1
|
Zhang S, Hagens LA, Heijnen NFL, Smit MR, Brinkman P, Fenn D, van der Poll T, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Breath metabolomics for diagnosis of acute respiratory distress syndrome. Crit Care 2024; 28:96. [PMID: 38521944 PMCID: PMC10960461 DOI: 10.1186/s13054-024-04882-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/18/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) poses challenges in early identification. Exhaled breath contains metabolites reflective of pulmonary inflammation. AIM To evaluate the diagnostic accuracy of breath metabolites for ARDS in invasively ventilated intensive care unit (ICU) patients. METHODS This two-center observational study included critically ill patients receiving invasive ventilation. Gas chromatography and mass spectrometry (GC-MS) was used to quantify the exhaled metabolites. The Berlin definition of ARDS was assessed by three experts to categorize all patients into "certain ARDS", "certain no ARDS" and "uncertain ARDS" groups. The patients with "certain" labels from one hospital formed the derivation cohort used to train a classifier built based on the five most significant breath metabolites. The diagnostic accuracy of the classifier was assessed in all patients from the second hospital and combined with the lung injury prediction score (LIPS). RESULTS A total of 499 patients were included in this study. Three hundred fifty-seven patients were included in the derivation cohort (60 with certain ARDS; 17%), and 142 patients in the validation cohort (47 with certain ARDS; 33%). The metabolites 1-methylpyrrole, 1,3,5-trifluorobenzene, methoxyacetic acid, 2-methylfuran and 2-methyl-1-propanol were included in the classifier. The classifier had an area under the receiver operating characteristics curve (AUROCC) of 0.71 (CI 0.63-0.78) in the derivation cohort and 0.63 (CI 0.52-0.74) in the validation cohort. Combining the breath test with the LIPS does not significantly enhance the diagnostic performance. CONCLUSION An exhaled breath metabolomics-based classifier has moderate diagnostic accuracy for ARDS but was not sufficiently accurate for clinical use, even after combination with a clinical prediction score.
Collapse
Affiliation(s)
- Shiqi Zhang
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands.
| | - Laura A Hagens
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
| | - Paul Brinkman
- Amsterdam UMC, Location AMC, University of Amsterdam, Pulmonary Medicine, Amsterdam, The Netherlands
| | - Dominic Fenn
- Amsterdam UMC, Location AMC, University of Amsterdam, Pulmonary Medicine, Amsterdam, The Netherlands
| | - Tom van der Poll
- Amsterdam UMC, Location AMC, Division of Infectious Diseases, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, Location AMC, Center of Experimental and Molecular Medicine (CEMM), University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Maastricht University Medical Centre+, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Amsterdam UMC, Location AMC, Department of Intensive Care, University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam UMC, Location AMC, University of Amsterdam, Pulmonary Medicine, Amsterdam, The Netherlands
| |
Collapse
|
2
|
de Kok JWTM, van Rosmalen F, Koeze J, Keus F, van Kuijk SMJ, Castela Forte J, Schnabel RM, Driessen RGH, van Herpt TTW, Sels JWEM, Bergmans DCJJ, Lexis CPH, van Doorn WPTM, Meex SJR, Xu M, Borrat X, Cavill R, van der Horst ICC, van Bussel BCT. Deep embedded clustering generalisability and adaptation for integrating mixed datatypes: two critical care cohorts. Sci Rep 2024; 14:1045. [PMID: 38200252 PMCID: PMC10781731 DOI: 10.1038/s41598-024-51699-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024] Open
Abstract
We validated a Deep Embedded Clustering (DEC) model and its adaptation for integrating mixed datatypes (in this study, numerical and categorical variables). Deep Embedded Clustering (DEC) is a promising technique capable of managing extensive sets of variables and non-linear relationships. Nevertheless, DEC cannot adequately handle mixed datatypes. Therefore, we adapted DEC by replacing the autoencoder with an X-shaped variational autoencoder (XVAE) and optimising hyperparameters for cluster stability. We call this model "X-DEC". We compared DEC and X-DEC by reproducing a previous study that used DEC to identify clusters in a population of intensive care patients. We assessed internal validity based on cluster stability on the development dataset. Since generalisability of clustering models has insufficiently been validated on external populations, we assessed external validity by investigating cluster generalisability onto an external validation dataset. We concluded that both DEC and X-DEC resulted in clinically recognisable and generalisable clusters, but X-DEC produced much more stable clusters.
Collapse
Affiliation(s)
- Jip W T M de Kok
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - Frank van Rosmalen
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technical Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - José Castela Forte
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
| | - Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Thijs T W van Herpt
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Chris P H Lexis
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
| | - William P T M van Doorn
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Steven J R Meex
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Minnan Xu
- Takeda Pharmaceuticals, Deerfield, IL, USA
| | - Xavier Borrat
- Department of Biostatistics Harvard T.H, Chan School of Public Health, Boston, MA, USA
- Anaesthesiology and Critical Care Department, Hospital Clinic de Barcelona, Barcelona, Spain
- Medical Informatics Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Rachel Cavill
- Department of Advanced Computing Sciences, Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan, 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
3
|
Hagens LA, Heijnen NFL, Smit MR, Verschueren ARM, Nijsen TME, Geven I, Presură CN, Rietman R, Fenn DW, Brinkman P, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Octane in exhaled breath to diagnose acute respiratory distress syndrome in invasively ventilated intensive care unit patients. ERJ Open Res 2023; 9:00214-2023. [PMID: 37850212 PMCID: PMC10577595 DOI: 10.1183/23120541.00214-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/03/2023] [Indexed: 10/19/2023] Open
Abstract
Background The concentration of exhaled octane has been postulated as a reliable biomarker for acute respiratory distress syndrome (ARDS) using metabolomics analysis with gas chromatography and mass spectrometry (GC-MS). A point-of-care (POC) breath test was developed in recent years to accurately measure octane at the bedside. The aim of the present study was to validate the diagnostic accuracy of exhaled octane for ARDS using a POC breath test in invasively ventilated intensive care unit (ICU) patients. Methods This was an observational cohort study of consecutive patients receiving invasive ventilation for at least 24 h, recruited in two university ICUs. GC-MS and POC breath tests were used to quantify the exhaled octane concentration. ARDS was assessed by three experts following the Berlin definition and used as the reference standard. The area under the receiver operating characteristic curve (AUC) was used to assess diagnostic accuracy. Results 519 patients were included and 190 (37%) fulfilled the criteria for ARDS. The median (interquartile range) concentration of octane using the POC breath test was not significantly different between patients with ARDS (0.14 (0.05-0.37) ppb) and without ARDS (0.11 (0.06-0.26) ppb; p=0.64). The AUC for ARDS based on the octane concentration in exhaled breath using the POC breath test was 0.52 (95% CI 0.46-0.57). Analysis of exhaled octane with GC-MS showed similar results. Conclusions Octane in exhaled breath has insufficient diagnostic accuracy for ARDS. This disqualifies the use of octane as a biomarker in the diagnosis of ARDS and challenges most of the research performed up to now in the field of exhaled breath metabolomics.
