardt A, Thormar K, Sessler DI, Juffermans NP, Lundgren JD, Jensen JU. Mild induced hypothermia and coagulation and platelet function in patients with septic shock: Secondary outcome of a randomized trial. Acta Anaesthesiol Scand 2023. [PMID: 37129236 DOI: 10.1111/aas.14254] [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: 09/22/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
Coagulation abnormalities and microthrombi contribute to septic shock, but the impact of body temperature regulation on coagulation in patients with sepsis is unknown. We tested the hypothesis that mild induced hypothermia reduces coagulation and platelet aggregation in patients with septic shock. Secondary analysis of randomized controlled trial. Adult patients with septic shock who required mechanical ventilation from eight intensive care units in Denmark were randomly assigned to mild induced hypothermia for 24 h or routine thermal management. Viscoelastography and platelet aggregation were assessed at trial inclusion, after 12 h of thermal management, and 24 h after inclusion. A total of 326 patients were randomized to mild induced hypothermia (n = 163) or routine thermal management (n = 163). Mild induced hypothermia slightly prolonged activated partial thromboplastin time and thrombus initiation time (R time 8.0 min [interquartile range, IQR 6.6-11.1] vs. 7.2 min [IQR 5.8-9.2]; p = .004) and marginally inhibited thrombus propagation (angle 68° [IQR 59-73] vs. 71° [IQR 63-75]; p = .014). The effect was also present after 24 h. Clot strength remained unaffected (MA 71 mm [IQR 66-76] with mild induced hypothermia vs. 72 mm (65-77) with routine thermal management, p = .9). The proportion of patients with hyperfibrinolysis was not affected (0.7% vs. 3.3%; p = .19), but the proportion of patients with no fibrinolysis was high in the mild hypothermia group (8.8% vs. 40.4%; p < .001). The mild induced hypothermia group had lower platelet aggregation: ASPI 85U (IQR 50-113) versus 109U (IQR 74-148, p < .001), ADP 61U (IQR 40-83) versus 79 U (IQR 54-101, p < .001), TRAP 108 (IQR 83-154) versus 119 (IQR 94-146, p = .042) and COL 50U (IQR 34-66) versus 67U (IQR 46-92, p < .001). In patients with septic shock, mild induced hypothermia slightly impaired clot initiation, but did not change clot strength. Platelet aggregation was slightly impaired. The effect of mild induced hypothermia on viscoelastography and platelet aggregation was however not in a range that would have clinical implications. We did observe a substantial reduction in fibrinolysis.
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Affiliation(s)
- Theis S Itenov
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Anesthesiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maria E Kromann
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sisse R Ostrowski
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Immunology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Thomas Mohr
- Department of Anesthesiology, Copenhagen University Hospital - Herlev-Gentofte, Copenhagen, Denmark
| | - Louise Gyldensted
- Department of Anesthesiology, Copenhagen University Hospital - Herlev-Gentofte, Copenhagen, Denmark
| | - Anne Lindhardt
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - North Zealand, Copenhagen, Denmark
| | - Katrin Thormar
- Department of Anesthesiology, Copenhagen University Hospital - Bispebjerg, Copenhagen, Denmark
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jens D Lundgren
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jens-Ulrik Jensen
- CHIP/PERSIMUNE, Department of infectious diseases, Rigshospitalet, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health sciences, University of Copenhagen, Copenhagen, Denmark
- Respiratory Section, Department of Internal Medicine, Copenhagen University Hospital - Gentofte, Copenhagen, Denmark
- Outcomes Research Consortium, Cleveland, Ohio, USA
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20
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Juffermans NP. ICM experimental is growing, from bench via bedside to big data-and back! Intensive Care Med Exp 2023; 11:24. [PMID: 37040033 PMCID: PMC10090241 DOI: 10.1186/s40635-023-00507-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 04/12/2023] Open
Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
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21
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Leone M, Juffermans NP, Nielsen ND. Ten tips on fever. Intensive Care Med 2023; 49:587-590. [PMID: 37010534 DOI: 10.1007/s00134-023-07049-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
- Marc Leone
- Department of anesthesiology and intensive care unit, North Hospital, Assistance Publique Hôpitaux, service d'anesthésie et de réanimation, hôpital Nord, Chemin des Bourrely, Universitaires de Marseille, Aix Marseille University, 13015, Marseille, France.
- Centre for Nutrition and Cardiovascular Disease (C2VN), INSERM, INRAE, Aix Marseille University, 13005, Marseille, France.
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centre Location AMC, Amsterdam, The Netherlands
- OLVG Hospital, Amsterdam, The Netherlands
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Section of Transfusion Medicine and Therapeutic Pathology, Department of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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22
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Determann RM, Juffermans NP, van der Voort PHJ. Selective Decontamination of the Digestive Tract and Hospital Mortality in Critically Ill Patients Receiving Mechanical Ventilation. JAMA 2023; 329:1029-1030. [PMID: 36976286 DOI: 10.1001/jama.2023.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Affiliation(s)
| | - Nicole P Juffermans
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Peter H J van der Voort
- Department of Critical Care, University Medical Center Groningen, Groningen, the Netherlands
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23
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Hilderink BN, Crane RF, Baysan M, Arbous S, van den Bogaard B, Mik EG, Ince C, Pillay J, Juffermans NP. A simulation of skin mitochondrial PO 2 in circulatory shock. J Appl Physiol (1985) 2023; 134:1165-1176. [PMID: 36927145 DOI: 10.1152/japplphysiol.00621.2022] [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] [Indexed: 03/18/2023] Open
Abstract
Circulatory shock is the inadequacy to supply mitochondria with enough oxygen to sustain aerobic energy metabolism. A novel non-invasive bedside measurement was recently introduced to monitor the mitochondrial oxygen tension in the skin (mitoPO2). As the most downstream marker of oxygen balance in the skin, mitoPO2 may provide additional information to improve shock management. However, a physiological basis for the interpretation of mitoPO2 values has not been established yet. In this paper we developed a mathematical model of skin mitoPO2 using a network of parallel microvessels, based on Krogh's cylinder model. The model contains skin blood flow velocity, heterogeneity of blood flow, hematocrit, arteriolar oxygen saturation and mitochondrial oxygen consumption as major variables. The major results of the model show that normal physiological mitoPO2 is in the range of 40-60mmHg. The relationship of mitoPO2 with skin blood flow velocity follows a hyperbolic curve, reaching a plateau at high skin blood flow velocity, suggesting that oxygen balance remains stable whilst peripheral perfusion declines. The model shows that a critical range exists where mitoPO2 rapidly deteriorates if skin perfusion further decreases. The model intuitively shows how tissue hypoxia could occur in the setting of septic shock, due to the profound impact of microcirculatory disturbance on mitoPO2, even at sustained cardiac output. MitoPO2 is the result of a complex interaction between all factors of oxygen delivery and the microcirculation. This mathematical framework can be used to interpret mitoPO2 values in shock, with the potential to enhance personalized clinical trial design.
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Affiliation(s)
- Bashar N Hilderink
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Reinier F Crane
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Meryem Baysan
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Bas van den Bogaard
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Egbert G Mik
- Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Janesh Pillay
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands.,Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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24
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Alshalani A, Beuger BM, van Bruggen R, Acker JP, Juffermans NP. Cultured CD71 + erythroid cells modulate the host immune response. Transfus Med 2023. [PMID: 36919690 DOI: 10.1111/tme.12964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/21/2022] [Accepted: 02/21/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE The study aimed to determine the impact of Red Blood Cells (RBCs) generated from peripheral blood mononuclear cells (PBMCs) on T cell proliferation and host response following whole blood stimulation. BACKGROUND Culturing RBCs is a potential solution for donor shortage. The impact of immature cultured RBCs which express CD71+ on host immune response is not known. METHODS/MATERIALS PBMCs were seeded in an erythroid expansion medium. CD71+ cells were isolated at days 14 and 21 of culture and incubated with either purified T cells or with LPS-stimulated whole blood. Controls were incubated with medium. RESULTS At day 9, the percentage of cells that expressed CD45 and CD71 reached to the highest level (32.9%, IQR; 26.2-39.05) while the percentage of cells that expressed CD71 and CD235a reached to the highest level on day 17 (70.2%, IQR; 66.1-72.8). Incubation of T cells with days 14 CD71+ cells and day 21 CD71+ cells increased T cell proliferation. In a whole blood stimulation assay, day 21 CD71+ cells, but not day 14 CD71+ cells, inhibited the production of IL-6 and TNFα. CONCLUSION Cultured erythroid cells can modulate the immune response by promoting T cell proliferation and inhibiting cytokine secretions following whole blood stimulation.
