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van Nieuw Amerongen MP, de Grooth HJ, Veerman GL, Ziesemer KA, van Berge Henegouwen MI, Tuinman PR. ASO Author Reflections: Prediction of Morbidity and Mortality After Esophagectomy: A Systematic Review. Ann Surg Oncol 2024; 31:3471-3472. [PMID: 38451389 PMCID: PMC10997706 DOI: 10.1245/s10434-024-15089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/08/2024] [Indexed: 03/08/2024]
Affiliation(s)
- M P van Nieuw Amerongen
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands.
| | - H J de Grooth
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands
| | - G L Veerman
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands
| | - K A Ziesemer
- Medical Library, Vrije Universiteit, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands
- Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam, The Netherlands
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2
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Klompmaker P, Mousa A, Tuinman PR. The authors reply. Crit Care Med 2024; 52:e254-e255. [PMID: 38619355 DOI: 10.1097/ccm.0000000000006232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Peter Klompmaker
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Amsterdam Leiden IC Focused Echography (ALIFE, www.alifeofpocus.com), Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
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3
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van Nieuw Amerongen MP, de Grooth HJ, Veerman GL, Ziesemer KA, van Berge Henegouwen MI, Tuinman PR. Prediction of Morbidity and Mortality After Esophagectomy: A Systematic Review. Ann Surg Oncol 2024; 31:3459-3470. [PMID: 38383661 PMCID: PMC10997705 DOI: 10.1245/s10434-024-14997-4] [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: 11/11/2023] [Accepted: 01/18/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Esophagectomy for esophageal cancer has a complication rate of up to 60%. Prediction models could be helpful to preoperatively estimate which patients are at increased risk of morbidity and mortality. The objective of this study was to determine the best prediction models for morbidity and mortality after esophagectomy and to identify commonalities among the models. PATIENTS AND METHODS A systematic review was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and was prospectively registered in PROSPERO ( https://www.crd.york.ac.uk/prospero/ , study ID CRD42022350846). Pubmed, Embase, and Clarivate Analytics/Web of Science Core Collection were searched for studies published between 2010 and August 2022. The Prediction model Risk of Bias Assessment Tool was used to assess the risk of bias. Extracted data were tabulated and a narrative synthesis was performed. RESULTS Of the 15,011 articles identified, 22 studies were included using data from tens of thousands of patients. This systematic review included 33 different models, of which 18 models were newly developed. Many studies showed a high risk of bias. The prognostic accuracy of models differed between 0.51 and 0.85. For most models, variables are readily available. Two models for mortality and one model for pulmonary complications have the potential to be developed further. CONCLUSIONS The availability of rigorous prediction models is limited. Several models are promising but need to be further developed. Some models provide information about risk factors for the development of complications. Performance status is a potential modifiable risk factor. None are ready for clinical implementation.
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Affiliation(s)
- M P van Nieuw Amerongen
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands.
| | - H J de Grooth
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands
| | - G L Veerman
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands
| | - K A Ziesemer
- Medical Library, Vrije Universiteit, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Adult Intensive Care Medicine, Amsterdam UMC (VUmc), Amsterdam, The Netherlands
- Amsterdam Institute for Immunology and Infectious Diseases, Amsterdam, The Netherlands
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Kreca SM, Albers IS, Musters SCW, van Dijkum EJMN, Tuinman PR, Eskes AM. The effect of family-centered care on unplanned emergency room visits, hospital readmissions and intensive care admissions after surgery: a root cause analysis from a prospective multicenter study in the Netherlands. Patient Saf Surg 2024; 18:14. [PMID: 38689336 PMCID: PMC11061973 DOI: 10.1186/s13037-024-00399-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Optimizing transitional care by practicing family-centered care might reduce unplanned events for patients who undergo major abdominal cancer surgery. However, it remains unknown whether involving family caregivers in patients' healthcare also has negative consequences for patient safety. This study assessed the safety of family involvement in patients' healthcare by examining the cause of unplanned events in patients who participated in a family involvement program (FIP) after major abdominal cancer surgery. METHODS This is a secondary analysis focusing on the intervention group of a prospective cohort study conducted in the Netherlands. Data were collected from April 2019 to May 2022. Participants in the intervention group were patients who engaged in a FIP. Unplanned events were analyzed, and root causes were identified using the medical version of a prevention- and recovery-information system for monitoring and analysis (PRISMA) that analyses unintended events in healthcare. Unplanned events were compared between patients who received care from family caregivers and patients who received professional at-home care after discharge. A Mann-Whitney U test was used to analyze data. RESULTS Of the 152 FIP participants, 68 experienced an unplanned event and were included. 112 unplanned events occurred with 145 root causes since some unplanned events had several root causes. Most root causes of unplanned events were patient-related factors (n = 109, 75%), such as patient characteristics and disease-related factors. No root causes due to inadequate healthcare from the family caregiver were identified. Unplanned events did not differ statistically (interquartile range 1-2) (p = 0.35) between patients who received care from trained family caregivers and those who received professional at-home care after discharge. CONCLUSION Based on the insights from the root-cause analysis in this prospective multicenter study, it appears that unplanned emergency room visits and hospital readmissions are not related to the active involvement of family caregivers in surgical follow-up care. Moreover, surgical follow-up care by trained family caregivers during hospitalization was not associated with increased rates of unplanned adverse events. Hence, the concept of active family involvement by proficiently trained family caregivers in postoperative care appears safe and feasible for patients undergoing major abdominal surgery.
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Affiliation(s)
- Sani Marijke Kreca
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Treatment and quality of life, Meibergdeef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Iris Sophie Albers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Anesthesiology, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Selma Clazina Wilhelmina Musters
- Cancer Center Amsterdam, Treatment and quality of life, Meibergdeef 9, 1105 AZ, Amsterdam, the Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Els Jaqueline Maria Nieveen van Dijkum
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Treatment and quality of life, Meibergdeef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Pieter Roel Tuinman
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, G01 2.03 Gold Coast campus Griffith University, Gold Coast, QLD, 4222, Australia
- Department of Intensive Care Amsterdam cardiovascular Sciences Amsterdam institute for Infection and Immunity, Amsterdam UMC location Vrije Universiteit Amsterdam NL, Amsterdam, The Netherlands
| | - Anne Maria Eskes
- Cancer Center Amsterdam, Treatment and quality of life, Meibergdeef 9, 1105 AZ, Amsterdam, the Netherlands.
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
- Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, G01 2.03 Gold Coast campus Griffith University, Gold Coast, QLD, 4222, Australia.
- Intensive Care, Amsterdam UMC location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, 1081HV, The Netherlands.
- Faculty of Health, Centre of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands.
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5
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Smit MR, Hagens LA, Heijnen NFL, Pisani L, Cherpanath TGV, Dongelmans DA, de Grooth HJS, Pierrakos C, Tuinman PR, Zimatore C, Paulus F, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ. Lung Ultrasound Prediction Model for Acute Respiratory Distress Syndrome: A Multicenter Prospective Observational Study. Am J Respir Crit Care Med 2023; 207:1591-1601. [PMID: 36790377 PMCID: PMC10273105 DOI: 10.1164/rccm.202210-1882oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Rationale: Lung ultrasound (LUS) is a promising tool for diagnosis of acute respiratory distress syndrome (ARDS), but adequately sized studies with external validation are lacking. Objectives: To develop and validate a data-driven LUS score for diagnosis of ARDS and compare its performance with that of chest radiography (CXR). Methods: This multicenter prospective observational study included invasively ventilated ICU patients who were divided into a derivation cohort and a validation cohort. Three raters scored ARDS according to the Berlin criteria, resulting in a classification of "certain no ARDS," or "certain ARDS" when experts agreed or "uncertain ARDS" when evaluations conflicted. Uncertain cases were classified in a consensus meeting. Results of a 12-region LUS exam were used in a logistic regression model to develop the LUS-ARDS score. Measurements and Main Results: Three hundred twenty-four (16% certain ARDS) and 129 (34% certain ARDS) patients were included in the derivation cohort and the validation cohort, respectively. With an ARDS diagnosis by the expert panel as the reference test, the LUS-ARDS score, including the left and right LUS aeration scores and anterolateral pleural line abnormalities, had an area under the receiver operating characteristic (ROC) curve of 0.90 (95% confidence interval [CI], 0.85-0.95) in certain patients of the derivation cohort and 0.80 (95% CI, 0.72-0.87) in all patients of the validation cohort. Within patients who had imaging-gold standard chest computed tomography available, diagnostic accuracy of eight independent CXR readers followed the ROC curve of the LUS-ARDS score. Conclusions: The LUS-ARDS score can be used to accurately diagnose ARDS also after external validation. The LUS-ARDS score may be a useful adjunct to a diagnosis of ARDS after further validation, as it showed performance comparable with that of the current practice with experienced CXR readers but more objectifiable diagnostic accuracy at each cutoff.
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Affiliation(s)
- Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Dave A. Dongelmans
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Harm-Jan S. de Grooth
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Charalampos Pierrakos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Pieter Roel Tuinman
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Intensive Care Unit, Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; and
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
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Heldeweg MLA, Mousa A, Lieveld AWE, Smit JM, Haaksma ME, Tuinman PR. Authors' reply: "Lung ultrasound to predict gas-exchange response to prone positioning in COVID-19 patients: A prospective study in pilot and confirmation cohorts". J Crit Care 2023:154321. [PMID: 37137783 PMCID: PMC10149293 DOI: 10.1016/j.jcrc.2023.154321] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Micah L A Heldeweg
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - Amne Mousa
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - Arthur W E Lieveld
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - J M Smit
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - M E Haaksma
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
| | - Pieter Roel Tuinman
- Department of intensive care medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands..
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7
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Heldeweg MLA, Heldeweg TTR, Schober P, Tuinman PR, de Grooth HJ. Interrater Agreement for Lung Ultrasound Scoring: Practice and Methods, Make Perfect. J Ultrasound Med 2023; 42:951-952. [PMID: 36125246 DOI: 10.1002/jum.16094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
- Department of Anesthesia, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Tomas T R Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Patrick Schober
- Department of Anesthesia, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
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Bos LDJ, de Grooth HJ, Tuinman PR. A structured diagnostic algorithm for patients with ARDS. Crit Care 2023; 27:94. [PMID: 36941668 PMCID: PMC10027589 DOI: 10.1186/s13054-023-04368-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Lieuwe Durk Jacobus Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Harm Jan de Grooth
- Department of Intensive Care, Amsterdam UMC, Location VUMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, Location VUMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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9
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Lieveld AWE, Heldeweg MLA, Schouwenburg J, Veldhuis L, Haaksma ME, van Haaften RM, Teunissen BP, Smit JM, Twisk J, Heunks L, Nanayakkara PWB, Tuinman PR. Monitoring of pulmonary involvement in critically ill COVID-19 patients - should lung ultrasound be preferred over CT? Ultrasound J 2023; 15:11. [PMID: 36842163 PMCID: PMC9968403 DOI: 10.1186/s13089-022-00299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 11/27/2022] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND It is unclear if relevant changes in pulmonary involvement in critically ill COVID-19 patients can be reliably detected by the CT severity score (CTSS) and lung ultrasound score (LUSS), or if these changes have prognostic implications. In addition, it has been argued that adding pleural abnormalities to the LUSS could improve its prognostic value. The objective of this study was to compare LUSS and CTSS for the monitoring of COVID-19 pulmonary involvement through: first, establishing the correlation of LUSS (± pleural abnormalities) and CTSS throughout admission; second, assessing agreement and measurement error between raters for LUSS, pleural abnormalities, and CTSS; third, evaluating the association of the LUSS (± pleural abnormalities) and CTSS with mortality at different timepoints. METHODS This is a prospective, observational study, conducted during the second COVID-19 wave at the AmsterdamUMC, location VUmc. Adult COVID-19 ICU patients were prospectively included when a CT or a 12-zone LUS was performed at admission or at weekly intervals according to local protocol. Patients were followed 90 days or until death. We calculated the: (1) Correlation of the LUSS (± pleural abnormalities) and CTSS throughout admission with mixed models; (2) Intra-class correlation coefficients (ICCs) and smallest detectable changes (SDCs) between raters; (3) Association between the LUSS (± pleural abnormalities) and CTSS with mixed models. RESULTS 82 consecutive patients were included. Correlation between LUSS and CTSS was 0.45 (95% CI 0.31-0.59). ICCs for LUSS, pleural abnormalities, and CTSS were 0.88 (95% CI 0.73-0.95), 0.94 (95% CI 0.90-0.96), and 0.84 (95% CI 0.65-0.93), with SDCs of 4.8, 1.4, and 3.9. The LUSS was associated with mortality in week 2, with a score difference between patients who survived or died greater than its SDC. Addition of pleural abnormalities was not beneficial. The CTSS was associated with mortality only in week 1, but with a score difference less than its SDC. CONCLUSIONS LUSS correlated with CTSS throughout ICU admission but performed similar or better at agreement between raters and mortality prognostication. Given the benefits of LUS over CT, it should be preferred as initial monitoring tool.