Collapse
Affiliation(s)
- Laura A Hagens
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Tamara M E Nijsen
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Inge Geven
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Cristian N Presură
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Ronald Rietman
- Sleep and Respiratory Solutions, Philips Research, Eindhoven, The Netherlands
| | - Dominic W Fenn
- Department of Respiratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Brinkman
- Department of Respiratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Respiratory Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Smit MR, Hagens LA, Heijnen NFL, Pisani L, Cherpanath TGV, Dongelmans DA, de Grooth HJS, Pierrakos C, Tuinman PR, Zimatore C, Paulus F, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ. Lung Ultrasound Prediction Model for Acute Respiratory Distress Syndrome: A Multicenter Prospective Observational Study. Am J Respir Crit Care Med 2023; 207:1591-1601. [PMID: 36790377 PMCID: PMC10273105 DOI: 10.1164/rccm.202210-1882oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Rationale: Lung ultrasound (LUS) is a promising tool for diagnosis of acute respiratory distress syndrome (ARDS), but adequately sized studies with external validation are lacking. Objectives: To develop and validate a data-driven LUS score for diagnosis of ARDS and compare its performance with that of chest radiography (CXR). Methods: This multicenter prospective observational study included invasively ventilated ICU patients who were divided into a derivation cohort and a validation cohort. Three raters scored ARDS according to the Berlin criteria, resulting in a classification of "certain no ARDS," or "certain ARDS" when experts agreed or "uncertain ARDS" when evaluations conflicted. Uncertain cases were classified in a consensus meeting. Results of a 12-region LUS exam were used in a logistic regression model to develop the LUS-ARDS score. Measurements and Main Results: Three hundred twenty-four (16% certain ARDS) and 129 (34% certain ARDS) patients were included in the derivation cohort and the validation cohort, respectively. With an ARDS diagnosis by the expert panel as the reference test, the LUS-ARDS score, including the left and right LUS aeration scores and anterolateral pleural line abnormalities, had an area under the receiver operating characteristic (ROC) curve of 0.90 (95% confidence interval [CI], 0.85-0.95) in certain patients of the derivation cohort and 0.80 (95% CI, 0.72-0.87) in all patients of the validation cohort. Within patients who had imaging-gold standard chest computed tomography available, diagnostic accuracy of eight independent CXR readers followed the ROC curve of the LUS-ARDS score. Conclusions: The LUS-ARDS score can be used to accurately diagnose ARDS also after external validation. The LUS-ARDS score may be a useful adjunct to a diagnosis of ARDS after further validation, as it showed performance comparable with that of the current practice with experienced CXR readers but more objectifiable diagnostic accuracy at each cutoff.
Collapse
Affiliation(s)
- Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Luigi Pisani
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Department of Anesthesia and Intensive Care, Miulli Regional Hospital, Acquaviva delle Fonti, Italy
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Dave A. Dongelmans
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Harm-Jan S. de Grooth
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Charalampos Pierrakos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Pieter Roel Tuinman
- Intensive Care, Amsterdam UMC, locatie Vrije Universiteit Amsterdam, Amsterdam, Nederland
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Intensive Care Unit, Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; and
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center (UMC), location University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
5
|
Fenn D, Lilien TA, Hagens LA, Smit MR, Heijnen NF, Tuip-de Boer AM, Neerincx AH, Golebski K, Bergmans DC, Schnabel RM, Schultz MJ, Maitland-van der Zee AH, Brinkman P, Bos LD. Validation of volatile metabolites of pulmonary oxidative injury: a bench to bedside study. ERJ Open Res 2023; 9:00427-2022. [PMID: 36949963 PMCID: PMC10026006 DOI: 10.1183/23120541.00427-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Background Changes in exhaled volatile organic compounds (VOCs) can be used to discriminate between respiratory diseases, and increased concentrations of hydrocarbons are commonly linked to oxidative stress. However, the VOCs identified are inconsistent between studies, and translational studies are lacking. Methods In this bench to bedside study, we captured VOCs in the headspace of A549 epithelial cells after exposure to hydrogen peroxide (H2O2), to induce oxidative stress, using high-capacity polydimethylsiloxane sorbent fibres. Exposed and unexposed cells were compared using targeted and untargeted analysis. Breath samples of invasively ventilated intensive care unit patients (n=489) were collected on sorbent tubes and associated with the inspiratory oxygen fraction (F IO2 ) to reflect pulmonary oxidative stress. Headspace samples and breath samples were analysed using gas chromatography and mass spectrometry. Results In the cell, headspace octane concentration was decreased after oxidative stress (p=0.0013), while the other VOCs were not affected. 2-ethyl-1-hexanol showed an increased concentration in the headspace of cells undergoing oxidative stress in untargeted analysis (p=0.00014). None of the VOCs that were linked to oxidative stress showed a significant correlation with F IO2 (Rs range: -0.015 to -0.065) or discriminated between patients with F IO2 ≥0.6 or below (area under the curve range: 0.48 to 0.55). Conclusion Despite a comprehensive translational approach, validation of known and novel volatile biomarkers of oxidative stress was not possible in patients at risk of pulmonary oxidative injury. The inconsistencies observed highlight the difficulties faced in VOC biomarker validation, and that caution is warranted in the interpretation of the pathophysiological origin of discovered exhaled breath biomarkers.