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Affiliation(s)
- Abdulrahman Alshalani
- Chair of Medical and Molecular Genetics Research, Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Boukje M Beuger
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada.,Innovation and Portfolio Management, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
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25
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Alshalani A, Beuger BM, Tuip-de Boer AM, van Bruggen R, Acker JP, Juffermans NP. The impact of biological age of red blood cell on in vitro endothelial activation markers. Front Physiol 2023; 14:1127103. [PMID: 36969576 PMCID: PMC10030615 DOI: 10.3389/fphys.2023.1127103] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/23/2023] [Indexed: 03/10/2023] Open
Abstract
Introduction: Blood donor characteristics influence red blood cell transfusion outcomes. As donor sex affects the distribution of young to old RBCs in the circulation, we hypothesized that the amount of circulating young RBCs in the blood product are associated with immune suppression.Materials and Methods: Blood samples were collected from healthy volunteers and density fractionated into young and old subpopulations. In an activated endothelial cell model, RBC adhesion to endothelium and secretion of endothelial activation markers were assessed. The impact of RBC biological age was also assessed in a T cell proliferation assay and in a whole blood stimulation assay.Results: After Percoll fractionation, young RBCs contained more reticulocytes compared to old RBCs. Young RBCs associated with lower levels of E-selectin, ICAM-1, and vWF from activated endothelial cells compared to old RBCs. RBC subpopulations did not affect T cell proliferation or cytokine responses following whole blood stimulation.Conclusion: Young RBCs contain more reticulocytes which are associated with lower levels of endothelial activation markers compared to old RBCs.
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Affiliation(s)
- Abdulrahman Alshalani
- Chair of Medical and Molecular Genetics Research, Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
- Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Abdulrahman Alshalani,
| | - Boukje M. Beuger
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Anita M. Tuip-de Boer
- Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, Amsterdam, Netherlands
| | - Robin van Bruggen
- Department of Molecular Hematology, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jason P. Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
- Innovation and Portfolio Management, Canadian Blood Services, Edmonton, AB, Canada
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, University of Amsterdam, Amsterdam, Netherlands
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, Netherlands
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26
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Tjerkstra MA, Wolfs AE, Verbaan D, Vandertop WP, Horn J, Müller MCA, Juffermans NP. A systematic review on viscoelastic testing in subarachnoid haemorrhage patients. World Neurosurg 2023:S1878-8750(23)00430-8. [PMID: 37004882 DOI: 10.1016/j.wneu.2023.03.108] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Bleeding and thromboembolic complications frequently occur following subarachnoid haemorrhage (SAH) and substantially contribute to poor outcome. Viscoelastic testing could be used for detection of coagulopathies following SAH. This review summarizes literature on the utility of viscoelastic testing to detect coagulopathy in SAH patients and explores whether viscoelastic parameters are associated with SAH-related complications and clinical outcome. MATERIALS AND METHODS PUBMED, EMBASE and Google Scholar were systematically searched on August 18th, 2022. Two authors independently selected studies which performed viscoelastic testing in SAH patients and assessed the quality of studies using the Newcastle Ottawa Scale or a previously published framework for quality assessment. Data was meta-analysed if methodologically possible. RESULTS The search yielded 19 studies (1160 SAH patients). Pooling of data including all relevant studies was not possible for any of the outcome measurements due to methodological differences. Thirteen of 19 studies evaluated the association of coagulation profiles and SAH, of which 11 studies showed a hypercoagulable profile. Rebleeding was associated with platelet dysfunction, deep venous thrombosis was associated with faster clot initiation and both delayed cerebral ischemia and poor outcome were associated with increased clot strength. CONCLUSIONS This explorative review shows that SAH patients frequently have a hypercoagulable profile. TEG- and ROTEM-parameters are associated with rebleeding, delayed cerebral ischemia, deep venous thrombosis and poor clinical outcome after SAH, however more research on the subject is needed. Future studies should focus on determining the optimal time frame and cut-off values for TEG or ROTEM to predict these complications.
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Affiliation(s)
- Maud A Tjerkstra
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands.
| | - Anne E Wolfs
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Janneke Horn
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Amsterdam UMC, University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam Neuroscience, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
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Talboom K, Borstlap WAA, Roodbeen SX, Bruns ERJ, Buskens CJ, Hompes R, Tytgat KMAJ, Tuynman JB, Consten ECJ, Heuff G, Kuiper T, van Geloven AAW, Veldhuis GJ, van der Hoeven JAB, Gerhards MF, Sietses C, Spinelli A, van de Ven AWH, van der Zaag ES, Westerterp M, van Westreenen HL, Dijkgraaf ML, Juffermans NP, Bemelman WA, Hess D, Swank HA, Scholten L, van der Bilt JDW, Jansen MA, van Duijvendijk P, Bezuur D, Carvello M, Foppa C, de Vos tot Nederveen Cappel WH, Geitenbeek RTJ, van Woensel L, De Castro SMM, Wientjes C, van Oostendorp S. Ferric carboxymaltose infusion versus oral iron supplementation for preoperative iron deficiency anaemia in patients with colorectal cancer (FIT): a multicentre, open-label, randomised, controlled trial. Lancet Haematol 2023; 10:e250-e260. [PMID: 36863386 DOI: 10.1016/s2352-3026(22)00402-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/17/2022] [Accepted: 12/08/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND A third of patients with colorectal cancer who are eligible for surgery in high-income countries have concomitant anaemia associated with adverse outcomes. We aimed to compare the efficacy of preoperative intravenous and oral iron supplementation in patients with colorectal cancer and iron deficiency anaemia. METHODS In the FIT multicentre, open-label, randomised, controlled trial, adult patients (aged 18 years or older) with M0 stage colorectal cancer scheduled for elective curative resection and iron deficiency anaemia (defined as haemoglobin level of less than 7·5 mmol/L (12 g/dL) for women and less than 8 mmol/L (13 g/dL) for men, and a transferrin saturation of less than 20%) were randomly assigned to either 1-2 g of ferric carboxymaltose intravenously or three tablets of 200 mg of oral ferrous fumarate daily. The primary endpoint was the proportion of patients with normalised haemoglobin levels before surgery (≥12 g/dL for women and ≥13 g/dL for men). An intention-to-treat analysis was done for the primary analysis. Safety was analysed in all patients who received treatment. The trial was registered at ClincalTrials.gov, NCT02243735, and has completed recruitment. FINDINGS Between Oct 31, 2014, and Feb 23, 2021, 202 patients were included and assigned to intravenous (n=96) or oral (n=106) iron treatment. Treatment began a median of 14 days (IQR 11-22) before surgery for intravenous iron and 19 days (IQR 13-27) for oral iron. Normalisation of haemoglobin at day of admission was reached in 14 (17%) of 84 patients treated intravenously and 15 (16%) of 97 patients treated orally (relative risk [RR] 1·08 [95% CI 0·55-2·10]; p=0·83), but the proportion of patients with normalised haemoglobin significantly increased for the intravenous treatment group at later timepoints (49 [60%] of 82 vs 18 [21%] of 88 at 30 days; RR 2·92 [95% CI 1·87-4·58]; p<0·0001). The most prevalent treatment-related adverse event was discoloured faeces (grade 1) after oral iron treatment (14 [13%] of 105), and no treatment-related serious adverse events or deaths were observed in either group. No differences in other safety outcomes were seen, and the most common serious adverse events were anastomotic leakage (11 [5%] of 202), aspiration pneumonia (5 [2%] of 202), and intra-abdominal abscess (5 [2%] 202). INTERPRETATION Normalisation of haemoglobin before surgery was infrequent with both treatment regimens, but significantly improved at all other timepoints following intravenous iron treatment. Restoration of iron stores was feasible only with intravenous iron. In selected patients, surgery might be delayed to augment the effect of intravenous iron on haemoglobin normalisation. FUNDING Vifor Pharma.
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Affiliation(s)
- Kevin Talboom
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | | | - Sapho X Roodbeen
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Emma R J Bruns
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | | | - Roel Hompes
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | | | - Jurriaan B Tuynman
- Department of Surgery, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands; Department of Surgery, University Medical Centre Groningen, Groningen, Netherlands
| | - Gijsbert Heuff
- Department of Surgery, Spaarne Gasthuis, Hoofddorp, Netherlands
| | - Teaco Kuiper
- Department of Gastroenterology, Amstelland Hospital, Amstelveen, Netherlands
| | | | - Gerrit J Veldhuis
- Department of Internal Medicine, Antonius Hospital, Sneek, Netherlands
| | | | - Michael F Gerhards
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Colin Sietses
- Department of Surgery, Hospital Gelderse Vallei, Ede, Netherlands
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | | | | | | | - Marcel L Dijkgraaf
- Epidemiology and Data Science, Amsterdam UMC, location University of Amsterdam, Amsterdam, Netherlands; Amsterdam Public Health Methodology, Amsterdam, Netherlands
| | - Nicole P Juffermans
- Department of Internal Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Wilhelmus A Bemelman
- Department of Surgery, Amsterdam UMC, Location AMC, Amsterdam, Netherlands; IBD Unit, Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita Salute San Raffaele, Milan, Italy.