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Affiliation(s)
- Arthur W. E. Lieveld
- grid.509540.d0000 0004 6880 3010Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location VU Medical Center, Postbox 7507, 1007MB Amsterdam, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Micah L. A. Heldeweg
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jasper Schouwenburg
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Lars Veldhuis
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Mark E. Haaksma
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Rutger M. van Haaften
- grid.509540.d0000 0004 6880 3010Section Emergency Radiology, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Berend P. Teunissen
- grid.509540.d0000 0004 6880 3010Section Emergency Radiology, Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Jasper M. Smit
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Jos Twisk
- grid.509540.d0000 0004 6880 3010Department of Epidemiology and Data Science, Amsterdam UMC, Location VU Medical Center, Amsterdam, The Netherlands
| | - Leo Heunks
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands
| | - Prabath W. B. Nanayakkara
- grid.509540.d0000 0004 6880 3010Section Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location VU Medical Center, Postbox 7507, 1007MB Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- grid.509540.d0000 0004 6880 3010Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VU Medical Center, Amsterdam, The Netherlands ,Amsterdam Leiden IC Focused Echography (ALIFE), Amsterdam, The Netherlands
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Overgaauw A, Meijboom LJ, van Es J, Lust EJ, Serne EH, Nanayakkara P, Smulders YM, Kooter AJ, Sprengers RW, de Grooth HJ, Lely RJ, Thijs A, Noordegraaf AV, Heunks L, Elbers P, Bogaard HJ, Tuinman PR, Nossent EJ. Real-world characteristics and outcomes of patients with intermediate high risk acute pulmonary embolism. Acute Med 2023; 22:61-66. [PMID: 37306130 DOI: 10.52964/amja.0936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Exact benefits of currently recommended close monitoring in intermediate high risk acute pulmonary embolism (PE) patients are unknown. METHODS This prospective observational cohort study determined clinical characteristics, and disease course of intermediate high risk acute PE patients in an academic hospital setting . Frequency of hemodynamic deterioration, use of rescue reperfusion therapy and PE related mortality, were outcomes of interest. RESULTS Of 98 intermediate high risk PE patients included for analysis, 81 patients (83%) were closely monitored. Two deteriorated hemodynamically and were treated with rescue reperfusion therapy. One patient survived after this. CONCLUSIONS In these 98 intermediate high risk PE patients, hemodynamic deterioration occurred in three patients and rescue reperfusion therapy of two closely monitored patients led to survival of one. Underlining the need for better recognition of patients benefitting from and research in the optimal way of close monitoring.
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Affiliation(s)
- Ajc Overgaauw
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - L J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - J van Es
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Cardiovascular Sciences, Amsterdam, The Netherlands
| | - E J Lust
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - E H Serne
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - Pwb Nanayakkara
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - Y M Smulders
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - A J Kooter
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - R W Sprengers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - H J de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - R J Lely
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - A Thijs
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - A Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Lma Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - Pwg Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - H J Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Cardiovascular Sciences, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - E J Nossent
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Cardiovascular Sciences, Amsterdam, The Netherlands
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Ruigrok D, Handoko ML, Meijboom LJ, Nossent EJ, Boonstra A, Braams NJ, van Wezenbeek J, Tepaske R, Tuinman PR, Heunks LM, Vonk Noordegraaf A, de Man FS, Symersky P, Bogaard HJ. Non-invasive follow-up strategy after pulmonary endarterectomy for CTEPH. ERJ Open Res 2022; 8:00564-2021. [PMID: 35586450 PMCID: PMC9108966 DOI: 10.1183/23120541.00564-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/16/2022] [Indexed: 11/26/2022] Open
Abstract
Background The success of pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is usually evaluated by performing a right heart catheterisation (RHC). Here, we investigate whether residual pulmonary hypertension (PH) can be sufficiently excluded without the need for a RHC, by making use of early post-operative haemodynamics, or N-terminal pro-brain natriuretic peptide (NT-proBNP), cardiopulmonary exercise testing (CPET) and transthoracic echocardiography (TTE) 6 months after PEA. Methods In an observational analysis, residual PH after PEA measured by RHC was related to haemodynamic data from the post-operative intensive care unit time and data from a 6-month follow-up assessment including NT-proBNP, TTE and CPET. After dichotomisation and univariate analysis, sensitivity, specificity, positive predictive value, negative predictive value (NPV) and likelihood ratios were calculated. Results Thirty-six out of 92 included patients had residual PH 6 months after PEA (39%). Correlation between early post-operative and 6-month follow-up mean pulmonary artery pressure was moderate (Spearman rho 0.465, p<0.001). Early haemodynamics did not predict late success. NT-proBNP >300 ng·L−1 had insufficient NPV (0.71) to exclude residual PH. Probability for PH on TTE had a moderate NPV (0.74) for residual PH. Peak oxygen consumption (V′O2) <80% predicted had the highest sensitivity (0.85) and NPV (0.84) for residual PH. Conclusions CPET 6 months after PEA, and to a lesser extent TTE, can be used to exclude residual CTEPH, thereby safely reducing the number of patients needing to undergo re-RHC after PEA. In approximately one-third to one-half of CTEPH patients, residual pulmonary hypertension after pulmonary endarterectomy can be excluded based on cardiopulmonary exercise testing or echocardiography, without the need for right heart catheterisationhttps://bit.ly/3pbj2Ge
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Pisani L, Algera AG, Neto AS, Azevedo L, Pham T, Paulus F, de Abreu MG, Pelosi P, Dondorp AM, Bellani G, Laffey JG, Schultz MJ, Martinez A, Leal L, Jorge Pereira A, de Oliveira Maia M, Neto JA, Piras C, Caser EB, Moreira CL, Braga Gusman P, Dalcomune DM, Ribeiro de Carvalho AG, Gondim LAR, Castelo Branco Reis LM, da Cunha Ribeiro D, de Assis Simões L, Campos RS, Fernandez Versiani dos Anjos JC, Bruzzi Carvalho F, Alves RA, Nunes LB, Réa-Neto Á, de Oliveira MC, Tannous L, Cardoso Gomes B, Rodriguez FB, Abelha P, Lugarinho ME, Japiassu A, de Melo HK, Lopes EA, Varaschin P, de Souza Dantas VC, Freitas Knibel M, Ponte M, de Azambuja Rodrigues PM, Costa Filho RC, Saddy F, Wanderley Castellões TF, Silva SA, Osorio LAG, Mannarino D, Espinoza R, Righy C, Soares M, Salluh J, Tanaka L, Aragão D, Tavares ME, Kehdi MGP, Rezende VMC, Carbonell RCC, Teixeira C, de Oliveira RP, Maccari JG, Castro PS, Berto P, Schwarz P, Torelly AP, Lisboa T, Moraes E, Dal-Pizzol F, Tomasi Damiani C, Ritter C, Ferreira JC, Teixeira Costa R, Caruso P, Amendola CP, de Oliveira AMRR, Silva UVA, Sanches LC, Almeida RDS, Azevedo LC, Park M, Schettino G, Assunção MS, Silva E, Barboza CE, Junior APN, Marzocchi Tierno PFGM, Malbouisson LM, Oliveira L, Cristovao D, Neto ML, Rego Ê, Fernandes FE, Romano MLP, Cavalcanti AB, de Souza Barros D, Rodgers H, Dixon B, Smith R, Kol M, Wong H, Schmid W, Hermans G, Ceunen H, Bourgeois M, Anquez N, Suzumura ÉA, Decruyenaere J, DeCrop L, Neto AS, Souza dos Santos R, Beraldo D, dos Santos MC, Pellegrini JAS, Piras C, Oliveira V, Munhoz C, Meira KL, Peçanha AC, da Silva Ramos FJ, Maia I, Bahl M, Biondi R, Prado D, Pinto SF, Salgado J, Falcão LF, Macruz T, de Oliveira GA, Cavalcanti AB, Romano MLP, Ruas K, Mecatti GC, Caser EB, Gava IA, Carreño N, Morales M, Avendaño R, Aguirre S, Luciano PM, Sribar A, Klaric V, Skilijic S, Dvorscak MB, Krkusek M, Jurjevic M, Karanovic N, Simurina T, Stourac P, Kratochvil M, Pacheco ED, Máca J, Wrigge H, Schlegel C, Treschan TA, Schaefer M, Aytulun A, Kienbaum P, Clarkson K, Jaafar R, Collins D, Mazza BF, Plant R, Melchionda G, Di Lauro E, Cortegiani A, Russotto V, Caione R, Mestria D, Volta CA, Spadaro S, Botteri M, Machado FR, Seghelini E, Brazzi L, Sales G, D'Antini D, Molin A, Severgnini P, Bacuzzi A, Peluso L, Verrastro P, Raimondo P, Ferreira E, Gecaj-Gashi A, Simonis FD, Tuinman PR, Alberts E, van den Hul I, Kuiper M, de Wilde RBP, Koopmans M, Kose I, Zincircioglu Ç, dos Santos RB, Dogan N, Aydin D, Denker AS, Buyukkocak U, Akgun N, Turan G, Senturk E, Demirtürk Z, Özcan PE, Ekinci O, Colombo AS, Saylan S, Eren G, Ulger F, Dilek A, Ulusoy H, Goktas U, Soyoral L, Toman H, Orak Y, Kahveci F, Nogueira AC, Mills GH, Pinder A, Walker R, Harrison J, Snell J, Seasman C, Pearson R, Sharman M, Kaloo C, Bynorth N, Fernandes JB, Matthews K, Hughes C, Rose A, Simeson K, Niska L, Huneke N, Adderly J, Padilla-Harris C, Oliver R, Brohi F, Nóbrega RS, Wilson N, Talbot H, Wilson D, Smith D, Dark P, Evans T, Fisher N, 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Jovanovic B, Surbatovic M, Veljovic M, Van Haren F. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. The Lancet Global Health 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.
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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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14
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Heldeweg MLA, Vermue L, Kant M, Brouwer M, Girbes ARJ, Haaksma ME, Heunks LMA, Mousa A, Smit JM, Smits TW, Paulus F, Ket JCF, Schultz MJ, Tuinman PR. The impact of lung ultrasound on clinical-decision making across departments: a systematic review. Ultrasound J 2022; 14:5. [PMID: 35006383 PMCID: PMC8748548 DOI: 10.1186/s13089-021-00253-3] [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: 07/27/2021] [Accepted: 12/25/2021] [Indexed: 12/12/2022] Open
Abstract
Background Lung ultrasound has established itself as an accurate diagnostic tool in different clinical settings. However, its effects on clinical-decision making are insufficiently described. This systematic review aims to investigate the impact of lung ultrasound, exclusively or as part of an integrated thoracic ultrasound examination, on clinical-decision making in different departments, especially the emergency department (ED), intensive care unit (ICU), and general ward (GW). Methods This systematic review was registered at PROSPERO (CRD42021242977). PubMed, EMBASE, and Web of Science were searched for original studies reporting changes in clinical-decision making (e.g. diagnosis, management, or therapy) after using lung ultrasound. Inclusion criteria were a recorded change of management (in percentage of cases) and with a clinical presentation to the ED, ICU, or GW. Studies were excluded if examinations were beyond the scope of thoracic ultrasound or to guide procedures. Mean changes with range (%) in clinical-decision making were reported. Methodological data on lung ultrasound were also collected. Study quality was scored using the Newcastle–Ottawa scale. Results A total of 13 studies were included: five studies on the ED (546 patients), five studies on the ICU (504 patients), two studies on the GW (1150 patients), and one study across all three wards (41 patients). Lung ultrasound changed the diagnosis in mean 33% (15–44%) and 44% (34–58%) of patients in the ED and ICU, respectively. Lung ultrasound changed the management in mean 48% (20–80%), 42% (30–68%) and 48% (48–48%) of patients in the ED, in the ICU and in the GW, respectively. Changes in management were non-invasive in 92% and 51% of patients in the ED and ICU, respectively. Lung ultrasound methodology was heterogeneous across studies. Risk of bias was moderate to high in all studies. Conclusions Lung ultrasound, exclusively or as a part of thoracic ultrasound, has substantial impact on clinical-decision making by changing diagnosis and management in the EDs, ICUs, and GWs. The current evidence level and methodological heterogeneity underline the necessity for well-designed trials and standardization of methodology. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-021-00253-3.