Collapse
Affiliation(s)
- Dominic Fenn
- Amsterdam UMC location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, Netherlands
- Amsterdam UMC location University of Amsterdam, Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam, Netherlands
- Corresponding author: Dominic Fenn ()
| | - Thijs A. Lilien
- Amsterdam UMC location University of Amsterdam, Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam, Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Paediatric Intensive Care, Amsterdam, Netherlands
| | - Laura A. Hagens
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care, Amsterdam, Netherlands
| | - Marry R. Smit
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care, Amsterdam, Netherlands
| | - Nanon F.L. Heijnen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Anita M. Tuip-de Boer
- Amsterdam UMC location University of Amsterdam, Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam, Netherlands
| | - Anne H. Neerincx
- Amsterdam UMC location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, Netherlands
| | - Korneliusz Golebski
- Amsterdam UMC location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Experimental Immunology, Amsterdam, Netherlands
| | - Dennis C.J.J. Bergmans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marcus J. Schultz
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care, Amsterdam, Netherlands
| | | | - Paul Brinkman
- Amsterdam UMC location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, Netherlands
| | - Lieuwe D.J. Bos
- Amsterdam UMC location University of Amsterdam, Department of Pulmonary Medicine, Amsterdam, Netherlands
- Amsterdam UMC location University of Amsterdam, Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam, Netherlands
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care, Amsterdam, Netherlands
| |
Collapse
|
6
|
Filippini DFL, Hagens LA, Heijnen NFL, Zimatore C, Atmowihardjo LN, Schnabel RM, Schultz MJ, Bergmans DCJJ, Bos LDJ, Smit MR. Prognostic Value of the Radiographic Assessment of Lung Edema Score in Mechanically Ventilated ICU Patients. J Clin Med 2023; 12:jcm12041252. [PMID: 36835791 PMCID: PMC9960783 DOI: 10.3390/jcm12041252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/19/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION The Radiographic Assessment of Lung Edema (RALE) score provides a semi-quantitative measure of pulmonary edema. In patients with acute respiratory distress syndrome (ARDS), the RALE score is associated with mortality. In mechanically ventilated patients in the intensive care unit (ICU) with respiratory failure not due to ARDS, a variable degree of lung edema is observed as well. We aimed to evaluate the prognostic value of RALE in mechanically ventilated ICU patients. METHODS Secondary analysis of patients enrolled in the 'Diagnosis of Acute Respiratory Distress Syndrome' (DARTS) project with an available chest X-ray (CXR) at baseline. Where present, additional CXRs at day 1 were analysed. The primary endpoint was 30-day mortality. Outcomes were also stratified for ARDS subgroups (no ARDS, non-COVID-ARDS and COVID-ARDS). RESULTS 422 patients were included, of which 84 had an additional CXR the following day. Baseline RALE scores were not associated with 30-day mortality in the entire cohort (OR: 1.01, 95% CI: 0.98-1.03, p = 0.66), nor in subgroups of ARDS patients. Early changes in RALE score (baseline to day 1) were only associated with mortality in a subgroup of ARDS patients (OR: 1.21, 95% CI: 1.02-1.51, p = 0.04), after correcting for other known prognostic factors. CONCLUSIONS The prognostic value of the RALE score cannot be extended to mechanically ventilated ICU patients in general. Only in ARDS patients, early changes in RALE score were associated with mortality.
Collapse
Affiliation(s)
- Daan F. L. Filippini
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence:
| | - Laura A. Hagens
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Nanon F. L. Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht University, 6229 HX Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Claudio Zimatore
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, 70124 Bari, Italy
| | - Leila N. Atmowihardjo
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
- Department of Research and Development, Hamilton Medical AG, 7402 Bonaduz, Switzerland
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht UMC+, Maastricht University, 6229 HX Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Pulmonology, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marry R. Smit
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
7
|
Lorusso R, De Piero ME, Mariani S, Di Mauro M, Folliguet T, Taccone FS, Camporota L, Swol J, Wiedemann D, Belliato M, Broman LM, Vuylsteke A, Kassif Y, Scandroglio AM, Fanelli V, Gaudard P, Ledot S, Barker J, Boeken U, Maier S, Kersten A, Meyns B, Pozzi M, Pedersen FM, Schellongowski P, Kirali K, Barrett N, Riera J, Mueller T, Belohlavek J, Lorusso R, De Piero ME, Mariani S, Di Mauro M, Folliguet T, Taccone FS, Camporota L, Swol J, Wiedemann D, Belliato M, Broman LM, Vuylsteke A, Kassif Y, Scandroglio AM, Fanelli V, Gaudard P, Ledot S, Barker J, Boeken U, Maier S, Kersten A, Meyns B, Pozzi M, Pedersen FM, Schellongowski P, Kirali K, Barrett N, Riera J, Mueller T, Belohlavek J, Lo Coco V, Van der Horst ICC, Van Bussel BCT, Schnabel RM, Delnoij T, Bolotin G, Lorini L, Schmiady MO, Schibilsky D, Kowalewski M, Pinto LF, Silva PE, Kornilov I, Blandino Ortiz A, Vercaemst L, Finney S, Roeleveld PP, Di Nardo M, Hennig F, Antonini