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Curry NS, Davenport R, Wong H, Gaarder C, Johansson P, Juffermans NP, Maegele M, Stensballe J, Brohi K, Laffan M, Stanworth SJ. Traumatic coagulopathy in the older patient: analysis of coagulation profiles from the Activation of Coagulation and Inflammation in Trauma-2 (ACIT-2) observational, multicenter study. J Thromb Haemost 2023; 21:215-226. [PMID: 36700506 DOI: 10.1016/j.jtha.2022.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Most studies describing traumatic coagulopathy have used data from patient cohorts with an average age of between 35 and 45 years. The last 10 years has seen a steep increase in the number of patients admitted with significant injury and bleeding who are older than the age of 65 years. Many coagulation protein levels alter significantly with normal aging, and it is possible that traumatic coagulopathy has a different signature with age. OBJECTIVES The aim of this study was to report the coagulation profiles, including standard and extended laboratory, as well as viscoelastic hemostatic assays, stratified according to age to explore age-related differences in hemostatic capability. METHODS In total, 1576 patients were analyzed from 6 European level 1 trauma centers. RESULTS As age increased, there was evidence of higher fibrinogen, greater thrombin generation, greater clotting factor consumption, and greater activation of fibrinolysis. Despite this, shock and severe injury led to the same pattern of changes within age groups: lower procoagulant factors (including fibrinogen), increased fibrinolysis, and higher levels of activated protein C. Thromboelastography and rotational thromboelastometry tests detected traumatic coagulopathy with prolongation of R/clotting time and reductions in clot amplitudes in each age cohort. Advancing age strongly correlated with higher fibrinogen levels and greater fibrinolysis. CONCLUSION Age-related coagulation changes are evident in injured patients. Broadly, similar patterns of coagulation abnormalities are seen across age groups following severe injury/shock, but thresholds for single clotting factors differ. Age-related differences may need to be considered when clinical treatments (eg, transfusion therapy) are indicated.
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Affiliation(s)
- Nicola S Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom.
| | - Ross Davenport
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Henna Wong
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | - Pär Johansson
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Maegele
- Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany
| | - Jakob Stensballe
- Department of Anesthesiology and Trauma Center, and Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Karim Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mike Laffan
- Imperial College and Hammersmith Hospital, London, United Kingdom
| | - Simon J Stanworth
- Radcliffe Department of Medicine, Oxford University, Oxford, United Kingdom; NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Juffermans NP, Rocco PRM, Laffey JG. Protective ventilation. Intensive Care Med 2022; 48:1629-1631. [PMID: 35939095 PMCID: PMC9592633 DOI: 10.1007/s00134-022-06820-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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centre Location AMC, Amsterdam, The Netherlands. .,OLVG Hospital, Amsterdam, The Netherlands.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, 21941-902, Brazil
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, SAOLTA University Health Group, Galway, Ireland
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30
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Vigstedt M, Baksaas-Aasen K, Henriksen HH, Maegele M, Stanworth S, Juffermans NP, Kolstadbråten KM, Naess PA, Brohi K, Gaarder C, Stensballe J, Johansson PI. Thrombelastography (TEG ® 6s) early amplitudes predict maximum amplitude in severely injured trauma patients. Scand J Clin Lab Invest 2022; 82:508-512. [PMID: 36073613 DOI: 10.1080/00365513.2022.2119599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Severely injured trauma patients are often coagulopathic and early hemostatic resuscitation is essential. Previous studies have revealed linear relationships between thrombelastography (TEG®) five- and ten-min amplitudes (A5 and A10), and maximum amplitude (MA), using TEG® 5000 technology. We aimed to investigate the performance of A5 and A10 in predicting low MA in severely injured trauma patients and identify optimal cut-off values for hemostatic intervention based on early amplitudes, using the cartridge-based TEG® 6s technology. Adult trauma patients with hemorrhagic shock were included in the iTACTIC randomized controlled trial at six European Level I trauma centers between 2016 and 2018. After admission, patients were randomized to hemostatic therapy guided by conventional coagulation tests (CCT) or viscoelastic hemostatic assays (VHA). Patients with available admission-TEG® 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG® and RapidTEG®, and <17 mm for TEG® functional fibrinogen (FF). One hundred eighty-seven patients were included. Median time to MA was 20 (Kaolin TEG®), 21 (RapidTEG®) and 12 (TEG® FF) min. For Kaolin TEG®, the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG® optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG® FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity). In summary, we found that TEG® 6s early amplitudes were sensitive and specific predictors of MA in severely injured trauma patients. Intervening on early amplitudes can save valuable time in hemostatic resuscitation.
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Affiliation(s)
- Martin Vigstedt
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Hanne H Henriksen
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marc Maegele
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - Simon Stanworth
- Oxford University Hospital NHS Trust, Oxford, UK.,NHS Blood and Transplant, Bristol, UK
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | | | - Pål A Naess
- Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | | | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Anaesthesiology, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Sloos PH, Vulliamy P, van 't Veer C, Gupta AS, Neal MD, Brohi K, Juffermans NP, Kleinveld DJB. Platelet dysfunction after trauma: From mechanisms to targeted treatment. Transfusion 2022; 62 Suppl 1:S281-S300. [PMID: 35748694 PMCID: PMC9546174 DOI: 10.1111/trf.16971] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Pieter H. Sloos
- Department of Intensive Care Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Paul Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Cornelis van 't Veer
- Center for Experimental and Molecular Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anirban Sen Gupta
- Department of Biomedical EngineeringCase Western Reserve UniversityClevelandOhioUSA
| | - Matthew D. Neal
- Pittsburgh Trauma and Transfusion Medicine Research Center and Division of Trauma and Acute Care SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Intensive Care MedicineErasmus MCRotterdamThe Netherlands
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Dujardin RWG, Garcia Rosenbaum G, Klercq TCJ, Thachil J, Nielsen ND, Juffermans NP. Rotational thromboelastometry in critically ill COVID-19 patients does not predict thrombosis. Res Pract Thromb Haemost 2022; 6:e12798. [PMID: 36090158 PMCID: PMC9448874 DOI: 10.1002/rth2.12798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background Critically ill COVID‐19 patients are in a hypercoagulable state with increased risk of thrombotic complications. Rotational thromboelastometry (ROTEM) is a viscoelastic test with the potential to reflect COVID‐19‐associated hypercoagulability and may therefore be useful to predict thrombotic complications. Objective To investigate the potential of ROTEM profiles to predict thrombotic complications in critically ill COVID‐19 patients. Patients/Methods Retrospective multicenter cohort study in 113 adult patients with confirmed COVID‐19 infection admitted to the intensive care unit (ICU) of two large teaching hospitals in the United States and in the Netherlands. ROTEM profiles of the EXTEM, INTEM, and FIBTEM tracings were measured within 72 h of ICU admission. Thrombotic complications encompass both arterial and venous thromboembolic complications, diagnosed with electrocardiogram, ultrasound, or computed tomography. ROTEM profiles were compared between patients with and without thrombosis. Univariable logistic regression followed by receiver operating characteristic (ROC) curves analysis was performed to identify ROTEM parameters associated with thrombosis. Results and Conclusions Of 113 patients, 27 (23.9%) developed a thrombotic event. In the univariable analysis, EXTEM clot amplitude at 10 min (CA10) and EXTEM maximum clot formation (MCF) were associated with thrombosis with a p < 0.2 (p = 0.07 and p = 0.05, respectively). In ROC curve analysis, EXTEM CA10 had an area under the curve (AUC) of 0.58 (95% CI 0.47–0.70) and EXTEM MCF had an AUC of 0.60 (95% CI 0.49–0.71). Thereby, ROTEM profiles at ICU admission did not have the potential to differentiate between patients with a high and low risk for thrombotic complications.