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Affiliation(s)
- Micah L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands. .,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands.
| | - Lian Vermue
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Max Kant
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Michelle Brouwer
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Mark E Haaksma
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands
| | - Thomas W Smits
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Johannes C F Ket
- Medical Library, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, 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
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Postbox 7507, 1007MB, Amsterdam, The Netherlands.,Amsterdam Leiden IC Echography (ALIFE), Amsterdam, The Netherlands
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15
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Jansen D, Jonkman AH, Vries HJD, Wennen M, Elshof J, Hoofs MA, van den Berg M, Man AMED, Keijzer C, Scheffer GJ, van der Hoeven JG, Girbes A, Tuinman PR, Marcus JT, Ottenheijm CAC, Heunks L. Positive end-expiratory pressure affects geometry and function of the human diaphragm. J Appl Physiol (1985) 2021; 131:1328-1339. [PMID: 34473571 DOI: 10.1152/japplphysiol.00184.2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Positive end-expiratory pressure (PEEP) is routinely applied in mechanically ventilated patients to improve gas exchange and respiratory mechanics by increasing end-expiratory lung volume (EELV). In a recent experimental study in rats, we demonstrated that prolonged application of PEEP causes diaphragm remodeling, especially longitudinal muscle fiber atrophy. This is of potential clinical importance, as the acute withdrawal of PEEP during ventilator weaning decreases EELV and thereby stretches the adapted, longitudinally atrophied diaphragm fibers to excessive sarcomere lengths, having a detrimental effect on force generation. Whether this series of events occurs in the human diaphragm is unknown. In the current study, we investigated if short-term application of PEEP affects diaphragm geometry and function, which are prerequisites for the development of longitudinal atrophy with prolonged PEEP application. Nineteen healthy volunteers were noninvasively ventilated with PEEP levels of 2, 5, 10, and 15 cmH2O. Magnetic resonance imaging was performed to investigate PEEP-induced changes in diaphragm geometry. Subjects were instrumented with nasogastric catheters to measure diaphragm neuromechanical efficiency (i.e., diaphragm pressure normalized to its electrical activity) during tidal breathing with different PEEP levels. We found that increasing PEEP from 2 to 15 cmH2O resulted in a caudal diaphragm displacement (19 [14-26] mm, P < 0.001), muscle shortening in the zones of apposition (20.6% anterior and 32.7% posterior, P < 0.001), increase in diaphragm thickness (36.4% [0.9%-44.1%], P < 0.001) and reduction in neuromechanical efficiency (48% [37.6%-56.6%], P < 0.001). These findings demonstrate that conditions required to develop longitudinal atrophy in the human diaphragm are present with the application of PEEP.NEW & NOTEWORTHY We demonstrate that PEEP causes changes in diaphragm geometry, especially muscle shortening, and decreases in vivo diaphragm contractile function. Thus, prerequisites for the development of diaphragm longitudinal muscle atrophy are present with the acute application of PEEP. Once confirmed in ventilated critically ill patients, this could provide a new mechanism for ventilator-induced diaphragm dysfunction and ventilator weaning failure in the intensive care unit (ICU).
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Affiliation(s)
- Diana Jansen
- Department of Anesthesiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annemijn H Jonkman
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Heder J de Vries
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Myrte Wennen
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Judith Elshof
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Maud A Hoofs
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Marloes van den Berg
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Angélique M E de Man
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Christiaan Keijzer
- Department of Anesthesiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Armand Girbes
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - J Tim Marcus
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Coen A C Ottenheijm
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Leo Heunks
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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16
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Schenk J, van der Ven WH, Schuurmans J, Roerhorst S, Cherpanath TGV, Lagrand WK, Thoral P, Elbers PWG, Tuinman PR, Scheeren TWL, Bakker J, Geerts BF, Veelo DP, Paulus F, Vlaar APJ. Definition and incidence of hypotension in intensive care unit patients, an international survey of the European Society of Intensive Care Medicine. J Crit Care 2021; 65:142-148. [PMID: 34148010 DOI: 10.1016/j.jcrc.2021.05.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/16/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Although hypotension in ICU patients is associated with adverse outcome, currently used definitions are unknown and no universally accepted definition exists. METHODS We conducted an international, peer-reviewed survey among ICU physicians and nurses to provide insight in currently used definitions, estimations of incidence, and duration of hypotension. RESULTS Out of 1394 respondents (1055 physicians (76%) and 339 nurses (24%)), 1207 (82%) completed the questionnaire. In all patient categories, hypotension definitions were predominantly based on an absolute MAP of 65 mmHg, except for the neuro(trauma) category (75 mmHg, p < 0.001), without differences between answers from physicians and nurses. Hypotension incidence was estimated at 55%, and time per day spent in hypotension at 15%, both with nurses reporting higher percentages than physicians (estimated mean difference 5%, p = 0.01; and 4%, p < 0.001). CONCLUSIONS An absolute MAP threshold of 65 mmHg is most frequently used to define hypotension in ICU patients. In neuro(trauma) patients a higher threshold was reported. The majority of ICU patients are estimated to endure hypotension during their ICU admission for a considerable amount of time, with nurses reporting a higher estimated incidence and time spent in hypotension than physicians.
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Affiliation(s)
- J Schenk
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands
| | - W H van der Ven
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands
| | - J Schuurmans
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Meibergdreef 9, Amsterdam, Netherlands
| | - S Roerhorst
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands
| | - T G V Cherpanath
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Meibergdreef 9, Amsterdam, Netherlands
| | - W K Lagrand
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Meibergdreef 9, Amsterdam, Netherlands
| | - P Thoral
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Intensive Care, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity, de Boelelaan 1117, Amsterdam, Netherlands
| | - P W G Elbers
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Intensive Care, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity, de Boelelaan 1117, Amsterdam, Netherlands
| | - P R Tuinman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Intensive Care, Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity, de Boelelaan 1117, Amsterdam, Netherlands
| | - T W L Scheeren
- University Medical Center Groningen, University of Groningen, Department of Anesthesiology, Groningen, Netherlands
| | - J Bakker
- New York University Langone Medical Center, New York University Langone Health, Department of Pulmonary and Critical Care, New York, USA; Columbia University Medical Center, Columbia University, Department of Pulmonology and Critical Care, New York, USA; Erasmus MC University Medical Center, Erasmus University, Department of Intensive Care, Rotterdam, Netherlands; Hospital Clínico Pontificia Universidad Católica de Chile, Pontificia Universidad Católica de Chile, Departamento de Medicina Intensiva, Santiago, Chile
| | - B F Geerts
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands
| | - D P Veelo
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands
| | - F Paulus
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Meibergdreef 9, Amsterdam, Netherlands; Amsterdam UMC, University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands
| | - A P J Vlaar
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Meibergdreef 9, Amsterdam, Netherlands; Amsterdam UMC, University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Meibergdreef 9, Amsterdam, Netherlands.
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17
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Bakkum MJ, Schouten VL, Smulders YM, Nossent EJ, van Agtmael MA, Tuinman PR. Accelerated treatment with rtPA for pulmonary embolism induced circulatory arrest. Thromb Res 2021; 203:74-80. [PMID: 33971387 DOI: 10.1016/j.thromres.2021.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/17/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
Patients with circulatory arrest due to pulmonary embolism (PE) should be treated with fibrinolytics. Current guidelines do not specify which regimen to apply, and it has been suggested that the regimen of 100 mg rtPA/2 h should be used, because this is recommended for hemodynamic instable PE in the ESC/ERS Guideline. This two hour regimen, however, is incompatible with key principles of cardiopulmonary resuscitation (CPR), such as employment of interventions that allow fast evaluation of effectiveness, and limitation of the total duration of CPR to avoid poor neurological outcomes. Additionally, the low flow-state during CPR has important consequences for the pharmacokinetic properties of rtPA. Arguably, the volume of distribution is lower, the metabolism reduced and the half life time longer. Therefore, these changes largely discard the rationale to use high dosages of rtPA over a prolonged period of time. More importantly, these changes highlight that the guideline recommendations, based on studies in patients without circulatory arrest, cannot be easily translated to the situation of circulatory arrest. An accelerated regimen of rtPA (0.6 mg/kg/15 min., max 50 mg) is mentioned by the 2019 ESC/ERS Guideline. However, empirical support or a rationale is not provided. Due to the rarity of the situation and ethical difficulties associated with randomizing unconscious patients, a randomized head-to-head comparison between the two regimens is unlikely to ever be performed. With this comprehensive overview of the pharmacokinetics of rtPA and current literature, a strong rationale is provided that the accelerated protocol is the regimen of choice for patients with PE-induced circulatory arrest.
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Affiliation(s)
- M J Bakkum
- Amsterdam UMC, Department of Internal Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - V L Schouten
- Amsterdam UMC, Department of Intensive Care Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands; Noordwest Ziekenhuisgroep, Department of Intensive Care, Location Alkmaar and Den Helder, Wilhelminalaan 12, 1815 JD Alkmaar, the Netherlands
| | - Y M Smulders
- Amsterdam UMC, Department of Internal Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - E J Nossent
- Amsterdam UMC, Department of Pulmonology, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - M A van Agtmael
- Amsterdam UMC, Department of Internal Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - P R Tuinman
- Amsterdam UMC, Department of Intensive Care Medicine, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
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18
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de Bruin S, Bos LD, van Roon MA, Tuip-de Boer AM, Schuurman AR, Koel-Simmelinck MJA, Bogaard HJ, Tuinman PR, van Agtmael MA, Hamann J, Teunissen CE, Wiersinga WJ, Koos Zwinderman AH, Brouwer MC, van de Beek D, Vlaar APJ. Clinical features and prognostic factors in Covid-19: A prospective cohort study. EBioMedicine 2021; 67:103378. [PMID: 34000622 PMCID: PMC8118723 DOI: 10.1016/j.ebiom.2021.103378] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Mortality rates are high among hospitalized patients with COVID-19, especially in those intubated on the ICU. Insight in pathways associated with unfavourable outcome may lead to new treatment strategies. METHODS We performed a prospective cohort study of patients with COVID-19 admitted to general ward or ICU who underwent serial blood sampling. To provide insight in the pathways involved in disease progression, associations were estimated between outcome risk and serial measurements of 64 biomarkers in potential important pathways of COVID-19 infection (inflammation, tissue damage, complement system, coagulation and fibrinolysis) using joint models combining Cox regression and linear mixed-effects models. For patients admitted to the general ward, the primary outcome was admission to the ICU or mortality (unfavourable outcome). For patients admitted to the ICU, the primary outcome was 12-week mortality. FINDINGS A total of 219 patients were included: 136 (62%) on the ward and 119 patients (54%) on the ICU; 36 patients (26%) were included in both cohorts because they were transferred from general ward to ICU. On the general ward, 54 of 136 patients (40%) had an unfavourable outcome and 31 (23%) patients died. On the ICU, 54 out of 119 patients (45%) died. Unfavourable outcome on the general ward was associated with changes in concentrations of IL-6, IL-8, IL-10, soluble Receptor for Advanced Glycation End Products (sRAGE), vascular cell adhesion molecule 1 (VCAM-1) and Pentraxin-3. Death on the ICU was associated with changes in IL-6, IL-8, IL-10, sRAGE, VCAM-1, Pentraxin-3, urokinase-type plasminogen activator receptor, IL-1-receptor antagonist, CD14, procalcitonin, tumor necrosis factor alfa, tissue factor, complement component 5a, Growth arrest-specific 6, angiopoietin 2, and lactoferrin. Pathway analysis showed that unfavourable outcome on the ward was mainly driven by chemotaxis and interleukin production, whereas death on ICU was associated with a variety of pathways including chemotaxis, cell-cell adhesion, innate host response mechanisms, including the complement system, viral life cycle regulation, angiogenesis, wound healing and response to corticosteroids. INTERPRETATION Clinical deterioration in patients with severe COVID-19 involves multiple pathways, including chemotaxis and interleukin production, but also endothelial dysfunction, the complement system, and immunothrombosis. Prognostic markers showed considerable overlap between general ward and ICU patients, but we identified distinct differences between groups that should be considered in the development and timing of interventional therapies in COVID-19. FUNDING Amsterdam UMC, Amsterdam UMC Corona Fund, and Dr. C.J. Vaillant Fonds.