MV, Davidson M, Jones TJ, Staudinger T, Mair P, Kilo J, Krapf C, Erbert K, Peer A, Bonaros N, Kotheletner F, Krenner Mag N, Shestakova L, Hermans G, Dauwe D, Meersseman P, Stockman B, Nobile L, Lhereux O, Nrasseurs A, Creuter J, De Backer D, Giglioli S, Michiels G, Foulon P, Raes M, Rodrigus I, Allegaert M, Jorens P, Debeucklare G, Piagnarelli M, Biston P, Peperstraete H, Vandewiele K, Germay O, Vandeweghe D, Havrin S, Bourgeois M, Lagny MG, Alois G, Lavios N, Misset B, Courcelle R, Timmermans PJ, Yilmaz A, Vantomout M, Lehaen J, Jassen A, Guterman H, Strauven M, Lormans P, Verhamme B, Vandewaeter C, Bonte F, Vionne D, Balik M, Blàha J, Lips M, Othal M, Bursa F, Spacek R, Christensen S, Jorgensen V, Sorensen M, Madsen SA, Puss S, Beljantsev A, Saiydoun G, Fiore A, Colson P, Bazalgette F, Capdevila X, Kollen S, Muller L, Obadia JF, Dubien PY, Ajrhourh L, Guinot PG, Zarka J, Besserve P, Malfertheiner MV, Dreier E, Heinze B, Akhyari P, Lichtenberg A, Aubin H, Assman A, Saeed D, Thiele H, Baumgaertel M, Schmitto JD, Ruslan N, Haverich A, Thielmann M, Brenner T, Ruhpawar A, Benk C, Czerny M, Staudacher DL, Beyersdorf F, Kalbhenn J, Henn P, Popov AF, Iuliu T, Muellenbach R, Reyher C, Rolfes C, Lotz G, Sonntagbauer M, Winkels H, Fichte J, Stohr R, Kalverkamp S, Karagiannidis C, Schafer S, Svetlitchny A, Fichte J, Hopf HB, Jarczak D, Groesdonk H, Rommer M, Hirsch J, Kaehny C, Soufleris D, Gavriilidis G, Pontikis K, Kyriakopoulou M, Kyriakoudi A, O'Brien S, Conrick-Martin I, Carton E, Makhoul M, Ben-Ari J, Hadash A, Kogan A, Kassif Lerner R, Abu-Shakra A, Matan M, Balawona A, Kachel E, Altshuler R, Galante O, Fuchs L, Almog Y, Ishay YS, Lichter Y, Gal-oz A, Carmi U, Nini A, Soroksky A, Dekel H, Rozman Z, Tayem E, Ilgiyaev E, Hochman Y, Miltau D, Rapoport A, Eden A, Kompanietz D, Yousif M, Golos M, Grazioli L, Ghitti D, Loforte A, Di Luca D, Baiocchi M, Pacini D, Cappai A, Meani P, Mondino M, Russo CF, Ranucci M, Fina D, Cotza M, Ballotta A, Landoni G, Nardelli P, Fominski EV, Brazzi L, Montrucchio G, Sales G, Simonetti U, Livigni S, Silengo D, Arena G, Sovatzis SS, Degani A, Riccardi M, Milanesi E, Raffa G, Martucci G, Arcadipane A, Panarello G, Chiarini G, Cattaneo S, Puglia C, Benussi S, Foti G, Giani M, Bombino M, Costa MC, Rona R, Avalli L, Donati A, Carozza R, Gasparri F, Carsetti A, Picichè M, Marinello A, Danzi V, Zanin A, Condello I, Fiore F, Moscarelli M, Nasso G, Speziale G, Sandrelli L, Montalto A, Musumeci F, Circelli A, Russo E, Agnoletti V, Rociola R, Milano AD, Pilato E, Comentale G, Montisci A, Alessandri F, Tosi A, Pugliese F, Giordano G, Carelli S, Grieco DL, Dell'Anna AM, Antonelli M, Ramoni E, Zulueta J, Del Giglio M, Petracca S, Bertini P, Guarracino F, De Simone L, Angeletti PM, Forfori F, Taraschi F, Quintiliani VN, Samalavicius R, Jankuviene A, Scupakova N, Urbonas K, Kapturauskas J, Soerensen G, Suwalski P, Linhares Santos L, Marques A, Miranda M, Teixeira S, Salgueiro A, Pereira F, Ketskalo M, Tsarenko S, Shilova A, Afukov I, Popugaev K, Minin S, Shelukhin D, Malceva O, Gleb M, Skopets A, Kornelyuk R, Kulikov A, Okhrimchuk V, Turchaninov A, Shelukhin D, Petrushin M, Sheck A, Mekulov A, Ciryateva S, Urusov D, Gorjup V, Golicnik A, Goslar T, Ferrer R, Martinez-Martinez M, Argudo E, Palmer N, De Pablo Sanchez R, Juan Higuera L, Arnau Blasco L, Marquez JA, Sbraga F, Fuset MP, De Gopegui PR, Claraco LM, De Ayala JA, Peiro M, Ricart P, Martinez S, Chavez F, Fabra M, Sandoval E, Toapanta D, Carraminana A, Tellez A, Ososio J, Milan P, Rodriguez J, Andoni G, Gutierrez C, Perez de la Sota E, Eixeres-Esteve A, Garcia-Maellas MT, Gutierrez-Gutierrez J, Arboleda-Salazar R, Santa Teresa P, Jaspe A, Garrido A, Castaneda G, Alcantara S, Martinez N, Perez M, Villanueva H, Vidal Gonzalez A, Paez J, Santon A, Perez C, Lopez M, Rubio Lopez MI, Gordillo A, Naranjo-Izurieta J, Munoz J, Alcalde I, Onieva F, Gimeno Costa R, Perez F, Madrid I, Gordon M, Albacete Moreno CL, Perez D, Lopez N, Martinenz D, Blanco-Schweizer P, Diez C, Perez D, Prieto A, Renedo G, Bustamante E, Cicuendez R, Citores R, Boado V, Garcia K, Voces R, Domezain M, Nunez Martinez JM, Vicente R, Martin D, Andreu A, Gomez Casal V, Chico I, Menor EM, Vara S, Gamacho J, Perez-Chomon H, Javier Gonzales F, Barrero I, Martin-Villen L, Fernandez E, Mendoza M, Navarro J, Colomina Climent J, Gonzales-Perez A, Muniz-Albaceita G, Amado L, Rodriguez R, Ruiz E, Eiras M, Grins E, Magnus R, Kanetoft M, Eidevald M, Watson P, Vogt PR, Steiger P, Aigner T, Weber A, Grunefelder J, Kunz M, Grapow M, Aymard T, Reser D, Agus G, Consiglio J, Haenggi M, Hansjoerg J, Iten M, Doeble T, Zenklusen U, Bechtold X, Faedda G, Iafrate M, Rohjer A, Bergamaschi L, Maessen J, Reis Miranda D, Endeman H, Gommers D, Meuwese C, Maas J, Van Gijlswijk MJ, Van Berg RN, Candura D, Van der Linden M, Kant M, Van der Heijden JJ, Scholten E, Van Belle-van Haren N, Lagrand WK, Vlaar AP, De Jong S, Cander B, Sargin M, Ugur M, Kaygin MA, Daly K, Agnew N, Head L, Kelly L, Anoma G, Russell C, Aquino V, Scott I, Flemming L, Gillon S, Moore O, Gelandt E, Auzinger G, Patel S, Loveridge R. In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study. Lancet Respir Med 2023; 11:151-162. [PMID: 36402148 PMCID: PMC9671669 DOI: 10.1016/s2213-2600(22)00403-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/18/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation. METHODS EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing. FINDINGS Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms. INTERPRETATION Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required. FUNDING None.