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Affiliation(s)
- Romein W G Dujardin
- Department of Intensive Care OLVG Hospital Amsterdam The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam UMC Amsterdam The Netherlands
| | - Gabriel Garcia Rosenbaum
- Department of Internal Medicine University of New Mexico School of Medicine Albuquerque New Mexico USA
| | - Timo C J Klercq
- Department of Intensive Care OLVG Hospital Amsterdam The Netherlands
| | - Jecko Thachil
- Department of Haematology Manchester Royal Infirmary Manchester UK
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine University of New Mexico School of Medicine Albuquerque New Mexico USA.,Department of Pathology University of New Mexico School of Medicine Albuquerque New Mexico USA
| | - Nicole P Juffermans
- Department of Intensive Care OLVG Hospital Amsterdam The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam UMC Amsterdam The Netherlands
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Klanderman RB, Bosboom JJ, Veelo DP, Roelofs JJTH, de Korte D, van Bruggen R, Vogt L, van Buul JD, Hollmann MW, Vroom MB, Juffermans NP, Geerts BF, Vlaar APJ. Prophylactic furosemide to prevent transfusion-associated circulatory overload: a randomized controlled study in rats. Sci Rep 2022; 12:12127. [PMID: 35840620 PMCID: PMC9287390 DOI: 10.1038/s41598-022-16465-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/11/2022] [Indexed: 11/08/2022] Open
Abstract
Transfusion-associated circulatory overload (TACO) is the leading cause of transfusion related morbidity and mortality. The only treatment is empirical use of furosemide. Our aim was to investigate if furosemide can prevent TACO. A randomized controlled trial was performed using a previously validated two-hit rat model for TACO. Volume incompliance was induced (first hit) in anemic, anesthetized Lewis rats. Rats were randomized to placebo, low-dose (5 mg kg-1) or high-dose (15 mg kg-1) furosemide-administered prior to transfusion (second-hit) and divided over two doses. Primary outcome was change in left-ventricular end-diastolic pressure (∆LVEDP) pre- compared to post-transfusion. Secondary outcomes included changes in preload, afterload, contractility and systemic vascular resistance, as well as pulmonary outcomes. Furosemide treated animals had a significantly lower ∆LVEDP compared to placebo (p = 0.041), a dose-response effect was observed. ∆LVEDP in placebo was median + 8.7 mmHg (IQR 5.9-11), + 3.9 (2.8-5.6) in the low-dose and 1.9 (- 0.6 to 5.6) in the high-dose group. The effect of furosemide became apparent after 15 min. While urine output was significantly higher in furosemide treated animals (p = 0.03), there were no significant changes in preload, afterload, contractility or systemic vascular resistance. Furosemide rapidly and dose-dependently decreases the rise in hydrostatic pulmonary pressure following transfusion, essential for preventing TACO.
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Affiliation(s)
- Robert B Klanderman
- Department of Intensive Care, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands.
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Anesthesiology, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Joachim J Bosboom
- Department of Anesthesiology, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Denise P Veelo
- Department of Anesthesiology, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dirk de Korte
- Department of Product and Process Development, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Liffert Vogt
- Department of Nephrology, Amsterdam UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jaap D van Buul
- Department of Molecular Hematology, Molecular Cell Biology Lab, Sanquin Research and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Margreeth B Vroom
- Department of Intensive Care, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart F Geerts
- Department of Anesthesiology, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam , UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC-AMC, University of Amsterdam, Amsterdam, The Netherlands
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Alshalani A, van Manen L, Boshuizen M, van Bruggen R, Acker JP, Juffermans NP. The Effect of Sex-Mismatched Red Blood Cell Transfusion on Endothelial Cell Activation in Critically Ill Patients. Transfus Med Hemother 2022; 49:98-105. [PMID: 35611381 PMCID: PMC9082204 DOI: 10.1159/000520651] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/30/2021] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Observational studies suggest that sex-mismatched transfusion is associated with increased mortality. Mechanisms driving mortality are not known but may include endothelial activation. The aim of this study is to investigate the effects of sex-mismatched red blood cell (RBC) transfusions on endothelial cell activation markers in critically ill patients. STUDY DESIGN AND METHODS In patients admitted to the intensive care unit who received a single RBC unit, blood samples were drawn before (T0), 1 h after (T1), and 24 h after transfusion (T24) for analysis of soluble syndecan-1, soluble intercellular adhesion molecule-1, soluble thrombomodulin (sTM), von Willebrand factor antigen, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNFα). Changes in the levels of these factors were compared between sex-matched and sex-mismatched groups. RESULTS Of 69 included patients, 32 patients were in the sex-matched and 37 patients were in the sex-mismatched group. Compared to baseline, sex-matched transfusion was associated with significant reduction in sTM level (p value = 0.03). Between-group comparison showed that levels of syndecan-1 and sTM were significantly higher in the sex-mismatched group compared to the sex-matched group at T24 (p value = 0.04 and 0.01, respectively). Also, TNFα and IL-6 levels showed a statistically marginal significant increase compared to baseline in the sex-mismatched group at T24 (p value = 0.06 and 0.05, respectively), but not in the sex-matched group. DISCUSSION Transfusion of a single sex-mismatched RBC unit was associated with higher syndecan-1 and sTM levels compared to transfusion of sex-matched RBC unit. These findings may suggest that sex-mismatched RBC transfusion is associated with endothelial activation.
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Affiliation(s)
- Abdulrahman Alshalani
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Clinical Laboratory Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Lisa van Manen
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Margit Boshuizen
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jason P. Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Centre for Innovation, Canadian Blood Services, Edmonton, Alberta, Canada
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
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35
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Wirtz MR, Roelofs JJ, Goslings JC, Juffermans NP. Treatment with ddAVP improves platelet-based coagulation in a rat model of traumatic hemorrhagic shock. Trauma Surg Acute Care Open 2022; 7:e000852. [PMID: 35340703 PMCID: PMC8905935 DOI: 10.1136/tsaco-2021-000852] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/16/2022] [Indexed: 11/03/2022] Open
Abstract
Objectives Trauma-induced hemorrhagic shock is characterized by increased endothelial permeability and coagulopathy. Vasopressin analog ddAVP (desmopressin) acts by reorganizing and redistributing adhesive and tight junction molecules, enhancing endothelial barrier function. Furthermore, ddAVP increases von Willebrand factor (vWF) plasma levels and thereby potentially enhances platelet-based coagulation. The objective of this study was to assess whether the use of ddAVP results in improvement of both endothelial barrier function and platelet-based coagulation, thereby improving shock reversal and reduce organ failure in a rat model of trauma and transfusion. Methods Blood products were prepared from syngeneic rat blood according to blood bank standards. Polytrauma was induced in Sprague Dawley rats by a fractured femur and crush injury to the intestines and liver. The rats were hemorrhaged until a mean arterial pressure of 40 mm Hg and transfused with RBCs, fresh frozen plasmas and platelets in a 1:1:1 ratio, and randomized to receive a single dose of ddAVP (n=7 per group). Blood samples were taken up to 6 hours after trauma to assess biochemistry, markers of endothelial injury and coagulation status by rotational thromboelastometry (ROTEM). Organ damage was assessed by histopathology. Results Rats receiving ddAVP showed significantly better shock reversal compared with controls. Also, coagulation parameters remained stable in the ddAVP treated group, whereas rats in the control group showed deterioration of coagulation parameters, including decreased clot strength and decreased platelet functioning (89% (IQR 82% to 92%) of baseline values). Platelet count and vWF antigen levels at exsanguination did not differ between groups. ddAVP did not reduce markers of endothelial dysfunction nor markers of organ injury. Conclusions The use of ddAVP in a rat trauma-transfusion model improved shock parameters and ROTEM parameters of clot formation. However, this did not abrogate the amount of organ failure. Level of evidence Level III.
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Affiliation(s)
- Mathijs R Wirtz
- Department of Intensive Care Medicine, Amsterdam University Medical Centres, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Joris J Roelofs
- Department of Pathology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam University Medical Centres, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Centres, Amsterdam, Netherlands
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Harmon MBA, Scicluna BP, Wiewel MA, Schultz MJ, Horn J, Cremer OL, Poll T, Joost Wiersinga W, Juffermans NP, Beer FM, Bos LD, Glas GJ, Horn J, Hoogendijk AJ, Hooijdonk RT, Huson MA, Poll T, Scicluna B, Schouten LR, Schultz MJ, Straat M, van Vught LA, Wieske L, Wiewel MA, Witteveen E, Bonten MJ, Cremer OL, Frencken JF, Groep K, Klein Klouwenberg PM, Koster–Brouwer ME, Ong DS, Varkila MR, Verboom DM. Patients with hypothermic sepsis have a unique gene expression profile compared to patients with fever and sepsis. J Cell Mol Med 2022; 26:1896-1904. [PMID: 35934940 PMCID: PMC8980902 DOI: 10.1111/jcmm.17156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/13/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022] Open
Abstract
The pathophysiology of hypothermia during sepsis is unclear. Using genomic profiling of blood leukocytes, we aimed to determine if hypothermia is associated with a different gene expression profile compared to fever during sepsis. Patients with sepsis and either hypothermia or fever within 24 hours after ICU admission were included in the study (n = 168). Hypothermia was defined as body temperature below 36 °C. Fever was defined as body temperature equal to or above 38.3°C. We compared blood gene expression (whole‐genome transcriptome in leukocytes) in hypothermic septic compared to febrile septic patients in an unmatched analysis and matched for APACHE IV score and the presence of shock. In total, 67 septic patients were hypothermic and 101 patients were febrile. Hypothermia was associated with a distinct gene expression profile in both unmatched and matched analyses. There were significant differences related to the up‐ and downregulation of canonical signalling pathways. In the matched analysis, the top upregulated gene was cold‐inducible mRNA binding protein (CIRBP) which plays a role in cold‐induced suppression of cell proliferation. In addition, we found three signalling pathways significantly upregulated in hypothermic patients compared to febrile patients; tryptophan degradation X, phenylalanine degradation IV and putrescine degradation III. In conclusion, there are distinct signalling pathways and genes associated with hypothermia, including tryptophan degradation and CIRBP expression, providing a possible link to the modulation of body temperature and early immunosuppression. Future studies may focus on the canonical signalling pathways presented in this paper to further investigate spontaneous hypothermia in sepsis.