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Affiliation(s)
- Sanne de Bruin
- From the Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Lieuwe D Bos
- From the Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marian A van Roon
- Department of Neurology, University of Amsterdam, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Anita M Tuip-de Boer
- From the Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Alex R Schuurman
- Department of Infectious Diseases, University of Amsterdam, Amsterdam UMC, Amsterdam Infection and Immunity, Amsterdam, The Netherlands
| | - Marleen J A Koel-Simmelinck
- Neurochemistry Laboratory, Department of Clinical Chemistry, Free University, Amsterdam, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jörg Hamann
- Biobank Core Facility, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Charlotte E Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Free University, Amsterdam, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Department of Infectious Diseases, University of Amsterdam, Amsterdam UMC, Amsterdam Infection and Immunity, Amsterdam, The Netherlands
| | - A H Koos Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, University of Amsterdam, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, University of Amsterdam, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands.
| | - Alexander P J Vlaar
- From the Department of Intensive Care, University of Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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19
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Shi ZH, Jonkman AH, Tuinman PR, Chen GQ, Xu M, Yang YL, Heunks LMA, Zhou JX. Role of a successful spontaneous breathing trial in ventilator liberation in brain-injured patients. Ann Transl Med 2021; 9:548. [PMID: 33987246 PMCID: PMC8105847 DOI: 10.21037/atm-20-6407] [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] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Spontaneous breathing trials (SBTs) have been shown to improve outcomes in critically ill patients. However, in patients with brain injury, indications for intubation and mechanical ventilation are different from those of non-neurological patients, and the role of an SBT in patients with brain injury is less established. The aim of the present study was to compare key respiratory variables acquired during a successful SBT between patients with successful ventilator liberation versus failed ventilator liberation. METHODS In this prospective study, patients with brain injury (≥18 years of age), who completed a 30-min SBT, were enrolled. Airway pressure, flow, esophageal pressure, and diaphragm electrical activity (ΔEAdi) were recorded before (baseline) and during the SBT. Respiratory rate (RR), tidal volume, inspiratory muscle pressure (ΔPmus), ΔEAdi, and neuromechanical efficiency (ΔPmus/ΔEAdi) of the diaphragm were calculated breath by breath and compared between the liberation success and failure groups. Failed liberation was defined as the need for invasive ventilator assistance within 48 h after the SBT. RESULTS In total, 46 patients (51.9±13.2 years, 67.4% male) completed the SBT. Seventeen (37%) patients failed ventilator liberation within 48 h. Another 11 patients required invasive ventilation within 7 days after completing the SBT. There were no differences in baseline characteristics between the success and failed groups. In-depth analysis showed similar changes in patterns and values of respiratory physiological parameters between the groups. CONCLUSIONS In patients with brain injury, ventilator liberation failure was common after successful SBT. In-depth physiological analysis during the SBT did not provide data to predict successful liberation in these patients. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (No. NCT02863237).
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Affiliation(s)
- Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leo M. A. Heunks
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
- Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, The Netherlands
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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20
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Juschten J, Tuinman PR, Guo T, Juffermans NP, Schultz MJ, Loer SA, Girbes ARJ, de Grooth HJ. Between-trial heterogeneity in ARDS research. Intensive Care Med 2021; 47:422-434. [PMID: 33713156 PMCID: PMC7955690 DOI: 10.1007/s00134-021-06370-w] [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: 12/23/2020] [Accepted: 02/15/2021] [Indexed: 02/07/2023]
Abstract
Purpose Most randomized controlled trials (RCTs) in patients with acute respiratory distress syndrome (ARDS) revealed indeterminate or conflicting study results. We aimed to systematically evaluate between-trial heterogeneity in reporting standards and trial outcome. Methods A systematic review of RCTs published between 2000 and 2019 was performed including adult ARDS patients receiving lung-protective ventilation. A random-effects meta-regression model was applied to quantify heterogeneity (non-random variability) and to evaluate trial and patient characteristics as sources of heterogeneity. Results In total, 67 RCTs were included. The 28-day control-group mortality rate ranged from 10 to 67% with large non-random heterogeneity (I2 = 88%, p < 0.0001). Reported baseline patient characteristics explained some of the outcome heterogeneity, but only six trials (9%) reported all four independently predictive variables (mean age, mean lung injury score, mean plateau pressure and mean arterial pH). The 28-day control group mortality adjusted for patient characteristics (i.e. the residual heterogeneity) ranged from 18 to 45%. Trials with significant benefit in the primary outcome reported a higher control group mortality than trials with an indeterminate outcome or harm (mean 28-day control group mortality: 44% vs. 28%; p = 0.001). Conclusion Among ARDS RCTs in the lung-protective ventilation era, there was large variability in the description of baseline characteristics and significant unexplainable heterogeneity in 28-day control group mortality. These findings signify problems with the generalizability of ARDS research and underline the urgent need for standardized reporting of trial and baseline characteristics. Supplementary Information The online version of this article (10.1007/s00134-021-06370-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- J Juschten
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands. .,Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - P R Tuinman
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - T Guo
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Division of System Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - N P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, Universiteit Van Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - M 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
| | - S A Loer
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A R J Girbes
- Department of Intensive Care, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, mail stop ZH 7D-172, 1081HV, Amsterdam, The Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J de Grooth
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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21
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Juschten J, Ingelse SA, Bos LDJ, Girbes ARJ, Juffermans NP, van der Poll T, Schultz MJ, Tuinman PR. Alkaline phosphatase in pulmonary inflammation-a translational study in ventilated critically ill patients and rats. Intensive Care Med Exp 2020; 8:46. [PMID: 33336319 PMCID: PMC7746537 DOI: 10.1186/s40635-020-00335-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/31/2022] Open
Abstract
Background Alkaline phosphatase (AP), a dephosphorylating enzyme, is involved in various physiological processes and has been shown to have anti-inflammatory effects. Aim To determine the correlation between pulmonary AP activity and markers of inflammation in invasively ventilated critically ill patients with or without acute respiratory distress syndrome (ARDS), and to investigate the effect of administration of recombinant AP on pulmonary inflammation in a well-established lung injury model in rats Methods AP activity was determined and compared with levels of various inflammatory mediators in bronchoalveolar lavage fluid (BALF) samples obtained from critically ill patients within 2 days of start of invasive ventilation. The endpoints of this part of the study were the correlations between AP activity and markers of inflammation, i.e., interleukin (IL)-6 levels in BALF. In RccHan Wistar rats, lung injury was induced by intravenous administration of 10 mg/kg lipopolysaccharide, followed by ventilation with a high tidal volume for 4 h. Rats received either an intravenous bolus of 1500 IU/kg recombinant AP or normal saline 2 h after intravenous LPS administration, right before start of ventilation. Endpoints of this part of the study were pulmonary levels of markers of inflammation, including IL-6, and markers of endothelial and epithelial dysfunction. Results BALF was collected from 83 patients; 10 patients had mild ARDS, and 15 had moderate to severe ARDS. AP activity correlated well with levels of IL-6 (r = 0.70), as well as with levels of other inflammatory mediators. Pulmonary AP activity between patients with and without ARDS was comparable (0.33 [0.14–1.20] vs 0.55 [0.21–1.42] U/L; p = 0.37). Animals with acute lung injury had markedly elevated pulmonary AP activity compared to healthy controls (2.58 [2.18–3.59] vs 1.01 [0.80–1.46] U/L; p < 0.01). Intravenous administration of recombinant AP did neither affect pulmonary inflammation nor endothelial and epithelial dysfunction. Conclusions In ventilated critically ill patients, pulmonary AP activity correlates well with markers of pulmonary inflammation, such as IL-6 and IL-8. In animals with lung injury, pulmonary AP activity is elevated. Administration of recombinant AP does not alter pulmonary inflammation and endothelial or epithelial dysfunction in the acute phase of a murine lung injury model.
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Affiliation(s)
- Jenny Juschten
- Department of Intensive Care, Amsterdam University Medical Centers, location "VU", Mail stop ZH 7D-172, De Boelelaan 1117, 1082 RW, Amsterdam, the Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, location "VU", Amsterdam, the Netherlands. .,Department of Intensive Care, Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands.
| | - Sarah A Ingelse
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands.,Emma Children's Hospital-Pediatric Intensive Care Unit, Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands
| | - Lieuwe D J Bos
- Department of Pulmonology, Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands
| | - Armand R J Girbes
- Department of Intensive Care, Amsterdam University Medical Centers, location "VU", Mail stop ZH 7D-172, De Boelelaan 1117, 1082 RW, Amsterdam, the Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, location "VU", Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands.,Department of Intensive Care, OLVG hospital, Amsterdam, The Netherlands
| | - Tom van der Poll
- Division of Infectious Diseases, Amsterdam University Medical Centers, location "AMC", Amsterdam, The Netherlands.,Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers, location "AMC", Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location "AMC", Amsterdam, the Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L⋅E⋅I⋅C⋅A), Amsterdam University Medical Centers, 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
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam University Medical Centers, location "VU", Mail stop ZH 7D-172, De Boelelaan 1117, 1082 RW, Amsterdam, the Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam University Medical Centers, location "VU", Amsterdam, the Netherlands
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22
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van den Berg A, van Eeghen EE, Kooter AJ, Tuinman TH, Tuinman PR. [Ayahuasca in the Netherlands: what the doctor should know about its side effects]. Ned Tijdschr Geneeskd 2020; 164:D4501. [PMID: 32940978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In the past few months, ayahuasca has received quite a bit of coverage in the lay press. Ayahuasca is a South American hallucinogenic tea that is gaining popularity in Europe and North America. In the Netherlands, ayahuasca is usually used in a group ceremony called an 'ayahuasca ceremony'. Use of ayahuasca is not associated with the development of substance dependency. The side effects of ayahuasca are considered mild. We describe a 36-year-old woman who developed severe hyponatremia after participating in an ayahuasca ceremony. We also discuss the mechanism of action, the effects, the therapeutic potential and the risks of this hallucinogenic agent.
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Affiliation(s)
- A van den Berg
- Amsterdam UMC, locatie VUmc, afd. Intensive Care, Amsterdam
- Contact: A. van den Berg
| | - E E van Eeghen
- Amsterdam UMC, locatie VUmc, afd. Interne geneeskunde, Amsterdam
| | - A J Kooter
- Amsterdam UMC, locatie VUmc, afd. Interne geneeskunde, Amsterdam
| | | | - P R Tuinman
- Amsterdam UMC, locatie VUmc, afd. Intensive Care, Amsterdam
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23
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Haaksma ME, Smit JM, Heldeweg MLA, Pisani L, Elbers P, Tuinman PR. Lung ultrasound and B-lines: B careful! Intensive Care Med 2020; 46:544-545. [PMID: 31996959 DOI: 10.1007/s00134-019-05911-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 12/21/2019] [Indexed: 12/21/2022]
Affiliation(s)
- M E Haaksma
- Department of Intensive Care Medicine, Amsterdam Leiden IC Focused Echography (ALIFE), Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - J M Smit
- Department of Intensive Care Medicine, Amsterdam Leiden IC Focused Echography (ALIFE), Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - M L A Heldeweg
- Department of Intensive Care Medicine, Amsterdam Leiden IC Focused Echography (ALIFE), Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - L Pisani
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Universiteit van Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - P Elbers
- Department of Intensive Care Medicine, Amsterdam Leiden IC Focused Echography (ALIFE), Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, Amsterdam Leiden IC Focused Echography (ALIFE), Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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24
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Zwager CL, Tuinman PR, de Grooth HJ, Kooter J, Ket H, Fleuren LM, Elbers PWG. Why physiology will continue to guide the choice between balanced crystalloids and normal saline: a systematic review and meta-analysis. Crit Care 2019; 23:366. [PMID: 31752973 PMCID: PMC6868741 DOI: 10.1186/s13054-019-2658-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/22/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Crystalloids are the most frequently prescribed drugs in intensive care medicine and emergency medicine. Thus, even small differences in outcome may have major implications, and therefore, the choice between balanced crystalloids versus normal saline continues to be debated. We examined to what extent the currently accrued information size from completed and ongoing trials on the subject allow intensivists and emergency physicians to choose the right fluid for their patients. METHODS Systematic review and meta-analysis with random effects inverse variance model. Published randomized controlled trials enrolling adult patients to compare balanced crystalloids versus normal saline in the setting of intensive care medicine or emergency medicine were included. The main outcome was mortality at the longest follow-up, and secondary outcomes were moderate to severe acute kidney injury (AKI) and initiation of renal replacement therapy (RRT). Trial sequential analyses (TSA) were performed, and risk of bias and overall quality of evidence were assessed. Additionally, previously published meta-analyses, trial sequential analyses and ongoing large trials were analysed for included studies, required information size calculations and the assumptions underlying those calculations. RESULTS Nine studies (n = 32,777) were included. Of those, eight had data available on mortality, seven on AKI and six on RRT. Meta-analysis showed no significant differences between balanced crystalloids versus normal saline for mortality (P = 0.33), the incidence of moderate to severe AKI (P = 0.37) or initiation of RRT (P = 0.29). Quality of evidence was low to very low. Analysis of previous meta-analyses and ongoing trials showed large differences in calculated required versus accrued information sizes and assumptions underlying those. TSA revealed the need for extremely large trials based on our realistic and clinically relevant assumptions on relative risk reduction and baseline mortality. CONCLUSIONS Our meta-analysis could not find significant differences between balanced crystalloids and normal saline on mortality at the longest follow-up, moderate to severe AKI or new RRT. Currently accrued information size is smaller, and the required information size is larger than previously anticipated. Therefore, completed and ongoing trials on the topic may fail to provide adequate guidance for choosing the right crystalloid. Thus, physiology will continue to play an important role for individualizing this choice.