Collapse
Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands.
| | - Maria Elena De Piero
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Silvia Mariani
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Michele Di Mauro
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Thierry Folliguet
- Department of Cardiac Surgery, Assistance Publique–Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Justyna Swol
- Department of Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University Hospital of Vienna, Vienna, Austria
| | - Mirko Belliato
- Anestesia e Rianimazione II Cardiopolmonare, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Policlinico San Matteo, Pavia, Italy
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Alain Vuylsteke
- ECMO Retrieval Service & Critical Care, Royal Papworth Hospital, NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Yigal Kassif
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Ramat Gan, Israel
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, Anesthesia and Intensive Care Medicine, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Centre Hospitalier Universitaire Montpellier, Montpellier, France,Le laboratoire de Physiologie et Médecine Expérimentale du Coeur et des Muscles (PhyMedExp), Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Stephane Ledot
- Intensive Care Unit, Royal Brompton & Harefield hospitals, London, UK
| | - Julian Barker
- Cardiothoracic Critical Care Unit, Whythenshawe Hospital, Manchester, UK
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center University Freiburg, Bad Krozingen, Germany,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Kersten
- Medizinische Klinik, Uniklinik Rheinisch-Westfälische Technische Hochschule, Aachen, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, Universitair Ziekenhuis Leuven Gasthuisberg University Hospital, Leuven, Belgium
| | - Matteo Pozzi
- Department of Cardiac Surgery, Louis Pradel Hospital, Lyon, France
| | - Finn M Pedersen
- Cardiothoracic Intensive Care Unit, University Hospital, Copenhagen, Denmark
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit, Comprehensive Cancer Center, Center of Excellence in Medical Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Kaan Kirali
- Cardiovascular Surgery Department, Kosuyolu High Specialization Education and Research Hospital, Istanbul, Türkiye
| | - Nicholas Barrett
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Jordi Riera
- Critical Care Department, Val d'Hebron Research Institute, Barcelona, Spain
| | - Thomas Mueller
- Department of Internal Medicine II, University Hospital of Regensburg, Regensburg, Germany
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine General Teaching Hospital, Prague, Czech Republic,1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Atmowihardjo LN, Heijnen NFL, Smit MR, Hagens LA, Filippini DFL, Zimatore C, Schultz MJ, Schnabel RM, Bergmans DCJJ, Aman J, Bos LDJ. Biomarkers of alveolar epithelial injury and endothelial dysfunction are associated with scores of pulmonary edema in invasively ventilated patients. Am J Physiol Lung Cell Mol Physiol 2023; 324:L38-L47. [PMID: 36348302 PMCID: PMC9799153 DOI: 10.1152/ajplung.00185.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Pulmonary edema is a central hallmark of acute respiratory distress syndrome (ARDS). Endothelial dysfunction and epithelial injury contribute to alveolar-capillary permeability but their differential contribution to pulmonary edema development remains understudied. Plasma levels of surfactant protein-D (SP-D), soluble receptor for advanced glycation end products (sRAGE), and angiopoietin-2 (Ang-2) were measured in a prospective, multicenter cohort of invasively ventilated patients. Pulmonary edema was quantified using the radiographic assessment of lung edema (RALE) and global lung ultrasound (LUS) score. Variables were collected within 48 h after intubation. Linear regression was used to examine the association of the biomarkers with pulmonary edema. In 362 patients, higher SP-D, sRAGE, and Ang-2 concentrations were significantly associated with higher RALE and global LUS scores. After stratification by ARDS subgroups (pulmonary, nonpulmonary, COVID, non-COVID), the positive association of SP-D levels with pulmonary edema remained, whereas sRAGE and Ang-2 showed less consistent associations throughout the subgroups. In a multivariable analysis, SP-D levels were most strongly associated with pulmonary edema when combined with sRAGE (RALE score: βSP-D = 6.79 units/log10 pg/mL, βsRAGE = 3.84 units/log10 pg/mL, R2 = 0.23; global LUS score: βSP-D = 3.28 units/log10 pg/mL, βsRAGE = 2.06 units/log10 pg/mL, R2 = 0.086), whereas Ang-2 did not further improve the model. Biomarkers of epithelial injury and endothelial dysfunction were associated with pulmonary edema in invasively ventilated patients. SP-D and sRAGE showed the strongest association, suggesting that epithelial injury may form a final common pathway in the alveolar-capillary barrier dysfunction underlying pulmonary edema.
Collapse
Affiliation(s)
| | - Nanon F. L. Heijnen
- 2Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands,8School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Marry R. Smit
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laura A. Hagens
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Daan F. L. Filippini
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Claudio Zimatore
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,3Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Marcus J. Schultz
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,4Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand,5Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom,6Department of Research and Development, Hamilton Medical AG, Bonaduz, Switzerland
| | - Ronny M. Schnabel
- 2Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
| | - Dennis C. J. J. Bergmans
- 2Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands,8School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Jurjan Aman
- 7Department of Pulmonology, Amsterdam UMC, Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Lieuwe D. J. Bos
- 1Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,7Department of Pulmonology, Amsterdam UMC, Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
9
|
Hagens LA, Van der Ven FLIM, Heijnen NFL, Smit MR, Gietema HA, Gerretsen SC, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Improvement of an interobserver agreement of ARDS diagnosis by adding additional imaging and a confidence scale. Front Med (Lausanne) 2022; 9:950827. [PMID: 36117964 PMCID: PMC9473335 DOI: 10.3389/fmed.2022.950827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) often is not recognized in clinical practice, largely due to variation in the interpretation of chest x-ray (CXR) leading to poor interobserver reliability. We hypothesized that the agreement in the interpretation of chest imaging for the diagnosis of ARDS in invasively ventilated intensive care unit patients between experts improves when using an 8-grade confidence scale compared to using a dichotomous assessment and that the agreement increases after adding chest computed tomography (CT) or lung ultrasound (LUS) to CXR. Three experts scored ARDS according to the Berlin definition based on case records from an observational cohort study using a dichotomous assessment and an 8-grade confidence scale. The intraclass correlation (ICC), imaging modality, and the scoring method were calculated per day and compared using bootstrapping. A consensus judgement on the presence of ARDS was based on the combined confidence grades of the experts, followed by a consensus meeting for conflicting scores. In total, 401 patients were included in the analysis. The best ICC was found using an 8-grade confidence scale for LUS (ICC: 0.49; 95%-CI: 0.29–0.63) and CT evaluation (ICC: 0.49; 95%-CI: 0.34–0.61). The ICC of CXR increased by 0.022 and of CT by 0.065 when 8-grade scoring was used instead of the dichotomous assessment. Adding information from LUS or chest CT increased the ICC by 0.25 when using the 8-grade confidence assessment. An agreement on the diagnosis of ARDS can increase substantially by adapting the scoring system from a dichotomous assessment to an 8-grade confidence scale and by adding additional imaging modalities such as LUS or chest CT. This suggests that a simple assessment of the diagnosis of ARDS with a chart review by one assessor is insufficient to define ARDS in future studies.