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Affiliation(s)
- Matthew B. A. Harmon
- Department of Intensive Care Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
| | - Brendon P. Scicluna
- Center for Experimental & Molecular Medicine Amsterdam University Medical Centers location Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Maryse A. Wiewel
- Center for Experimental & Molecular Medicine Amsterdam University Medical Centers location Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
- Mahidol Oxford Research Unit Mahidol University Bangkok Thailand
- Nuffield Department of Medicine University of Oxford Oxford UK
| | - Janneke Horn
- Department of Intensive Care Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
| | - Olaf L. Cremer
- Department of Intensive Care Medicine University Medical Center Utrecht Utrecht The Netherlands
| | - Tom Poll
- Center for Experimental & Molecular Medicine Amsterdam University Medical Centers location Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - W. Joost Wiersinga
- Center for Experimental & Molecular Medicine Amsterdam University Medical Centers location Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology Amsterdam University Medical Centers location Academic Medical Centre University of Amsterdam Amsterdam The Netherlands
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37
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Klanderman RB, Wijnberge M, Bosboom JJ, Roelofs JJTH, de Korte D, van Bruggen R, Hollmann MW, Vroom MB, Veelo DP, Juffermans NP, Geerts BF, Vlaar APJ. Differential effects of speed and volume on transfusion-associated circulatory overload: A randomized study in rats. Vox Sang 2022; 117:371-378. [PMID: 34396543 PMCID: PMC9291097 DOI: 10.1111/vox.13191] [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: 03/02/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Transfusion-associated circulatory overload (TACO) is the primary cause of transfusion-related mortality. Speed and volume of transfusion are major risk factors. The aim of this study was to investigate the interaction of red blood cell (RBC) transfusion speed and volume on the development of TACO. MATERIALS AND METHODS A validated model for TACO in anaemic Lewis rats with an acute myocardial infarction was used. The effect on pulmonary hydrostatic pressure of one, two or four units of packed RBCs transfused in either 30 or 60 min was evaluated (3.3-26.6 ml·kg-1 ·hr-1 ). Pulmonary capillary pressure was measured as left ventricular end-diastolic pressure (LVEDP). Cardiac stress biomarkers atrial natriuretic-peptide (ANP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured 1-h post-transfusion. RESULTS Thirty animals were included (n = 5 per group). Transfusion of RBCs increased LVEDP in a volume-dependent manner (ΔLVEDP [mmHg]: -0.95, +0.50, +6.26, p < 0.001). Fast transfusion increased overall ΔLVEDP by +3.5 mmHg and up to +11.8 mmHg in the four units' group (p = 0.016). Doubling transfusion speed increased ΔLVEDP more than doubling volume in the larger volume groups. No difference in ANP or NT-proBNP were seen in high transfusion volume or groups. CONCLUSION Transfusion volume dose-dependently increased LVEDP, with speed of transfusion rapidly elevating LVEDP at higher transfusion volumes. ANP and NT-proBNP were not impacted by transfusion volume or speed in this model. TACO is seen as purely volume overload, however, this study emphasizes that limiting transfusion speed, as a modifiable risk factor, might aid in preventing TACO.
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Affiliation(s)
- Robert B. Klanderman
- Department of Intensive CareAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Marije Wijnberge
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | | | | | - Dirk de Korte
- Department of Product and Process DevelopmentSanquin Blood Bank – AmsterdamAmsterdamThe Netherlands
- Department of Blood Cell ResearchSanquin Research and Landsteiner Laboratory – AmsterdamAmsterdamThe Netherlands
| | - Robin van Bruggen
- Department of Blood Cell ResearchSanquin Research and Landsteiner Laboratory – AmsterdamAmsterdamThe Netherlands
| | - Markus W. Hollmann
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | | | - Denise P. Veelo
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Nicole P. Juffermans
- Department of Intensive CareAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Bart F. Geerts
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive CareAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
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38
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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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39
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Morales-Quinteros L, Schultz MJ, Serpa-Neto A, Antonelli M, Grieco DL, Roca O, Juffermans NP, de Haro C, de Mendoza D, Blanch L, Camprubí-Rimblas M, Gomà G, Artigas-Raventós A. Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxemic respiratory failure (PRONELIFE)-protocol for a randomized clinical trial. Trials 2022; 23:30. [PMID: 35012606 PMCID: PMC8744392 DOI: 10.1186/s13063-021-05991-2] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND It is uncertain whether awake prone positioning can prevent intubation for invasive ventilation in spontaneous breathing critically ill patients with acute hypoxemic respiratory failure. Awake prone positioning could benefit these patients for various reasons, including a reduction in direct harm to lung tissue, and prevention of tracheal intubation-related complications. DESIGN AND METHODS The PRONELIFE study is an investigator-initiated, international, multicenter, randomized clinical trial in patients who may need invasive ventilation because of acute hypoxemic respiratory failure. Consecutive patients admitted to participating ICUs are randomly assigned to standard care with awake prone positioning, versus standard care without awake prone positioning. The primary endpoint is a composite of tracheal intubation and all-cause mortality in the first 14 days after enrolment. Secondary endpoints include time to tracheal intubation and effects of awake prone positioning on oxygenation parameters, dyspnea sensation, and complications. Other endpoints are the number of days free from ventilation and alive at 28 days, total duration of use of noninvasive respiratory support, total duration of invasive ventilation, length of stay in ICU and hospital, and mortality in ICU and hospital, and at 28, 60, and 90 days. We will also collect data regarding the tolerance of prone positioning. DISCUSSION The PRONELIFE study is among the first randomized clinical trials investigating the effect of awake prone positioning on intubation rate in ICU patients with acute hypoxemic failure from any cause. The PRONELIFE study is sufficiently sized to determine the effect of awake prone positioning on intubation for invasive ventilation-patients are eligible in case of acute hypoxemic respiratory failure without restrictions regarding etiology. The PRONELIFE study is a pragmatic trial in which blinding is impossible-however, as around 35 ICUs worldwide will participate in this study, its findings will be highly generalizable. The findings of the PRONELIFE study have the potential to change clinical management of patients who may need invasive ventilation because of acute hypoxemic respiratory failure. TRIAL REGISTRATION ISRCTN ISRCTN11536318 . Registered on 17 September 2021. The PRONELIFE study is registered at clinicaltrials.gov with reference number NCT04142736 (October, 2019).
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Affiliation(s)
- L Morales-Quinteros
- Department of Intensive Care Medicine, Hospital Universitari Sant Pau, Barcelona, Spain. .,Translational Research Laboratory, Institut d'Investigació i Innovació Parc Taulí I3PT Universitat Autònoma de Barcelona Sabadell, Parc del Tauli- 08208 Sabadell, Barcelona, Spain.