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Affiliation(s)
- Charlotte L Zwager
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jos Kooter
- Department of Internal Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Hans Ket
- University Library, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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25
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Touw HR, Schuitemaker AE, Daams F, van der Peet DL, Bronkhorst EM, Schober P, Boer C, Tuinman PR. Routine lung ultrasound to detect postoperative pulmonary complications following major abdominal surgery: a prospective observational feasibility study. Ultrasound J 2019; 11:20. [PMID: 31523784 PMCID: PMC6745303 DOI: 10.1186/s13089-019-0135-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 03/09/2019] [Accepted: 08/16/2019] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative pulmonary complications after major abdominal surgery are associated with adverse outcome. The diagnostic accuracy of chest X-rays (CXR) to detect pulmonary disorders is limited. Alternatively, lung ultrasound (LUS) is an established evidence-based point-of-care diagnostic modality which outperforms CXR in critical care. However, its feasibility and diagnostic ability for postoperative pulmonary complications following abdominal surgery are unknown. In this prospective observational feasibility study, we included consecutive patients undergoing major abdominal surgery with an intermediate or high risk developing postoperative pulmonary complications according to the Assess Respiratory risk In Surgical patients in CATalonia (ARISCAT) score. LUS was routinely performed on postoperative days 0–3 by a researcher blinded for CXR or other clinical findings. Then, reports were drawn up for LUS concerning feasibility and detection rates of postoperative pulmonary complications. CXRs were performed on demand according to daily clinical practice. Subsequently, we compared LUS and CXR findings. Results A total of 98 consecutive patients with an ARISCAT score of 41 (34–49) were included in the study. LUS was feasible in all patients. In 94 (95%) patients, LUS detected one or more postoperative pulmonary complications during the first four postoperative days. On day 0, LUS detected 31 out of 43 patients (72.1%) with one or more postoperative pulmonary complications, compared to 13 out of 36 patients (36.1%) with 1 or more postoperative pulmonary complications detected with CXR RR 2.0 (95 CI [1.24–3.20]) (p = 0.004). The number of discordant observations between both modalities was high for atelectasis 23 (43%) and pleural effusion 29 (54%), but not for pneumothorax, respiratory infection and pulmonary edema 8 (15%), 3 (5%), and 5 (9%), respectively. Conclusions This study shows that LUS is highly feasible and frequently detects postoperative pulmonary complications after major abdominal surgery. Discordant observations in atelectasis and pleural effusions for LUS and CXR can be explained by a superior diagnostic ability of LUS in detecting these conditions. The effects of LUS as primary imaging modality on patient outcome should be evaluated in future studies.
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Affiliation(s)
- H R Touw
- Department of Anaesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | - A E Schuitemaker
- Department of Anaesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - F Daams
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - D L van der Peet
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - E M Bronkhorst
- Department of Health Evidence, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - P Schober
- Department of Anaesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C Boer
- Department of Anaesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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26
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Abstract
When using lung ultrasound to determine the cause of acute respiratory failure, the BLUE protocol is often used. In a 65-year old patient, an A/B-profile was found, suggesting pneumonia, following the flowchart of this protocol. In this case, however, pulmonary hemorrhage confirmed by bronchoscopy was the final diagnosis. This case report outlines the importance of understanding the limitations of the BLUE protocol and that lung ultrasound findings should always be used in the context of the patient’s history and physical exam. In addition, pulmonary hemorrhage should be considered in patients with no clinical signs of pneumonia and/or presence of risk factors for lung bleeding as a rare cause of lung ultrasound A/B-profile.
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Affiliation(s)
- Mark E Haaksma
- Research VUMC Intensive Care (REVIVE), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity Institute (AI&II), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Intensive Care, VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Leiden Focused Intensive care Focused Echography (ALIFE), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands
| | - Esther J Nossent
- Amsterdam Medical Data Science (AMDS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Pulmonology, VU University Medical Center, Amsterdam, Amsterdam, The Netherlands
| | - Paul Elbers
- Research VUMC Intensive Care (REVIVE), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity Institute (AI&II), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Intensive Care, VU University Medical Center, Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Research VUMC Intensive Care (REVIVE), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Medical Data Science (AMDS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Science (ACS), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Infection and Immunity Institute (AI&II), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Intensive Care, VU University Medical Center, Amsterdam, Amsterdam, The Netherlands.,Amsterdam Leiden Focused Intensive care Focused Echography (ALIFE), VU University Medical Center, Amsterdam, Amsterdam, The Netherlands
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27
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Juschten J, Ingelse SA, Maas MAW, Girbes ARJ, Juffermans NP, Schultz MJ, Tuinman PR. Antithrombin plus alpha-1 protease inhibitor does not affect coagulation and inflammation in two murine models of acute lung injury. Intensive Care Med Exp 2019; 7:36. [PMID: 31346884 PMCID: PMC6658634 DOI: 10.1186/s40635-019-0240-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 02/22/2019] [Accepted: 03/07/2019] [Indexed: 01/23/2023] Open
Abstract
Background In acute respiratory distress syndrome (ARDS), uncontrolled production of activators of coagulation and proinflammatory mediators results in a shift from an adequate local innate immune response to hypercoagulability and inflammation. This study aimed to investigate whether the protease inhibitors antithrombin (AT) and alpha-1 protease inhibitor (A1PI) may attenuate an exaggerated pulmonary immune response. Methods Lung injury was induced either by single intranasal administration of lipopolysaccharide (LPS) (5 mg/kg) in BALB/c mice or by combination of an intravenous injection of LPS (10 mg/kg) with subsequent injurious ventilation using high tidal volumes (12–15 ml/kg) for 4 h in RccHan Wistar rats. Animals received either a single bolus of AT (250 IU/kg) or A1PI (60 mg/kg) alone or in combination, with or without intravenous low-dose heparin (100 U/kg). Control animals received saline. Additional controls received neither LPS, nor ventilation, nor treatment. Endpoints were local and systemic markers of coagulation, e.g., thrombin–antithrombin complexes (TATc), and inflammation, e.g., interleukin-6. Results Both lung injury models resulted in a pronounced immune response within the pulmonary compartment shown by elevated levels of markers of coagulation and inflammation. The two-hit lung injury model also induced profound systemic coagulopathy and inflammation. Monotherapy with AT or A1PI did not reduce pulmonary coagulopathy or inflammation in any lung injury model. Nor did combination therapy with AT and A1PI result in a decrease of coagulation or inflammatory parameters. AT markedly reduced systemic levels of TATc in the two-hit lung injury model. Systemic inflammation was not affected by the different interventions. Additional administration of heparin did not lead to macroscopic bleeding incidences. Conclusions In two different murine models of acute lung injury, neither single therapy with AT or A1PI nor combination of both agents attenuates the pronounced pulmonary coagulation or inflammatory response.
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Affiliation(s)
- Jenny Juschten
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, Netherlands. .,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, Netherlands. .,Department of Intensive Care, Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands. .,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands.
| | - Sarah Anne Ingelse
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands.,Emma Children's Hospital-Pediatric Intensive Care Unit, Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands
| | - Martinus Adrianus Wilhelmus Maas
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands
| | - Armand Roelof Johan Girbes
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, Netherlands
| | - Nicole Petra Juffermans
- Department of Intensive Care, Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands
| | - Marcus Josephus Schultz
- Department of Intensive Care, Amsterdam UMC, Academic Medical Center, Amsterdam, Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Pieter Roel Tuinman
- Department of Intensive Care, Amsterdam UMC, VU Medical Center, Amsterdam, Netherlands.,Research VUmc Intensive Care (REVIVE), Amsterdam UMC, VU Medical Center, Amsterdam, Netherlands
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28
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Jonkman AH, Jansen D, Gadgil S, Keijzer C, Girbes ARJ, Scheffer GJ, van der Hoeven JG, Tuinman PR, Spoelstra-de Man AME, Sinderby CS, Heunks LMA. Monitoring patient-ventilator breath contribution in the critically ill during neurally adjusted ventilatory assist: reliability and improved algorithms for bedside use. J Appl Physiol (1985) 2019; 127:264-271. [PMID: 31161879 DOI: 10.1152/japplphysiol.00071.2019] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The patient-ventilator breath contribution (PVBC) index estimates the relative contribution of the patient to total tidal volume (Vtinsp) during mechanical ventilation in neurally adjusted ventilator assist mode and has been used to titrate ventilator support. The reliability of this index in ventilated patients is unknown and was investigated in this study. PVBC was calculated by comparing tidal volume (Vtinsp) and diaphragm electrical activity (EAdi) during assisted breaths (Vtinsp/EAdi)assist and during unassisted breaths (Vtinsp/EAdi)no-assist. Vtinsp was normalized to peak EAdi (EAdipeak) using 1) one assisted breath, 2) five consecutive assisted breaths, or 3) five assisted breaths with matching EAdi preceding the unassisted breath (N1PVBC2, X5PVBC2, and PX5VBCEAdi-matching2 , respectively). In addition, PVBC was calculated by comparing only Vtinsp for breaths with matching EAdi (PVBCβ2). Test-retest reliability of the different PVBC calculation methods was evaluated with the intraclass correlation coefficient (ICC) using five repeated PVBC maneuvers performed with a 1-min interval. In total, 125 PVBC maneuvers were analyzed in 25 patients. ICC [95% confidence interval] values were 0.46 [0.23-0.66], 0.51 [0.33-0.70], and 0.42 [0.14-0.69] for N1PVBC2, X5PVBC2, PX5VBCEAdi-matching2 , respectively. Complex waveform analyses showed that insufficient EAdi filtering by the ventilator software affects reliability of PVBC calculation. With our new EAdi-matching techniques reliability improved (PVBCβ2 ICC: 0.78 [0.60-0.90]). We conclude that current techniques to calculate PVBC exhibit low reliability and that our newly developed criteria and estimation of PVBC-using Vtinsp of assisted breaths and unassisted breaths with matching EAdi-improves reliability. This may help implementation of PVBC in clinical practice. NEW & NOTEWORTHY The patient-ventilator breath contribution (PVBC) index estimates the relative contribution of the patient to tidal volume generated by the patient and the mechanical ventilator during mechanical ventilation in neurally adjusted ventilator assist mode. It could be used to titrate ventilator support and thus to limit development of diaphragm dysfunction in intensive care unit patients. Currently available methods for bedside assessment of PVBC are unreliable. Our newly developed criteria and estimation of PVBC largely improve reliability and help to quantify patient contribution to total inspiratory effort.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | - Diana Jansen
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Suvarna Gadgil
- Department of Anesthesiology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center , Nijmegen , The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
| | | | - Christer S Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario , Canada
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam , The Netherlands
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29
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Simonis FD, Serpa Neto A, Binnekade JM, Braber A, Bruin KCM, Determann RM, Goekoop GJ, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, de Wilde RBP, Vriends M, Gama de Abreu M, Pelosi P, Schultz MJ. Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial. JAMA 2018; 320:1872-1880. [PMID: 30357256 PMCID: PMC6248136 DOI: 10.1001/jama.2018.14280] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS). OBJECTIVE To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017, including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands. INTERVENTIONS Invasive ventilation using low tidal volumes (n = 477) or intermediate tidal volumes (n = 484). MAIN OUTCOMES AND MEASURES The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, or pneumothorax. RESULTS In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. At day 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stay or 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and 90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24]; P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severe atelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55). CONCLUSIONS AND RELEVANCE In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02153294.