Collapse
Affiliation(s)
- Laura A. Hagens
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Laura A. Hagens
| | - Fleur L. I. M. Van der Ven
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Intensive Care, Rode Kruis Ziekenhuis, Brandwondencentrum, Beverwijk, Netherlands
| | - Nanon F. L. Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marry R. Smit
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Hester A. Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Suzanne C. Gerretsen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - Dennis C. J. J. Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
- School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, Netherlands
| | - Ronny M. Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Amsterdam University Medical Center, Location Amsterdam Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
10
|
Heijnen NF, Hagens LA, van Schooten FJ, Bos LD, van der Horst IC, Mommers A, Schultz MJ, Smit MR, Bergmans DC, Smolinska A, Schnabel RM. Breath octane and acetaldehyde as markers for ARDS in invasively ventilated patients suspected to have VAP. ERJ Open Res 2022; 8:00624-2021. [PMID: 35350275 PMCID: PMC8943290 DOI: 10.1183/23120541.00624-2021] [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: 11/04/2021] [Accepted: 01/18/2022] [Indexed: 11/05/2022] Open
Abstract
RationaleThe concentration of octane and acetaldehyde in exhaled breath has good diagnostic accuracy for Acute Respiratory Distress Syndrome (ARDS). We aimed to determine whether breath octane and acetaldehyde are able to distinguish the presence and absence of ARDS in critically ill patients suspected to have ventilator-associated pneumonia (VAP).MethodsThis is a secondary analysis of a prospective observational study into exhaled breath analysis using gas-chromatography-time of flight-mass spectrometry. Difference in the relative abundance of octane and acetaldehyde in exhaled breath was compared between patients with and without ARDS using the Mann-Whitney U-test and the association was quantified using logistic regression. The discriminative accuracy of octane and acetaldehyde, alone or in combination, was calculated using the area under the curve of the ROC (AUROCC).ResultsWe included 98 patients of whom 32 had ARDS and 66 did not. The area under the acetaldehyde peak was higher in patients with ARDS (p=0.03), and associated with the presence of ARDS (OR: 1.06 per 100000 count change (95% CI: 1.02–1.13), p=0.01). A combined model with octane and acetaldehyde showed a high specificity and low sensitivity (respectively, 90% and 40.6%), with a low accuracy (AUROCC: 0.65, 95% CI: 0.53–0.78).ConclusionPatients suspected to have VAP with ARDS had a higher acetaldehyde concentration in exhaled breath than patients suspected to have VAP without ARDS. However, in this patient population, discrimination of these breath biomarkers for ARDS was poor, indicating the difficulty of translating diagnostic tests between clinical settings.
Collapse
|
11
|
Cuijpers ACM, Coolsen MME, Schnabel RM, Lubbers T, van der Horst ICC, van Santen S, Olde Damink SWM, van de Poll MCG. Self-perceived recovery and quality of life in elderly patients surviving ICU-admission for abdominal sepsis. J Intensive Care Med 2021; 37:970-978. [PMID: 34756128 PMCID: PMC9136475 DOI: 10.1177/08850666211052460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Introduction Concern for loss of physical performance and Health-Related Quality of Life (HRQoL) may raise doubts regarding the meaningfulness of an Intensive Care (ICU) admission in elderly patients. We evaluated self-perceived long-term recovery and satisfaction in elderly surviving an abdominal sepsis related ICU-admission and related this to objective measures of HRQoL. Methods A cross-sectional survey study was performed in all ICU-survivors with age ≥70 admitted with abdominal sepsis. HRQoL, frailty and self-perceived long-term recovery were measured using the EQ-5D-3L, Groningen Frailty Indicator, and a self-developed questionnaire, respectively. Results Of 144 patients admitted, 48 were alive at follow up (2.42 [0.92; 3.83] years), and 29 (60%) returned the survey. Eleven patients out of 29 (38%) recovered to baseline functioning, and reported higher HRQoL compared to unrecovered patients (0.861 [0.807; 1.000] and 0.753 [0.499; 0.779] respectively, p=0.005). Of the unrecovered patients, 53% were satisfied with their functioning, and 94% were willing to return to ICU. Conclusions Mortality in elderly patients with abdominal sepsis is high and ICU-admission should be weighed carefully. However, despite substantial functional decline in survivors, it does not necessarily cause self-perceived unsatisfactory functioning, poor HRQoL and unwillingness to receive life-sustaining therapy again. Caution is advised to use an anticipated loss of functioning as an argument to deny an ICU-admission.