| | - M J Schultz
- Department of Intensive & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, location "AMC", Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - A Serpa-Neto
- Department of Intensive & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, location "AMC", Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.,Department of Intensive Care Medicine, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - M Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, "A. Gemelli" University Hospital, Rome, Italy
| | - D L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, "A. Gemelli" University Hospital, Rome, Italy
| | - O Roca
- Department of Intensive Care Medicine & Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - N P Juffermans
- Department of Intensive & Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, location "AMC", Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis (OLVG) Hospital, Amsterdam, The Netherlands
| | - C de Haro
- Translational Research Laboratory, Institut d'Investigació i Innovació Parc Taulí I3PT Universitat Autònoma de Barcelona Sabadell, Parc del Tauli- 08208 Sabadell, Barcelona, Spain.,Department of Intensive Care Medicine, Corporación Sanitaria Universitaria Parc Tauli, Barcelona, Spain
| | - D de Mendoza
- Department of Intensive Care Medicine, Sagrat Cor University Hospital, Grupo Quironsalud, Barcelona, Spain
| | - Ll Blanch
- Translational Research Laboratory, Institut d'Investigació i Innovació Parc Taulí I3PT Universitat Autònoma de Barcelona Sabadell, Parc del Tauli- 08208 Sabadell, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Intensive Care Medicine, Corporación Sanitaria Universitaria Parc Tauli, Barcelona, Spain
| | - M Camprubí-Rimblas
- Translational Research Laboratory, Institut d'Investigació i Innovació Parc Taulí I3PT Universitat Autònoma de Barcelona Sabadell, Parc del Tauli- 08208 Sabadell, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Gomà
- Department of Intensive Care Medicine, Corporación Sanitaria Universitaria Parc Tauli, Barcelona, Spain
| | - A Artigas-Raventós
- Translational Research Laboratory, Institut d'Investigació i Innovació Parc Taulí I3PT Universitat Autònoma de Barcelona Sabadell, Parc del Tauli- 08208 Sabadell, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Intensive Care Medicine, Corporación Sanitaria Universitaria Parc Tauli, Barcelona, Spain
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Sloos PH, Maas MAW, Hollmann MW, Juffermans NP, Kleinveld DJB. The effect of shock duration on trauma-induced coagulopathy in a murine model. Intensive Care Med Exp 2022; 10:1. [PMID: 34993669 PMCID: PMC8738789 DOI: 10.1186/s40635-021-00428-1] [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: 10/13/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background Trauma-induced coagulopathy (TIC) is a life-threatening condition associated with high morbidity and mortality. TIC can present with different coagulation defects. In this study, the aim was to determine the effect of shock duration on TIC characteristics. We hypothesized that longer duration of shock leads to a more hypocoagulable rotational thromboelastometry (ROTEM) profile compared to a shorter duration of shock. Methods Male B57BL/6J(c) mice (n = 5–10 per group) were sedated and mechanically ventilated. Trauma was induced by bilateral lower limb fractures and crush injuries to the liver and small intestine. Shock was induced by blood withdrawals until a mean arterial pressure of 25–30 mmHg was achieved. Groups reflected trauma and shock for 30 min (TS30) and trauma and shock for 90 min (TS90). Control groups included ventilation only (V90) and trauma only (T90). Results Mice in the TS90 group had significantly increased base deficit compared to the V90 group. Mortality was 10% in the TS30 group and 30% in the TS90 group. ROTEM profile was more hypocoagulable, as shown by significantly lower maximum clot firmness (MCF) in the TS30 group (43.5 [37.5–46.8] mm) compared to the TS90 group (52.0 [47.0–53.0] mm, p = 0.04). ROTEM clotting time and parameters of clot build-up did not significantly differ between groups. Conclusions TIC characteristics change with shock duration. Contrary to the hypothesis, a shorter duration of shock was associated with decreased maximum clotting amplitudes compared to a longer duration of shock. The effect of shock duration on TIC should be further assessed in trauma patients. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00428-1.
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Affiliation(s)
- Pieter H Sloos
- Department of Intensive Care Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - M Adrie W Maas
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Department of Anaesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Derek J B Kleinveld
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands. .,Department of Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands.
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41
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van Haaps TF, Collard D, van Osch FHM, Middeldorp S, Coppens M, de Kruif MD, Vlot EA, Douma RA, Ten Cate H, Juffermans NP, Gritters N, Vlaar AP, Reidinga AC, Heuvelmans MA, Oudkerk M, Büller HR, van den Bergh JPW, Maas A, Ten Wolde M, Simsek S, Beudel M, van Es N. Pre-admission anticoagulant therapy and mortality in hospitalized COVID-19 patients: A retrospective cohort study. Thromb Res 2021; 208:35-38. [PMID: 34688100 PMCID: PMC8518131 DOI: 10.1016/j.thromres.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/26/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Thijs F van Haaps
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Didier Collard
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frits H M van Osch
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, the Netherlands & NUTRIM, School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands; Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Martijn D de Kruif
- Department of Pulmonary Medicine, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Eline A Vlot
- Department of Anaesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Renée A Douma
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM) and Maastricht University Medical Center, Maastricht, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Niels Gritters
- Department of Intensive Care Medicine, Treant Zorggroep, Emmen, the Netherlands
| | - Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Auke C Reidinga
- Department of Anaesthesiology, Martini Hospital, Groningen, the Netherlands
| | | | - Matthijs Oudkerk
- Institute of Diagnostic Accuracy (iDNA), Groningen, the Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | - Arno Maas
- Department of Internal Medicine, VieCuri Medical Center, Venlo, the Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
| | - Suat Simsek
- Department of Internal Medicine, Northwest Clinic, Alkmaar, the Netherlands
| | | | - Martijn Beudel
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience Institute, Amsterdam, the Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Müller MCA, Dujardin RWG, Thachil J, van Mierlo G, Zeerleder SS, Juffermans NP. The relation between fibrinogen level, neutrophil activity and nucleosomes in the onset of disseminated intravascular coagulation in the critically ill. J Intern Med 2021; 290:922-927. [PMID: 34137469 DOI: 10.1111/joim.13346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nucleosomes and neutrophil extracellular traps (NETs) are important in the pathophysiology of disseminated intravascular coagulation (DIC). Fibrinogen, as an acute phase reactant, may be protective by engaging neutrophils. We hypothesize that DIC can occur when NET formation becomes uncontrolled in relation to low fibrinogen levels. PATIENTS/METHOD The ratio of both circulating nucleosomes and human neutrophil elastase alpha-1-antitrypsine complexes (HNE-a1ATc) to fibrinogen was correlated to thrombocytopenia, DIC and organ failure in 64 critically ill coagulopathic patients. RESULTS A high nucleosome to fibrinogen ratio correlated with thrombocytopenia and organ failure (ρ -0.391, p 0.01 and ρ 0.556, p 0.01, respectively). A high HNE-a1ATc to fibrinogen ratio correlated with thrombocytopenia, DIC and organ failure (ρ -0.418, p 0.01, ρ 0.391, p 0.01 and ρ 0.477, p 0.01 respectively). CONCLUSION These findings support the hypothesis that fibrinogen is protective against DIC by counterbalancing excessive neutrophil activation.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Romein W G Dujardin
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jecko Thachil
- Department of Hematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Sacha S Zeerleder
- Sanquin Research, Amsterdam, The Netherlands.,Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, The Netherlands
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43
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Haksteen WE, Hilderink BN, Dujardin RWG, Jansen RR, Hodiamont CJ, Tuinman PR, Smit JM, Müller MCA, Juffermans NP. Venous thromboembolism is not a risk factor for the development of bloodstream infections in critically ill COVID-19 patients. Thromb Res 2021; 206:128-130. [PMID: 34461426 PMCID: PMC8384728 DOI: 10.1016/j.thromres.2021.08.019] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/16/2021] [Accepted: 08/19/2021] [Indexed: 12/03/2022]
Affiliation(s)
- Wolmet E Haksteen
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
| | | | - Romein W G Dujardin
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
| | - Rogier R Jansen
- Department of Medical Microbiology, OLVG Hospital, Amsterdam, the Netherlands
| | - Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands; Department of Medical Microbiology, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Jasper M Smit
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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44
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Kleinveld DJB, van Amstel RBE, Wirtz MR, Geeraedts LMG, Goslings JC, Hollmann MW, Juffermans NP. Platelet-to-red blood cell ratio and mortality in bleeding trauma patients: A systematic review and meta-analysis. Transfusion 2021; 61 Suppl 1:S243-S251. [PMID: 34269443 PMCID: PMC8362120 DOI: 10.1111/trf.16455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/18/2021] [Accepted: 01/18/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet-to-red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet-to-RBC. METHODS Pubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30-day mortality, thromboembolic events, organ failure, and correction of coagulopathy. RESULTS In total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53-0.89]) and 30- day mortality (OR 0.78 [0.63-0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma-induced coagulopathy. CONCLUSIONS In traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.
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Affiliation(s)
- Derek J B Kleinveld
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rombout B E van Amstel
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mathijs R Wirtz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leo M G Geeraedts
- Department of Trauma Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
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45
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marcella M Muller
- Department of Intensive Care Medicine, Amsterdam UMC, Amsterdam, The Netherlands
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46
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Hodiamont CJ, Juffermans NP, Berends SE, van Vessem DJ, Hakkens N, Mathôt RAA, de Jong MD, van Hest RM. Impact of a vancomycin loading dose on the achievement of target vancomycin exposure in the first 24 h and on the accompanying risk of nephrotoxicity in critically ill patients. J Antimicrob Chemother 2021; 76:2941-2949. [PMID: 34337660 PMCID: PMC8521408 DOI: 10.1093/jac/dkab278] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/09/2021] [Indexed: 12/29/2022] Open
Abstract
Background The advocated pharmacokinetic/pharmacodynamic (PK/PD) target for vancomycin, AUC/MIC ≥ 400 mg·h/L, may not be reached with a conventional fixed starting dose of 1000 mg in critically ill patients, but increasing the dose may cause nephrotoxicity. Objectives To evaluate the effect of a weight-based loading dose of 25 mg/kg vancomycin on PK/PD target attainment in the first 24 h (AUC0–24) in critically ill patients and to evaluate whether this increases the risk of acute kidney injury (AKI). Patients and methods A prospective observational before/after study was performed in ICU patients, comparing the percentage of vancomycin courses with AUC0–24 ≥ 400 mg·h/L and the incidence of AKI, defined as worsening of the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) score. The conventional dose group received 1000 mg of vancomycin as initial dose; the loading dose group received a weight-based loading dose of 25 mg/kg. A population PK model developed using non-linear mixed-effects modelling was used to estimate AUC0–24 in all patients. Results One hundred and four courses from 82 patients were included. With a loading dose, the percentage of courses achieving AUC0–24 ≥ 400 mg·h/L increased significantly from 53.8% to 88.0% (P = 0.0006). The percentage of patients with new-onset AKI was not significantly higher when receiving a 25 mg/kg loading dose (28.6% versus 37.8%; P = 0.48). However, the risk of AKI was significantly higher in patients achieving AUC0–24 > 400 mg·h/L compared with patients achieving AUC < 400 mg·h/L (39.0% versus 14.8%; P = 0.031). Conclusions A weight-based loading dose of 25 mg/kg vancomycin led to significantly more patients achieving AUC0–24 ≥ 400 mg·h/L without increased risk of AKI. However, some harm cannot be ruled out since higher exposure was associated with increased risk of AKI.