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Affiliation(s)
| | - Fabienne D Simonis
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Jan M Binnekade
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Annemarije Braber
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Karina C M Bruin
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | - Rogier M Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Geert-Jan Goekoop
- Department of Intensive Care, Westfriesgasthuis, Hoorn, the Netherlands
| | - Jeroen Heidt
- Department of Intensive Care Tergooi, Hilversum, the Netherlands
| | - Janneke Horn
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Gerard Innemee
- Department of Intensive Care Tergooi, Hilversum, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, the Netherlands
| | - Rob B P de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Marijn Vriends
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, the Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
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30
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Touw HR, Parlevliet KL, Beerepoot M, Tuinman PR. Ultrasound for detecting postoperative pulmonary complications: a reply. Anaesthesia 2018; 73:1443. [PMID: 30298586 DOI: 10.1111/anae.14462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- H R Touw
- Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - K L Parlevliet
- Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M Beerepoot
- Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - P R Tuinman
- Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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31
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IJssennagger CE, Ten Hoorn S, Van Wijk A, Van den Broek JM, Girbes AR, Tuinman PR. Caregivers' perceptions towards communication with mechanically ventilated patients: The results of a multicenter survey. J Crit Care 2018; 48:263-268. [PMID: 30245368 DOI: 10.1016/j.jcrc.2018.08.036] [Citation(s) in RCA: 10] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/13/2018] [Accepted: 08/25/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to investigate ICU health care providers' perception towards communication and associated problems with mechanically ventilated (MV) patients. The primary aim was to quantify the extent of the problem and to determine its effect on patient care and job satisfaction. METHODS A multicenter survey study was conducted among nurses, residents and intensivists of 15 ICUs in the Netherlands using an online questionnaire. RESULTS Out of 1740 caregivers, 457 responses were received. Communication difficulties were experienced in half of the interactions with MV patients. Over 75% of participants indicated that patient care was negatively affected. Job satisfaction was negatively affected in 43% of the participants, primarily with feelings of unfulfillment (76%) and frustration (72%). Patient factors considered relevant to communication difficulties were delirium, disease severity and anxiety, among others. To facilitate communication, the use of basic gestures remained the most preferred method. CONCLUSIONS In half of the interactions with MV patients, health care professionals experience significant communication difficulties. The respondents indicated that these difficulties frequently lead to negative effects on patient care and job satisfaction. These results emphasize the need for improvements such as the development of communication protocols, skills training and continued research into new communication methods.
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Affiliation(s)
- C E IJssennagger
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands.
| | - S Ten Hoorn
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - A Van Wijk
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J M Van den Broek
- Zaans Medisch Centrum, Department of Intensive Care Medicine, Zaandam, the Netherlands
| | - A R Girbes
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Research VUmc Intensive Care (REVIVE), Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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32
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van der Heiden PLJ, Arbous MS, van Beers EJ, van den Bergh WM, le Cessie S, Demandt AMP, Eefting M, Hess C, Kusadasi N, Marijt WAF, van Mook WNKA, Müller MCA, Tuinman PR, van Vliet M, van Westerloo DJ, Blijlevens NMA. Predictors of short-term and long-term mortality in critically ill patients admitted to the intensive care unit following allogeneic stem cell transplantation. Bone Marrow Transplant 2018; 54:418-424. [PMID: 30082850 DOI: 10.1038/s41409-018-0277-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 04/23/2018] [Accepted: 06/20/2018] [Indexed: 01/01/2023]
Abstract
Historically, the mortality of patients admitted to the ICU after allogeneic stem cell transplantation (alloSCT) is high. Advancements in transplantation procedures, infectious monitoring and supportive care may have improved the outcome. This study aimed to determine short-term and long-term mortality after ICU admission of patients after alloSCT and to identify prognostic clinical and transplantation-related determinants present at ICU admission for long-term outcome. A multicenter cohort study was performed to determine 30-day and 1-year mortality within 2 years following alloSCT. A total of 251 patients were included. The 30-day and 1-year mortality was 55% and 80%, respectively. Platelet count <25 × 109/L (OR: 2.26, CI: 1.02-5.01) and serum bilirubin >19 μmol/L (OR: 2.47 CI: 1.08-5.65) at admission, other donor than a HLA-matched-related or HLA-matched-unrelated donor (OR: 4.59, CI: 1.49-14.1) and vasoactive medication within 24 h (OR: 2.35, CI: 1.28-4.31) were associated with increased 30-day mortality. Other donor than a HLA-matched-related or HLA-matched-unrelated donor (OR: 1.9, CI: 1.13-3.19), serum bilirubin >77 (OR: 2.05, CI: 1.28-3.30) and vasoactive medication within 24 h (OR: 1.65, CI: 1.12-2.43) were associated with increased 1-year mortality. Neutropenia was associated with decreased 30-day and 1-year mortality (OR: 0.29, CI: 0.14-0.59 and OR: 0.70, CI: 0.48-0.98). Myeloablative conditioning and T cell-depleted transplantation were not associated with increased mortality.
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Affiliation(s)
- P L J van der Heiden
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - M S Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E J van Beers
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - A M P Demandt
- Department of Hematology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M Eefting
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - C Hess
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N Kusadasi
- Departement of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - W A F Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - W N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, VU university Medical Center, Amsterdam, The Netherlands
| | - M van Vliet
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - N M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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33
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Algera AG, Pisani L, Bergmans DCJ, den Boer S, de Borgie CAJ, Bosch FH, Bruin K, Cherpanath TG, Determann RM, Dondorp AM, Dongelmans DA, Endeman H, Haringman JJ, Horn J, Juffermans NP, van Meenen DM, van der Meer NJ, Merkus MP, Moeniralam HS, Purmer I, Tuinman PR, Slabbekoorn M, Spronk PE, Vlaar APJ, Gama de Abreu M, Pelosi P, Serpa Neto A, Schultz MJ, Paulus F. RELAx - REstricted versus Liberal positive end-expiratory pressure in patients without ARDS: protocol for a randomized controlled trial. Trials 2018; 19:272. [PMID: 29739430 PMCID: PMC5941564 DOI: 10.1186/s13063-018-2640-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 12/05/2017] [Accepted: 04/10/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Evidence for benefit of high positive end-expiratory pressure (PEEP) is largely lacking for invasively ventilated, critically ill patients with uninjured lungs. We hypothesize that ventilation with low PEEP is noninferior to ventilation with high PEEP with regard to the number of ventilator-free days and being alive at day 28 in this population. METHODS/DESIGN: The "REstricted versus Liberal positive end-expiratory pressure in patients without ARDS" trial (RELAx) is a national, multicenter, randomized controlled, noninferiority trial in adult intensive care unit (ICU) patients with uninjured lungs who are expected not to be extubated within 24 h. RELAx will run in 13 ICUs in the Netherlands to enroll 980 patients under invasive ventilation. In all patients, low tidal volumes are used. Patients assigned to ventilation with low PEEP will receive the lowest possible PEEP between 0 and 5 cm H2O, while patients assigned to ventilation with high PEEP will receive PEEP of 8 cm H2O. The primary endpoint is the number of ventilator-free days and being alive at day 28, a composite endpoint for liberation from the ventilator and mortality until day 28, with a noninferiority margin for a difference between groups of 0.5 days. Secondary endpoints are length of stay (LOS), mortality, and occurrence of pulmonary complications, including severe hypoxemia, major atelectasis, need for rescue therapies, pneumonia, pneumothorax, and development of acute respiratory distress syndrome (ARDS). Hemodynamic support and sedation needs will be collected and compared. DISCUSSION RELAx will be the first sufficiently sized randomized controlled trial in invasively ventilated, critically ill patients with uninjured lungs using a clinically relevant and objective endpoint to determine whether invasive, low-tidal-volume ventilation with low PEEP is noninferior to ventilation with high PEEP. TRIAL REGISTRATION ClinicalTrials.gov , ID: NCT03167580 . Registered on 23 May 2017.
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Affiliation(s)
- Anna Geke Algera
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Dennis C. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sylvia den Boer
- Department of Intensive Care, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
| | | | - Frank H. Bosch
- Department of Intensive Care, Rijnstate, Arnhem, The Netherlands
| | - Karina Bruin
- Department of Intensive Care, Westfriesgasthuis, Hoorn, The Netherlands
| | - Thomas G. Cherpanath
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Rogier M. Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Arjen M. Dondorp
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Madihol–Oxford Research Unit (MORU), Madihol University, Bangkok, Thailand
| | - Dave A. Dongelmans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - David M. van Meenen
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Hazra S. Moeniralam
- Department of Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Ilse Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, VU Medical Center, Amsterdam, The Netherlands
- REVIVE Research VU Medical Center, VU Medical Center, Amsterdam, The Netherlands
| | - Mathilde Slabbekoorn
- Department of Intensive Care, Haaglanden Medical Center, The Hague, The Netherlands
| | - Peter E. Spronk
- Department of Intensive Care, Gelre Hospital, Apeldoorn, The Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital – IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - for the RELAx Investigators and the PROVE Network Investigators
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Intensive Care, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Rijnstate, Arnhem, The Netherlands
- Department of Intensive Care, Westfriesgasthuis, Hoorn, The Netherlands
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
- Madihol–Oxford Research Unit (MORU), Madihol University, Bangkok, Thailand
- Department of Intensive Care, Isala Clinics, Zwolle, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Amphia Hospital, Breda, The Netherlands
- Department of Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
- Department of Intensive Care, VU Medical Center, Amsterdam, The Netherlands
- REVIVE Research VU Medical Center, VU Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Intensive Care, Gelre Hospital, Apeldoorn, The Netherlands
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital – IRCCS for Oncology, University of Genoa, Genoa, Italy
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Touw HR, Parlevliet KL, Beerepoot M, Schober P, Vonk A, Twisk JW, Elbers PW, Boer C, Tuinman PR. Lung ultrasound compared with chest X-ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study. Anaesthesia 2018. [PMID: 29529332 PMCID: PMC6099367 DOI: 10.1111/anae.14243] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Postoperative pulmonary complications are common after cardiothoracic surgery and are associated with adverse outcomes. The ability to detect postoperative pulmonary complications using chest X-rays is limited, and this technique requires radiation exposure. Little is known about the diagnostic accuracy of lung ultrasound for the detection of postoperative pulmonary complications after cardiothoracic surgery, and we therefore aimed to compare lung ultrasound with chest X-ray to detect postoperative pulmonary complications in this group of patients. We performed this prospective, observational, single-centre study in a tertiary intensive care unit treating adult patients who had undergone cardiothoracic surgery. We recorded chest X-ray findings upon admission and on postoperative days 2 and 3, as well as rates of postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications that required therapy according to the treating physician as part of their standard clinical practice. Lung ultrasound was performed by an independent researcher at the time of chest X-ray. We compared lung ultrasound with chest X-ray for the detection of postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications. We also assessed inter-observer agreement for lung ultrasound, and the time to perform both imaging techniques. Subgroup analyses were performed to compare the time to detection of clinically-relevant postoperative pulmonary complications by both modalities. We recruited a total of 177 patients in whom both lung ultrasound and chest X-ray imaging were performed. Lung ultrasound identified 159 (90%) postoperative pulmonary complications on the day of admission compared with 107 (61%) identified with chest X-ray (p < 0.001). Lung ultrasound identified 11 out of 17 patients (65%) and chest X-ray 7 out of 17 patients (41%) with clinically-relevant postoperative pulmonary complications (p < 0.001). The clinically-relevant postoperative pulmonary complications were detected earlier using lung ultrasound compared with chest X-ray (p = 0.024). Overall inter-observer agreement for lung ultrasound was excellent (κ = 0.907, p < 0.001). Following cardiothoracic surgery, lung ultrasound detected more postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications than chest X-ray, and at an earlier time-point. Our results suggest lung ultrasound may be used as the primary imaging technique to search for postoperative pulmonary complications after cardiothoracic surgery, and will enhance bedside decision making.