Collapse
Affiliation(s)
- Anne C M Cuijpers
- 82246Department of surgery - Maastricht University Medical Centre, , Maastricht, the Netherlands.,82246Department of Intensive Care Medicine - Maastricht University Medical Centre, Maastricht, the Netherlands.,199236School for Oncology and Developmental Biology (GROW) - Maastricht University, Maastricht, The Netherlands
| | - Marielle M E Coolsen
- 82246Department of surgery - Maastricht University Medical Centre, , Maastricht, the Netherlands
| | - Ronny M Schnabel
- 82246Department of Intensive Care Medicine - Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Tim Lubbers
- 82246Department of surgery - Maastricht University Medical Centre, , Maastricht, the Netherlands.,199236School for Oncology and Developmental Biology (GROW) - Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- 82246Department of Intensive Care Medicine - Maastricht University Medical Centre, Maastricht, the Netherlands.,199236Cardiovascular Research Institute Maastricht (CARIM) - Maastricht University, Maastricht, The Netherlands
| | - Susanne van Santen
- 82246Department of Intensive Care Medicine - Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Steven W M Olde Damink
- 82246Department of surgery - Maastricht University Medical Centre, , Maastricht, the Netherlands.,385783School for Nutrition and Translational Research in Metabolism (NUTRIM) - Maastricht University, Maastricht, The Netherlands.,Department of General, 39058Visceral and Transplantation Surgery - RWTH University Hospital Aachen, Aachen, Germany
| | - Marcel C G van de Poll
- 82246Department of surgery - Maastricht University Medical Centre, , Maastricht, the Netherlands.,82246Department of Intensive Care Medicine - Maastricht University Medical Centre, Maastricht, the Netherlands.,385783School for Nutrition and Translational Research in Metabolism (NUTRIM) - Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
12
|
Hagens LA, Heijnen NFL, Smit MR, Verschueren ARM, Nijsen TME, Geven I, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Diagnosis of acute respiratory distress syndrome (DARTS) by bedside exhaled breath octane measurements in invasively ventilated patients: protocol of a multicentre observational cohort study. Ann Transl Med 2021; 9:1262. [PMID: 34532399 PMCID: PMC8421964 DOI: 10.21037/atm-21-1384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/28/2021] [Indexed: 11/08/2022]
Abstract
Background Acute respiratory distress syndrome (ARDS) is currently diagnosed by the Berlin Definition. Diagnosis is subjective and often late. Untargeted metabolomics analysis of exhaled breath with gas chromatography and mass spectrometry (GC-MS) showed that the breath concentration of octane has a high diagnostic accuracy for ARDS. To facilitate rapid bedside measurement of this biomarker, a point-of-care (POC) breath test was developed. A prototype already showed good reproducibility and repeatability for the detection of octane. In this study we aim to measure octane in exhaled breath of invasively ventilated intensive care unit (ICU) patients and validate the diagnostic accuracy of the breath test for the early diagnosis of ARDS. Methods This is a multicentre observational cohort study in patients admitted to the ICU receiving invasive ventilation for at least 24 hours. At least 500 patients in two academic hospitals in The Netherlands will be included. ARDS patients will be compared to patients without ARDS. ARDS diagnosis will be based on the Berlin Definition. Two diagnostic assessments will be performed during the first 72 hours of invasive ventilation, including breath sampling, arterial blood gas analysis and lung ultrasound (LUS). In patients fulfilling the criteria for ARDS, three additional breath samples will be taken to assess resolution. The primary endpoint is the diagnostic accuracy for ARDS, defined by the area under the receiver operating characteristics curve (AUROCC) of octane concentration in exhaled breath. Secondary endpoints are the association between exhaled breath octane and ARDS adjusted for confounders, and the added diagnostic accuracy of the breath test on top of the Lung Injury Prediction Score (LIPS). Discussion This is the first study that validates a metabolic biomarker of ARDS in an adequate sample size. The major novelty is the use of a POC breath test that has been specifically developed for the purpose of diagnosing ARDS. Strengths are; assessment in the early phase, in patients at risk for ARDS, longitudinal sampling and an expert panel to reliably diagnose ARDS. This study will provide a decisive answer on the question if exhaled breath metabolomics can be used to diagnose ARDS. Trial registration The trial is registered at trialregister.nl (ID: NL8226) with the tag “DARTS”.
Collapse
Affiliation(s)
- Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alwin R M Verschueren
- Sleep & Respiratory Solutions, Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Tamara M E Nijsen
- Sleep & Respiratory Solutions, Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Inge Geven
- Sleep & Respiratory Solutions, Philips Research, High Tech Campus, Eindhoven, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Heijnen NFL, Hagens LA, Smit MR, Cremer OL, Ong DSY, van der Poll T, van Vught LA, Scicluna BP, Schnabel RM, van der Horst ICC, Schultz MJ, Bergmans DCJJ, Bos LDJ. Biological Subphenotypes of Acute Respiratory Distress Syndrome Show Prognostic Enrichment in Mechanically Ventilated Patients without Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 203:1503-1511. [PMID: 33465019 DOI: 10.1164/rccm.202006-2522oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Recent studies showed that biological subphenotypes in acute respiratory distress syndrome (ARDS) provide prognostic enrichment and show potential for predictive enrichment. Objectives: To determine whether these subphenotypes and their prognostic and potential for predictive enrichment could be extended to other patients in the ICU, irrespective of fulfilling the definition of ARDS. Methods: This is a secondary analysis of a prospective observational study of adult patients admitted to the ICU. We tested the prognostic enrichment of both cluster-derived and latent-class analysis (LCA)-derived biological ARDS subphenotypes by evaluating the association with clinical outcome (ICU-day, 30-day mortality, and ventilator-free days) using logistic regression and Cox regression analysis. We performed a principal component analysis to compare blood leukocyte gene expression profiles between subphenotypes and the presence of ARDS. Measurements and Main Results: We included 2,499 mechanically ventilated patients (674 with and 1,825 without ARDS). The cluster-derived "reactive" subphenotype was, independently of ARDS, significantly associated with a higher probability of ICU mortality, higher 30-day mortality, and a lower probability of successful extubation while alive compared with the "uninflamed" subphenotype. The blood leukocyte gene expression profiles of individual subphenotypes were similar for patients with and without ARDS. LCA-derived subphenotypes also showed similar profiles. Conclusions: The prognostic and potential for predictive enrichment of biological ARDS subphenotypes may be extended to mechanically ventilated critically ill patients without ARDS. Using the concept of biological subphenotypes for splitting cohorts of critically ill patients could add to improving future precision-based trial strategies and lead to identifying treatable traits for all critically ill patients.
Collapse
Affiliation(s)
- Nanon F L Heijnen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | | | | | - David S Y Ong
- Division of Infectious Diseases.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Infection and Immunity
| | - Tom van der Poll
- Laboratory of Experimental Intensive Care and Anesthesiology, and.,Department of Respiratory Medicine, Amsterdam University Medical Centers, location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Brendon P Scicluna
- Laboratory of Experimental Intensive Care and Anesthesiology, and.,Department of Intensive Care Medicine and
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Medical Microbiology and Infection Control, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; and
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care Medicine.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
14
|
Hagens LA, Verschueren ARM, Lammers A, Heijnen NFL, Smit MR, Nijsen TME, Geven I, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Development and validation of a point-of-care breath test for octane detection. Analyst 2021; 146:4605-4614. [PMID: 34160491 DOI: 10.1039/d1an00378j] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is a demand for a non-invasive bedside method to diagnose Acute Respiratory Distress Syndrome (ARDS). Octane was discovered and validated as the most important breath biomarker for diagnosis of ARDS using gas-chromatography and mass-spectrometry (GC-MS). However, GC-MS is unsuitable as a point-of-care (POC) test in the intensive care unit (ICU). Therefore, we determined if a newly developed POC breath test can reliably detect octane in exhaled breath of invasively ventilated ICU patients. METHODS Two developmental steps were taken to design a POC breath test that relies on gas-chromatography using air as carrier gas with a photoionization detector. Calibration measurements were performed with a laboratory prototype in healthy subjects. Subsequently, invasively ventilated patients were included for validation and assessment of repeatability. After evolving to a POC breath test, this device was validated in a second group of invasively ventilated patients. Octane concentration was based on the area under the curve, which was extracted from the chromatogram and compared to known values from calibration measurements. RESULTS Five healthy subjects and 53 invasively ventilated patients were included. Calibration showed a linear relation (R2 = 1.0) between the octane concentration and the quantified octane peak in the low parts per billion (ppb) range. For the POC breath test the repeatability was excellent (R2 = 0.98, ICC = 0.97 (95% CI 0.94-0.99)). CONCLUSION This is the first study to show that a POC breath test can rapidly and reliably detect octane, with excellent repeatability, at clinically relevant levels of low ppb in exhaled breath of ventilated ICU patients. This opens possibilities for targeted exhaled breath analysis to be used as a bedside test and makes it a potential diagnostic tool for the early detection of ARDS.