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Affiliation(s)
- C J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - N P Juffermans
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S E Berends
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - D J van Vessem
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - N Hakkens
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - M D de Jong
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - R M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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47
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Van Daele R, Bekkers B, Lindfors M, Broman LM, Schauwvlieghe A, Rijnders B, Hunfeld NGM, Juffermans NP, Taccone FS, Coimbra Sousa CA, Jacquet LM, Laterre PF, Nulens E, Grootaert V, Lyster H, Reed A, Patel B, Meersseman P, Debaveye Y, Wauters J, Vandenbriele C, Spriet I. A Large Retrospective Assessment of Voriconazole Exposure in Patients Treated with Extracorporeal Membrane Oxygenation. Microorganisms 2021; 9:microorganisms9071543. [PMID: 34361978 PMCID: PMC8303158 DOI: 10.3390/microorganisms9071543] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 05/31/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Voriconazole is one of the first-line therapies for invasive pulmonary aspergillosis. Drug concentrations might be significantly influenced by the use of extracorporeal membrane oxygenation (ECMO). We aimed to assess the effect of ECMO on voriconazole exposure in a large patient population. METHODS Critically ill patients from eight centers in four countries treated with voriconazole during ECMO support were included in this retrospective study. Voriconazole concentrations were collected in a period on ECMO and before/after ECMO treatment. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure and to assess the impact of possible saturation of the circuit's binding sites over time. RESULTS Sixty-nine patients and 337 samples (190 during and 147 before/after ECMO) were analyzed. Subtherapeutic concentrations (<2 mg/L) were observed in 56% of the samples during ECMO and 39% without ECMO (p = 0.80). The median trough concentration, for a similar daily dose, was 2.4 (1.2-4.7) mg/L under ECMO and 2.5 (1.4-3.9) mg/L without ECMO (p = 0.58). Extensive inter-and intrasubject variability were observed. Neither ECMO nor squared day of ECMO (saturation) were retained as significant covariates on voriconazole exposure. CONCLUSIONS No significant ECMO-effect was observed on voriconazole exposure. A large proportion of patients had voriconazole subtherapeutic concentrations.
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Affiliation(s)
- Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium;
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
- Correspondence:
| | - Britt Bekkers
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Mattias Lindfors
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17177 Stockholm, Sweden; (M.L.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, 17177 Stockholm, Sweden; (M.L.); (L.M.B.)
- Department of Physiology and Pharmacology, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Alexander Schauwvlieghe
- Department of Hematology, Ghent University Hospital, 9000 Ghent, Belgium;
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands;
| | - Bart Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands;
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands
| | - Nicole G. M. Hunfeld
- Department of Intensive Care and Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 CP Rotterdam, The Netherlands;
| | - Nicole P. Juffermans
- Department of Intensive Care, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (F.S.T.); (C.A.C.S.)
| | - Carlos Antônio Coimbra Sousa
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (F.S.T.); (C.A.C.S.)
| | - Luc-Marie Jacquet
- Cardiovascular Intensive Care, Cliniques Universitaires Saint-Luc, 1050 Brussels, Belgium;
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques Universitaires St-Luc, Université Catholique de Louvain, 1050 Brussels, Belgium;
| | - Eric Nulens
- Laboratory Medicine, Medical Microbiology, Algemeen Ziekenhuis Sint-Jan, Brugge-Oostende, 8000 Brugge, Belgium;
| | - Veerle Grootaert
- Pharmacy Department, Algemeen Ziekenhuis Sint-Jan Brugge-Oostende AV, 8000 Brugge, Belgium;
| | - Haifa Lyster
- Pharmacy Department, Royal Brompton & Harefield Hospitals, London SW3 6NP, UK;
- Cardiothoracic Transplant Unit, Royal Brompton & Harefield Hospitals, London SW3 6NP, UK;
| | - Anna Reed
- Cardiothoracic Transplant Unit, Royal Brompton & Harefield Hospitals, London SW3 6NP, UK;
- Imperial College London, London SW3 6NP, UK
| | - Brijesh Patel
- Division of Anaesthetics, Pain Medicine & Intensive Care, Department of Surgery & Cancer, Faculty of Medicine, Imperial College, London SW3 6NP, UK;
- Department of Adult Intensive Care, The Royal Brompton and Harefield Hospitals, London SW3 6NP, UK;
| | - Philippe Meersseman
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Yves Debaveye
- Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium;
- Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Joost Wauters
- Department of Microbiology and Immunology, KU Leuven, 3000 Leuven, Belgium;
- Medical Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Adult Intensive Care, The Royal Brompton and Harefield Hospitals, London SW3 6NP, UK;
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium;
- Pharmacy Department, University Hospitals Leuven, 3000 Leuven, Belgium;
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48
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van Manen L, van Hezel ME, Boshuizen M, Straat M, de Man AME, Dekimpe C, Vanhoorelbeke K, van Bruggen R, Juffermans NP. Effect of red blood cell transfusion on inflammation, endothelial cell activation and coagulation in the critically ill. Vox Sang 2021; 117:64-70. [PMID: 34196412 PMCID: PMC9291904 DOI: 10.1111/vox.13125] [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: 01/03/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 01/28/2023]
Abstract
Background and Objectives Red blood cell (RBC) transfusion is a frequently applied intervention in an intensive care unit. However, transfusion is associated with adverse outcomes including organ failure and thrombo‐embolic events. Mechanisms of these effects are not known but may be related to activation of the endothelium or of the coagulation or inflammatory system. We hypothesized that a RBC transfusion in the critically ill would result in further activation of these systems. Materials and Methods In 74 non‐bleeding critically ill patients receiving one RBC unit, markers of inflammation, endothelial cell activation and coagulation were measured before transfusion, at 1 h after transfusion and 24 h after transfusion. The impact of disease severity of the recipient on these changes was assessed by comparing septic and non‐septic patients (according to sepsis‐3 definition) and by correlation of biomarkers with the sequential organ failure assessment (SOFA) score. Results Levels of von Willebrand Factor (vWF), soluble ICAM‐1, soluble thrombomodulin, fibrinogen and d‐dimer were already high at baseline, whereas ADAMTS13 levels were low. VWF levels increased significantly 24 h after RBC transfusion (median 478% (338–597) vs. 526% (395–623), p = 0.009). The other biomarkers did not change significantly. Post transfusion change was not dependent on the presence of sepsis and was not correlated with SOFA score. Conclusion RBC transfusion in critically ill patients was associated with an increase in circulating vWF levels, suggesting a further increase in activation of the endothelium, a finding that was independent of the presence of sepsis or organ injury level.