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Affiliation(s)
- H R Touw
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands.,Department of Anaesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - K L Parlevliet
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - M Beerepoot
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - P Schober
- Department of Anaesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - A Vonk
- Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - J W Twisk
- Department of Epidemiology and Biostatistics, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - P W Elbers
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - C Boer
- Department of Anaesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Infection and Immunity Institute, VU University Medical Center Amsterdam, the Netherlands
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35
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Algera AG, Pisani L, Chaves RCDF, Amorim TC, Cherpanath T, Determann R, Dongelmans DA, Paulus F, Tuinman PR, Pelosi P, Gama de Abreu M, Schultz MJ, Serpa Neto A. Effects of peep on lung injury, pulmonary function, systemic circulation and mortality in animals with uninjured lungs-a systematic review. Ann Transl Med 2018; 6:25. [PMID: 29430442 DOI: 10.21037/atm.2017.12.05] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
It is well-known that positive end-expiratory pressure (PEEP) can prevent ventilator-induced lung injury (VILI) and improve pulmonary physiology in animals with injured lungs. It's uncertain whether PEEP has similar effects in animals with uninjured lungs. A systematic review of randomized controlled trials (RCTs) comparing different PEEP levels in animals with uninjured lungs was performed. Trials in animals with injured lungs were excluded, as were trials that compared ventilation strategies that also differed with respect to other ventilation settings, e.g., tidal volume size. The search identified ten eligible trials in 284 animals, including rodents and small as well as large mammals. Duration of ventilation was highly variable, from 1 to 6 hours and tidal volume size varied from 7 to 60 mL/kg. PEEP ranged from 3 to 20 cmH2O, and from 0 to 5 cmH2O, in the 'high PEEP' or 'PEEP' arms, and in the 'low PEEP' or 'no PEEP' arms, respectively. Definitions used for lung injury were quite diverse, as were other outcome measures. The effects of PEEP, at any level, on lung injury was not straightforward, with some trials showing less injury with 'high PEEP' or 'PEEP' and other trials showing no benefit. In most trials, 'high PEEP' or 'PEEP' was associated with improved respiratory system compliance, and better oxygen parameters. However, 'high PEEP' or 'PEEP' was also associated with occurrence of hypotension, a reduction in cardiac output, or development of hyperlactatemia. There were no differences in mortality. The number of trials comparing 'high PEEP' or 'PEEP' with 'low PEEP' or 'no PEEP' in animals with uninjured lungs is limited, and results are difficult to compare. Based on findings of this systematic review it's uncertain whether PEEP, at any level, truly prevents lung injury, while most trials suggest potential harmful effects on the systemic circulation.
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Affiliation(s)
- Anna Geke Algera
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Thiago Chaves Amorim
- Department of Anesthesiology, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thomas Cherpanath
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier Determann
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Groups, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Abstract
Peripheral intravenous (IV) catheters can break off while still in the patient, with possible detrimental effects such as upstream migration to the heart. These catheters have probably been damaged by the needle during a difficult insertion. A peripheral IV catheter was removed in a 90 year old patient and only half of the catheter was retrieved. By using ultrasound examination the remaining part of the IV catheter was identified, and retrieved surgically, before it could migrate towards the heart. This case report suggests that ultrasound should not only be used for difficult placement of a peripheral IV catheter, but can also be used when removal is complicated.
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Affiliation(s)
- Pieter J Schraverus
- Department of Intensive Care, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
| | - Suzanne van Rijswijk
- Department of Intensive Care, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
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Abstract
Ultrasound of the diaphragm in critically ill patients has become a diagnostic technique of emerging interest among clinicians and scientists. The advantages include that it is widely available, non-invasive and examination can be performed after relatively short training and at low costs. It is used to estimate muscle mass by measurement of muscle thickness and diagnose weakness by the assessment of diaphragm movement during unassisted breathing. Thickening of the muscle during inspiration has been used to quantify force generation. The enthusiasm that surrounds this topic is shared by many clinicians and we agree that ultrasound is a valuable tool to screen for diaphragm dysfunction in intensive care unit (ICU) patients. However, in our opinion much more studies are required to validate ultrasound as a tool to quantify breathing effort. More sophisticated ultrasound techniques, such as speckle tracking imaging are promising techniques to evaluate respiratory muscle function in patients, including the critically ill.
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Affiliation(s)
- Mark Haaksma
- Department of Intensive Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
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38
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Tuinman PR, Ten Hoorn S. Freedom of speech for all critically ill patients: work in progress. Crit Care 2017; 21:27. [PMID: 28173826 PMCID: PMC5296959 DOI: 10.1186/s13054-017-1608-2] [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] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- P R Tuinman
- Department of Intensive Care Medicine and Research VUmc Intensive Care (REVIVE), VU University Medical Center Amsterdam, Room ZH-7D-166, De Boelelaan 1117, PO Box 7057, MB, Amsterdam, 1007, The Netherlands. .,Institute for Cardiovascular Research VU (ICaR-VU), VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
| | - S Ten Hoorn
- Department of Intensive Care Medicine and Research VUmc Intensive Care (REVIVE), VU University Medical Center Amsterdam, Room ZH-7D-166, De Boelelaan 1117, PO Box 7057, MB, Amsterdam, 1007, The Netherlands.,Institute for Cardiovascular Research VU (ICaR-VU), VU University Medical Center Amsterdam, Amsterdam, The Netherlands
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39
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Elbers PWG, Kamp O, van der Sluijs JP, Lely R, Tuinman PR. [Should every doctor be allowed to use ultrasound? Dilemmas surrounding broad application of ultrasound in clinical practice]. Ned Tijdschr Geneeskd 2017; 161:D1063. [PMID: 28488552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Ultrasound is rapidly gaining ground in clinical medicine. This offers distinct advantages for diagnosis and treatment. This is notably the case when moving images are created by the treating physician, who can integrate them immediately with all other clinical information. The downside of a broad application of ultrasound is an increase in the number of incidental findings and missed diagnoses. This is amplified by the frequent lack of formal requirements for training and skills. Storage of ultrasound images may furthermore lead to verifiable misinterpretations. We are of the opinion that responsible integration of ultrasound in clinical practice requires clear peer agreements without sectarian thinking. To illustrate this, we discuss the dilemmas surrounding increased use of ultrasound from a medicolegal perspective.
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Serpa Neto A, Filho RR, Cherpanath T, Determann R, Dongelmans DA, Paulus F, Tuinman PR, Pelosi P, de Abreu MG, Schultz MJ. Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials. Ann Intensive Care 2016; 6:109. [PMID: 27813023 PMCID: PMC5095097 DOI: 10.1186/s13613-016-0208-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/19/2016] [Indexed: 12/17/2022] Open
Abstract
Background The aim of this investigation was to compare ventilation at different levels of positive end-expiratory pressure (PEEP) with regard to clinical important outcomes of intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) at onset of ventilation. Methods Meta-analysis of randomized controlled trials (RCTs) comparing a lower level of PEEP with a higher level of PEEP was performed. The primary outcome was in-hospital mortality. Results Twenty-one RCTs (1393 patients) were eligible. PEEP ranged from 0 to 10 cmH2O and from 5 to 30 cmH2O in the lower PEEP and the higher PEEP arms of included RCTs, respectively. In-hospital mortality was not different between the two PEEP arms in seven RCTs (risk ratio [RR] 0.87; 95% confidence interval [CI] 0.62–1.21; I2 = 26%, low quality of evidence [QoE]), as was duration of mechanical ventilation in three RCTs (standardized mean difference [SMD] 0.68; 95% CI −0.24 to 1.61; I2 = 82%, very low QoE). PaO2/FiO2 was higher in the higher PEEP arms in five RCTs (SMD 0.72; 95% CI 0.10–1.35; I2 = 86%, very low QoE). Development of ARDS and the occurrence of hypoxemia (2 RCTs) were lower in the higher PEEP arms in four RCTs and two RCTs, respectively (RR 0.43; 95% CI 0.21–0.91; I2 = 56%, low QoE; RR 0.42; 95%–CI 0.19–0.92; I2 = 19%, low QoE). There was no association between the level of PEEP and any hemodynamic parameter (four RCTs). Conclusion Ventilation with higher levels of PEEP in ICU patients without ARDS at onset of ventilation was not associated with lower in-hospital mortality or shorter duration of ventilation, but with a lower incidence of ARDS and hypoxemia, as well as higher PaO2/FiO2. These findings should be interpreted with caution, as heterogeneity was moderate to high, the QoE was low to very low, and the available studies prevented us from addressing the effects of moderate levels of PEEP. Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0208-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. .,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Roberto Rabello Filho
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thomas Cherpanath
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier Determann
- Department of Critical Care, Westfriesgasthuis, Hoorn, The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, Free University Medical Center, Amsterdam, The Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Groups, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR. Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Crit Care 2016; 20:333. [PMID: 27756433 PMCID: PMC5070186 DOI: 10.1186/s13054-016-1483-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 09/13/2016] [Indexed: 11/30/2022]
Abstract
Background Ventilator-dependent patients in the ICU often experience difficulties with one of the most basic human functions, namely communication, due to intubation. Although various assistive communication tools exist, these are infrequently used in ICU patients. We summarized the current evidence on communication methods with mechanically ventilated patients in the ICU. Secondly, we developed an algorithm for communication with these patients based on current evidence. Methods We performed a systematic review. PubMed, Embase, Cochrane, Cinahl, PsychInfo, and Web of Science databases were systematically searched to November 2015. Studies that reported a communication intervention with conscious nonverbal mechanically ventilated patients in the ICU aged 18 years or older were included. The methodological quality was assessed using the Quality Assessment Tool. Results The search yielded 9883 publications, of which 31 articles, representing 29 different studies, fulfilled the inclusion criteria. The overall methodological quality varied from poor to moderate. We identified four communication intervention types: (1) communication boards were studied in three studies—they improved communication and increased patient satisfaction, but they can be time-consuming and limit the ability to produce novel utterances; (2) two types of specialized talking tracheostomy tubes were assessed in eight studies—audible voicing was achieved in the majority of patients (range 74–100 %), but more studies are needed to facilitate safe and effective use; (3) an electrolarynx improved communication in seven studies—its effectiveness was mainly demonstrated with tracheostomized patients; and (4) “high-tech” augmentative and alternative communication (AAC) devices in nine studies with diverse computerized AAC devices proved to be beneficial communication methods—two studies investigated multiple AAC interventions, and different control devices (e.g., touch-sensitive or eye/blink detection) can be used to ensure that physical limitations do not prevent use of the devices. We developed an algorithm for the assessment and selection of a communication intervention with nonverbal and conscious mechanically intubated patients in the ICU. Conclusions Although evidence is limited, results suggest that most communication methods may be effective in improving patient–healthcare professional communication with mechanically ventilated patients. A combination of methods is advised. We developed an algorithm to standardize the approach for selection of communication techniques. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1483-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Ten Hoorn
- Department of Intensive Care Medicine and Research VUmc Intensive Care (REVIVE), VU University Medical Center Amsterdam, Room ZH-7D-166, De Boelelaan 1117, PO Box 7057, Amsterdam, 1007 MB, The Netherlands.,Institute for Cardiovascular Research VU (ICaR-VU), VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - P W Elbers
- Department of Intensive Care Medicine and Research VUmc Intensive Care (REVIVE), VU University Medical Center Amsterdam, Room ZH-7D-166, De Boelelaan 1117, PO Box 7057, Amsterdam, 1007 MB, The Netherlands.,Institute for Cardiovascular Research VU (ICaR-VU), VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - A R Girbes
- Department of Intensive Care Medicine and Research VUmc Intensive Care (REVIVE), VU University Medical Center Amsterdam, Room ZH-7D-166, De Boelelaan 1117, PO Box 7057, Amsterdam, 1007 MB, The Netherlands.,Institute for Cardiovascular Research VU (ICaR-VU), VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine and Research VUmc Intensive Care (REVIVE), VU University Medical Center Amsterdam, Room ZH-7D-166, De Boelelaan 1117, PO Box 7057, Amsterdam, 1007 MB, The Netherlands. .,Institute for Cardiovascular Research VU (ICaR-VU), VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
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Touw HRW, Tuinman PR, Gelissen HPMM, Lust E, Elbers PWG. Response to the letter of Trovato et al. Neth J Med 2015; 73:306. [PMID: 26228203] [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] [Indexed: 06/04/2023]
Affiliation(s)
- H R W Touw
- Department of Intensive Care Medicine, Department of Anesthesiology, VU University Medical Center, Amsterdam, the Netherlands
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43
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Simonis FD, Binnekade JM, Braber A, Gelissen HP, Heidt J, Horn J, Innemee G, de Jonge E, Juffermans NP, Spronk PE, Steuten LM, Tuinman PR, Vriends M, de Vreede G, de Wilde RB, Serpa Neto A, Gama de Abreu M, Pelosi P, Schultz MJ. PReVENT--protective ventilation in patients without ARDS at start of ventilation: study protocol for a randomized controlled trial. Trials 2015; 16:226. [PMID: 26003545 PMCID: PMC4453265 DOI: 10.1186/s13063-015-0759-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [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: 09/15/2014] [Accepted: 05/14/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND It is uncertain whether lung-protective mechanical ventilation using low tidal volumes should be used in all critically ill patients, irrespective of the presence of the acute respiratory distress syndrome (ARDS). A low tidal volume strategy includes use of higher respiratory rates, which could be associated with increased sedation needs, a higher incidence of delirium, and an increased risk of patient-ventilator asynchrony and ICU-acquired weakness. Another alleged side-effect of low tidal volume ventilation is the risk of atelectasis. All of these could offset the beneficial effects of low tidal volume ventilation as found in patients with ARDS. METHODS/DESIGN PReVENT is a national multicenter randomized controlled trial in invasively ventilated ICU patients without ARDS with an anticipated duration of ventilation of longer than 24 hours in 5 ICUs in The Netherlands. Consecutive patients are randomly assigned to a low tidal volume strategy using tidal volumes from 4 to 6 ml/kg predicted body weight (PBW) or a high tidal volume ventilation strategy using tidal volumes from 8 to 10 ml/kg PBW. The primary endpoint is the number of ventilator-free days and alive at day 28. Secondary endpoints include ICU and hospital length of stay (LOS), ICU and hospital mortality, the incidence of pulmonary complications, including ARDS, pneumonia, atelectasis, and pneumothorax, the cumulative use and duration of sedatives and neuromuscular blocking agents, incidence of ICU delirium, and the need for decreasing of instrumental dead space. DISCUSSION PReVENT is the first randomized controlled trial comparing a low tidal volume strategy with a high tidal volume strategy, in patients without ARDS at onset of ventilation, that recruits a sufficient number of patients to test the hypothesis that a low tidal volume strategy benefits patients without ARDS with regard to a clinically relevant endpoint. TRIAL REGISTRATION The trial is registered at www.clinicaltrials.gov under reference number NCT02153294 on 23 May 2014.
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Affiliation(s)
- Fabienne D Simonis
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Annemarije Braber
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - Harry P Gelissen
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands.
| | - Jeroen Heidt
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | - Janneke Horn
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Gerard Innemee
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands.
| | - Lotte M Steuten
- Department of Health Technology and Services Research, Twente University, Enschede, The Netherlands.
| | - Pieter Roel Tuinman
- Department of Intensive Care & REVIVE Research VUmc Intensive Care, VU Medical Center, Amsterdam, The Netherlands.
| | - Marijn Vriends
- Department of Intensive Care, Tergooi, Hilversum, The Netherlands.
| | | | - Rob B de Wilde
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Ary Serpa Neto
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy.
| | - Marcus J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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44
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Touw HRW, Tuinman PR, Gelissen HPMM, Lust E, Elbers PWG. Lung ultrasound: routine practice for the next generation of internists. Neth J Med 2015; 73:100-107. [PMID: 25852109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The lung is at the crossroads of ventilation and circulation and can provide a wealth of diagnostic information. In the past, lung ultrasound (LUS) was considered impossible. However, the interplay between air, fluid and pleurae creates distinctive artefacts. Combinations of these artefacts can help differentiate between various pathological processes, including pulmonary oedema, pneumonia, pulmonary embolism, obstructive airway disease and pneumothorax. LUS, when used by experienced physicians, is superior to chest X-ray and comparable to computed tomography for establishing a diagnosis in acutely dyspnoeic patients. LUS allows for rapid, non-invasive and bedside patient assessment. It is therefore unfortunate that unlike many other medical specialists in the Netherlands, internists have not yet incorporated LUS into their daily practice. OBJECTIVES This review aims to be the starting point for internists wanting to acquire competence in LUS. REVIEW CONTENT: This narrative review describes the principles of ultrasound equipment, LUS artefacts, gives practical guidance to perform LUS and provides a road map towards LUS competence. Furthermore, it presents a decision tree to differentiate between causes of acute dyspnoea. AUTHORS CONCLUSIONS LUS is a promising diagnostic technique that can be of great help for the internist. It can be applied directly at the bedside and can also be used to follow up on disease progression and therapy. It is our belief that it will replace the stethoscope and that it will be the most used imaging technique in the near future, especially in dyspnoeic patients.
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Affiliation(s)
- H R W Touw
- Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, the Netherlands
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Kuipers MT, Aslami H, Tuinman PR, Tuip-de Boer AM, Jongsma G, van der Sluijs KF, Choi G, Wolthuis EK, Roelofs JJ, Bresser P, Schultz MJ, van der Poll T, Wieland CW. The receptor for advanced glycation end products in ventilator-induced lung injury. Intensive Care Med Exp 2014. [PMID: 26215707 PMCID: PMC4678142 DOI: 10.1186/s40635-014-0022-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [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] [Indexed: 01/10/2023] Open
Abstract
Background Mechanical ventilation (MV) can cause ventilator-induced lung injury (VILI). The innate immune response mediates this iatrogenic inflammatory condition. The receptor for advanced glycation end products (RAGE) is a multiligand receptor that can amplify immune and inflammatory responses. We hypothesized that RAGE signaling contributes to the pro-inflammatory state induced by MV. Methods RAGE expression was analyzed in lung brush and lavage cells obtained from ventilated patients and lung tissue of ventilated mice. Healthy wild-type (WT) and RAGE knockout (KO) mice were ventilated with relatively low (approximately 7.5 ml/kg) or high (approximately 15 ml/kg) tidal volume. Positive end-expiratory pressure was set at 2 cm H2O during both MV strategies. Also, WT and RAGE KO mice with lipopolysaccharide (LPS)-induced lung injury were ventilated with the above described ventilation strategies. In separate experiments, the contribution of soluble RAGE, a RAGE isoform that may function as a decoy receptor, in ventilated RAGE KO mice was investigated. Lung wet-to-dry ratio, cell and neutrophil influx, cytokine and chemokine concentrations, total protein levels, soluble RAGE, and high-mobility group box 1 (HMGB1) presence in lung lavage fluid were analyzed. Results MV was associated with increased RAGE mRNA levels in both human lung brush samples and lung tissue of healthy mice. In healthy high tidal volume-ventilated mice, RAGE deficiency limited inflammatory cell influx. Other VILI parameters were not affected. In our second set of experiments where we compared RAGE KO and WT mice in a 2-hit model, we observed higher pulmonary cytokine and chemokine levels in RAGE KO mice undergoing LPS/high tidal volume MV as compared to WT mice. Third, in WT mice undergoing the LPS/high tidal volume MV, we observed HMGB1 presence in lung lavage fluid. Moreover, MV increased levels of soluble RAGE in lung lavage fluid, with the highest levels found in LPS/high tidal volume-ventilated mice. Administration of soluble RAGE to LPS/high tidal volume-ventilated RAGE KO mice attenuated the production of inflammatory mediators. Conclusions RAGE was not a crucial contributor to the pro-inflammatory state induced by MV. However, the presence of sRAGE limited the production of pro-inflammatory mediators in our 2-hit model of LPS and high tidal volume MV. Electronic supplementary material The online version of this article (doi:10.1186/s40635-014-0022-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maria T Kuipers
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Centre, University of Amsterdam, room M0-220, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands,
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Cornet AD, Hofstra JJ, Vlaar AP, Tuinman PR, Levi M, Girbes AR, Schultz MJ, Groeneveld AB, Beishuizen A. Activated protein C attenuates pulmonary coagulopathy in patients with acute respiratory distress syndrome. J Thromb Haemost 2013; 11:894-901. [PMID: 23433188 PMCID: PMC9906436 DOI: 10.1111/jth.12179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Acute respiratory distress syndrome (ARDS) frequently complicates critical illness. We hypothesized that an infusion of recombinant human activated protein C (rh-APC), a natural anticoagulant, would attenuate pulmonary coagulopathy and injury. METHODS In this sub study of a multicenter open-label randomized controlled trial of patients with ARDS, we compared an intravenous (i.v.) infusion of rh-APC (24 mcg kg(-1) h(-1) for 96 h) with placebo. Patients with sepsis or septic shock were excluded. RESULTS In 27 patients serial non-directed bronchoalveolar lavage fluid (NBLF) samples were obtained: 16 patients were treated with rh-APC and 11 patients with placebo. The rh-APC infusion was associated with higher APC levels in plasma during the infusion period of 4 days (P = 0.001), as well as higher APC levels in NBLF up to day 5 after the start of the infusion (P = 0.028). An infusion of rh-APC was associated with lower levels of thrombin-antithrombin complexes (P = 0.009) and soluble tissue factor (P = 0.011) in NBLF, compared with treatment with placebo. An infusion of rh-APC affected fibrinolysis, as plasminogen activator activity levels in NBLF were higher in the patients treated with rh-APC (P = 0.01), presumably as a result of lower NBLF levels of plasminogen activator inhibitor 1, (P = 0.01). The rh-APC infusion decreased the lung injury score (P = 0.005) and simplified the acute physiology score (P = 0.013) on day 5, when compared with baseline. The rh-APC infusion was not associated with bleeding complications. CONCLUSION An infusion of rh-APC in patients with ARDS attenuates pulmonary coagulopathy and injury.
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Affiliation(s)
- A D Cornet
- Department of Intensive Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
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Müller M, Tuinman PR, Jongsma G, Boer AMTD, Boon L, Zeerleder SS, ermans NPJ. C1 inhibitor attenuates pulmonary inflammation in an in vivo model of transfusion-related acute lung injury. Crit Care 2013. [PMCID: PMC3642561 DOI: 10.1186/cc12310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Helmerhorst HJF, van Tol EN, Tuinman PR, de Vries PJ, Hartskeerl RA, Grobusch MP, Hovius JW. Severe pulmonary manifestation of leptospirosis. Neth J Med 2012; 70:215-221. [PMID: 22744922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Based on increasing incidence and the occurrence of worldwide outbreaks, leptospirosis is recognised as an emerging zoonosis. Severe manifestations are associated with high morbidity and mortality rates and may therefore pose an important risk to public health, especially in certain high prevalence areas. A considerable number of infections progress to a severe form, which can present as the well-known triad of jaundice, impaired renal function and haemorrhage, known as Weil's disease. The severe pulmonary form of leptospirosis (SPFL) is a less known entity and is characterised by intra-alveolar haemorrhage and can lead to acute respiratory failure and death when adequate treatment fails. Prognostic factors correlating with severity and survival of leptospirosis include indicators of renal failure, pulmonary involvement and electrolyte imbalances. We report an imported case of SPFL in a returning traveller, and review the literature discussing epidemiology, clinical manifestations, prognostic factors and treatment of this resurgent disease.
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Affiliation(s)
- H J F Helmerhorst
- Department of Internal Medicine, Academic Medical Center, University of Amsterdam, the Netherlands
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Abstract
Aspirin has been found to improve outcomes in an animal model of transfusion-related acute lung injury. We examined the association of aspirin use before admission to the intensive care unit and the development of transfusion-related acute lung injury in critically ill patients. We performed a post-hoc analysis of a nested case-control study that had been undertaken in a tertiary referral hospital. Transfusion-related acute lung injury cases were matched with controls (transfused patients not developing lung injury). Of these 218 patients, 66 used aspirin (30%). Use of aspirin did not alter the risk of transfusion-related acute lung injury after transfusion of platelets (OR 1.06, CI 0.59-1.91, p = 0.85), plasma (OR 1.06, 95% CI 0.59-1.92, p = 0.84), or red blood cells (OR 1.09, 95% CI 0.61-1.94, p = 0.77). Adjustment for confounding variables using propensity scoring also did not affect the risk of acquiring transfusion-related acute lung injury (p = 0.66). In conclusion, aspirin did not protect against transfusion-related lung injury in this cohort of critically ill patients.
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Affiliation(s)
- P R Tuinman
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Academic Medical Center, Amsterdam, the Netherlands.
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Tuinman PR, Nieuwenhuis MBB, Groen E, Kersten MJ. A young woman with generalised lymphadenopathy. Systemic lupus erythematosus (SLE). Neth J Med 2011; 69:284-288. [PMID: 21868814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- P R Tuinman
- Department of Hematology, Academic Medical Center Amsterdam, the Netherlands.
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