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Affiliation(s)
- Lisa van Manen
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location VUmc, University of Amsterdam, Amsterdam, The Netherlands.,Department of Blood Cell Research, Sanquin research and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Maike E van Hezel
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location VUmc, University of Amsterdam, Amsterdam, The Netherlands.,Department of Blood Cell Research, Sanquin research and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Margit Boshuizen
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location VUmc, University of Amsterdam, Amsterdam, The Netherlands.,Department of Blood Cell Research, Sanquin research and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Marleen Straat
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location VUmc, University of Amsterdam, Amsterdam, The Netherlands
| | - Angelique M E de Man
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Charlotte Dekimpe
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin research and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, Location VUmc, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, OLVG Hospital, Amsterdam, The Netherlands
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49
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van den Brink DP, Kleinveld DJB, Sloos PH, Thomas KA, Stensballe J, Johansson PI, Pati S, Sperry J, Spinella PC, Juffermans NP. Plasma as a resuscitation fluid for volume-depleted shock: Potential benefits and risks. Transfusion 2021; 61 Suppl 1:S301-S312. [PMID: 34057210 PMCID: PMC8361764 DOI: 10.1111/trf.16462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/04/2021] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Daan P. van den Brink
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Derek J. B. Kleinveld
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | - Pieter H. Sloos
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | | | - Jakob Stensballe
- Department of Anesthesia and Trauma Center, Centre of Head and OrthopedicsRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
- Department of Clinical immunologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Pär I. Johansson
- Department of Clinical immunologyRigshospitalet, Copenhagen University HospitalCopenhagenDenmark
| | - Shibani Pati
- Department of Laboratory MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Jason Sperry
- Department of Surgery and Critical Care MedicineUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | | | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
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50
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Aman J, Duijvelaar E, Botros L, Kianzad A, Schippers JR, Smeele PJ, Azhang S, Bartelink IH, Bayoumy AA, Bet PM, Boersma W, Bonta PI, Boomars KAT, Bos LDJ, van Bragt JJMH, Braunstahl GJ, Celant LR, Eger KAB, Geelhoed JJM, van Glabbeek YLE, Grotjohan HP, Hagens LA, Happe CM, Hazes BD, Heunks LMA, van den Heuvel M, Hoefsloot W, Hoek RJA, Hoekstra R, Hofstee HMA, Juffermans NP, Kemper EM, Kos R, Kunst PWA, Lammers A, van der Lee I, van der Lee EL, Maitland-van der Zee AH, Mau Asam PFM, Mieras A, Muller M, Neefjes L, Nossent EJ, Oswald LMA, Overbeek MJ, Pamplona C, Paternotte N, Pronk N, de Raaf MA, van Raaij BFM, Reijrink M, Schultz MJ, Serpa Neto A, Slob EM, Smeenk FWJM, Smit MR, Smits AJ, Stalenhoef JE, Tuinman PR, Vanhove ALEM, Wessels JN, van Wezenbeek JCC, Vonk Noordegraaf A, de Man FS, Bogaard HJ. Imatinib in patients with severe COVID-19: a randomised, double-blind, placebo-controlled, clinical trial. Lancet Respir Med 2021; 9:957-968. [PMID: 34147142 PMCID: PMC8232929 DOI: 10.1016/s2213-2600(21)00237-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The major complication of COVID-19 is hypoxaemic respiratory failure from capillary leak and alveolar oedema. Experimental and early clinical data suggest that the tyrosine-kinase inhibitor imatinib reverses pulmonary capillary leak. METHODS This randomised, double-blind, placebo-controlled, clinical trial was done at 13 academic and non-academic teaching hospitals in the Netherlands. Hospitalised patients (aged ≥18 years) with COVID-19, as confirmed by an RT-PCR test for SARS-CoV-2, requiring supplemental oxygen to maintain a peripheral oxygen saturation of greater than 94% were eligible. Patients were excluded if they had severe pre-existing pulmonary disease, had pre-existing heart failure, had undergone active treatment of a haematological or non-haematological malignancy in the previous 12 months, had cytopenia, or were receiving concomitant treatment with medication known to strongly interact with imatinib. Patients were randomly assigned (1:1) to receive either oral imatinib, given as a loading dose of 800 mg on day 0 followed by 400 mg daily on days 1-9, or placebo. Randomisation was done with a computer-based clinical data management platform with variable block sizes (containing two, four, or six patients), stratified by study site. The primary outcome was time to discontinuation of mechanical ventilation and supplemental oxygen for more than 48 consecutive hours, while being alive during a 28-day period. Secondary outcomes included safety, mortality at 28 days, and the need for invasive mechanical ventilation. All efficacy and safety analyses were done in all randomised patients who had received at least one dose of study medication (modified intention-to-treat population). This study is registered with the EU Clinical Trials Register (EudraCT 2020-001236-10). FINDINGS Between March 31, 2020, and Jan 4, 2021, 805 patients were screened, of whom 400 were eligible and randomly assigned to the imatinib group (n=204) or the placebo group (n=196). A total of 385 (96%) patients (median age 64 years [IQR 56-73]) received at least one dose of study medication and were included in the modified intention-to-treat population. Time to discontinuation of ventilation and supplemental oxygen for more than 48 h was not significantly different between the two groups (unadjusted hazard ratio [HR] 0·95 [95% CI 0·76-1·20]). At day 28, 15 (8%) of 197 patients had died in the imatinib group compared with 27 (14%) of 188 patients in the placebo group (unadjusted HR 0·51 [0·27-0·95]). After adjusting for baseline imbalances between the two groups (sex, obesity, diabetes, and cardiovascular disease) the HR for mortality was 0·52 (95% CI 0·26-1·05). The HR for mechanical ventilation in the imatinib group compared with the placebo group was 1·07 (0·63-1·80; p=0·81). The median duration of invasive mechanical ventilation was 7 days (IQR 3-13) in the imatinib group compared with 12 days (6-20) in the placebo group (p=0·0080). 91 (46%) of 197 patients in the imatinib group and 82 (44%) of 188 patients in the placebo group had at least one grade 3 or higher adverse event. The safety evaluation revealed no imatinib-associated adverse events. INTERPRETATION The study failed to meet its primary outcome, as imatinib did not reduce the time to discontinuation of ventilation and supplemental oxygen for more than 48 consecutive hours in patients with COVID-19 requiring supplemental oxygen. The observed effects on survival (although attenuated after adjustment for baseline imbalances) and duration of mechanical ventilation suggest that imatinib might confer clinical benefit in hospitalised patients with COVID-19, but further studies are required to validate these findings. FUNDING Amsterdam Medical Center Foundation, Nederlandse Organisatie voor Wetenschappelijk Onderzoek/ZonMW, and the European Union Innovative Medicines Initiative 2.
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Affiliation(s)
- Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Erik Duijvelaar
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Liza Botros
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Azar Kianzad
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Job R Schippers
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Patrick J Smeele
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Sara Azhang
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Department of Pulmonology, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Imke H Bartelink
- Department of Pharmacy, Amsterdam UMC, VUMC, Amsterdam, Netherlands
| | - Ahmed A Bayoumy
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Department of Pulmonology, Chest Unit, Suez Canal University, Suez, Egypt
| | - Pierre M Bet
- Department of Pharmacy, Amsterdam UMC, VUMC, Amsterdam, Netherlands
| | - Wim Boersma
- Department of Pulmonology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - Peter I Bonta
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Karin A T Boomars
- Department of Pulmonology, Erasmus Medisch Centrum, Rotterdam, Netherlands
| | - Lieuwe D J Bos
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands; Department of Intensive Care, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Job J M H van Bragt
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gert-Jan Braunstahl
- Department of Pulmonology, Sint Franciscus Ziekenhuis, Rotterdam, Netherlands
| | - Lucas R Celant
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Katrien A B Eger
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Yurika L E van Glabbeek
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Hans P Grotjohan
- Department of Pulmonology, Isala Ziekenhuizen, Zwolle, Netherlands
| | - Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Chris M Happe
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Boaz D Hazes
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Leo M A Heunks
- Department of Intensive Care, Amsterdam UMC, VUMC, Amsterdam, Netherlands
| | | | | | - Rianne J A Hoek
- Department of Pharmacy, Amsterdam UMC, VUMC, Amsterdam, Netherlands
| | - Romke Hoekstra
- Department of Pulmonology, Antonius Ziekenhuis, Sneek, Netherlands
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Amsterdam UMC, AMC, Amsterdam, Netherlands; Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | | | - Renate Kos
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Peter W A Kunst
- Department of Pulmonology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Ariana Lammers
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ivo van der Lee
- Department of Pulmonology, Spaarne Gasthuis, Haarlem, Netherlands
| | - E Laurien van der Lee
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Pearl F M Mau Asam
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | - Adinda Mieras
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Mirte Muller
- Department of Pulmonology, Catharina Ziekenhuis, Eindhoven, Netherlands
| | - Liesbeth Neefjes
- Department of Pulmonology, Catharina Ziekenhuis, Eindhoven, Netherlands
| | - Esther J Nossent
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Laurien M A Oswald
- Department of Pulmonology, Sint Franciscus Ziekenhuis, Rotterdam, Netherlands
| | - Maria J Overbeek
- Department of Pulmonology, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Carolina Pamplona
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Nienke Paternotte
- Department of Pulmonology, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - Niels Pronk
- Department of Pulmonology, Gelre Ziekenhuis, Apeldoorn, Netherlands
| | - Michiel A de Raaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bas F M van Raaij
- Department of Pulmonology Leiden University Medical Center, Leiden, Netherlands
| | - Merlijn Reijrink
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - Ary Serpa Neto
- Department of Critical Care Medicine and Institute of Education and Research, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Elise M Slob
- Department of Respiratory Medicine, Amsterdam UMC, AMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, AMC, Amsterdam, Netherlands
| | - A Josien Smits
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Janneke E Stalenhoef
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam UMC, VUMC, Amsterdam, Netherlands
| | - Arthur L E M Vanhove
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jessie N Wessels
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jessie C C van Wezenbeek
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Frances S de Man
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Harm J Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VUMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
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