Collapse
Affiliation(s)
- Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Alwin R M Verschueren
- Remote Patient Monitoring & Connected Care, Philips Research, High Tech Campus 4, 5656 AE, Eindhoven, Netherlands
| | - Ariana Lammers
- Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Tamara M E Nijsen
- Remote Patient Monitoring & Connected Care, Philips Research, High Tech Campus 4, 5656 AE, Eindhoven, Netherlands
| | - Inge Geven
- Remote Patient Monitoring & Connected Care, Philips Research, High Tech Campus 4, 5656 AE, Eindhoven, Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands and Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand and Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands and School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands and Department of Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
15
|
Driessen RGH, Groven RVM, van Koll J, Oudhuis GJ, Posthouwer D, van der Horst ICC, Bergmans DCJJ, Schnabel RM. Appropriateness of empirical antibiotic therapy and added value of adjunctive gentamicin in patients with septic shock: a prospective cohort study in the ICU. Infect Dis (Lond) 2021; 53:830-838. [PMID: 34156899 DOI: 10.1080/23744235.2021.1942543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES To determine the appropriateness of empiric antibiotic therapy and the possible benefit of adding short-course gentamicin in septic shock patients with abdominal, urogenital, or an unknown focus. Secondary objectives were the effect of gentamicin addition on shock reversal and the incidence of a fungal infection. METHODS Microbiological cultures, antibiotic treatment, and antibiotic resistance patterns of the cultured microorganisms were recorded during the first 5 days of admission. Inappropriate antibiotic therapy was defined as a prescription within the first 24 h that did not cover cultured bacteria during the first 5 days of admission and was determined in the overall group and in patients receiving adjunctive gentamicin (combination therapy) versus patients receiving monotherapy. Binomial logistic regression analysis was used to investigate the association of gentamicin addition with shock reversal. RESULTS Of 203 septic shock patients, with abdominal (n = 143), urogenital (n = 27) or unknown (n = 33) focus, 115 patients received monotherapy, and 88 patients received combination therapy. Inappropriate therapy occurred in 29 patients (14%), more frequently in monotherapy (17%) versus combination therapy (10%). Combination therapy would have been effective in 55% of patients with inappropriate monotherapy. We found no association between gentamicin addition and shock reversal (p = .223). A fungal infection was present in 22 patients (11%). CONCLUSION Inappropriate empirical antibiotic therapy occurs in 17% of septic shock patients receiving monotherapy. In 55% of these patients, additional gentamicin would have resulted in appropriate therapy. When clinical course is unfavourable, lowering the threshold for administering adjunctive aminoglycoside and antifungal therapy should be considered.
Collapse
Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rald V M Groven
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Johan van Koll
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Guy J Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Dirk Posthouwer
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Internal Medicine, Department of Infectious Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
16
|
Mulder MMG, Brandts LI, Brüggemann RAG, Koelmann M, Streng AS, Olie RH, Gietema HA, Spronk HMH, van der Horst ICC, Sels JWEM, Wildberger JE, van Kuijk SMJ, Schnabel RM, Ten Cate H, Henskens YMC, van Bussel BCT. Serial markers of coagulation and inflammation and the occurrence of clinical pulmonary thromboembolism in mechanically ventilated patients with SARS-CoV-2 infection; the prospective Maastricht intensive care COVID cohort. Thromb J 2021; 19:35. [PMID: 34059058 PMCID: PMC8165953 DOI: 10.1186/s12959-021-00286-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022] Open
Abstract
Background The incidence of pulmonary thromboembolism is high in SARS-CoV-2 patients admitted to the Intensive Care. Elevated biomarkers of coagulation (fibrinogen and D-dimer) and inflammation (c-reactive protein (CRP) and ferritin) are associated with poor outcome in SARS-CoV-2. Whether the time-course of fibrinogen, D-dimer, CRP and ferritin is associated with the occurrence of pulmonary thromboembolism in SARS-CoV-2 patients is unknown. We hypothesise that patients on mechanical ventilation with SARS-CoV-2 infection and clinical pulmonary thromboembolism have lower concentrations of fibrinogen and higher D-dimer, CRP, and ferritin concentrations over time compared to patients without a clinical pulmonary thromboembolism. Methods In a prospective study, fibrinogen, D-dimer, CRP and ferritin were measured daily. Clinical suspected pulmonary thromboembolism was either confirmed or excluded based on computed tomography pulmonary angiography (CTPA) or by transthoracic ultrasound (TTU) (i.e., right-sided cardiac thrombus). In addition, patients who received therapy with recombinant tissue plasminogen activator were included when clinical instability in suspected pulmonary thromboembolism did not allow CTPA. Serial data were analysed using a mixed-effects linear regression model, and models were adjusted for known risk factors (age, sex, APACHE-II score, body mass index), biomarkers of coagulation and inflammation, and anticoagulants. Results Thirty-one patients were considered to suffer from pulmonary thromboembolism ((positive CTPA (n = 27), TTU positive (n = 1), therapy with recombinant tissue plasminogen activator (n = 3)), and eight patients with negative CTPA were included. After adjustment for known risk factors and anticoagulants, patients with, compared to those without, clinical pulmonary thromboembolism had lower average fibrinogen concentration of − 0.9 g/L (95% CI: − 1.6 – − 0.1) and lower average ferritin concentration of − 1045 μg/L (95% CI: − 1983 – − 106) over time. D-dimer and CRP average concentration did not significantly differ, 561 μg/L (− 6212–7334) and 27 mg/L (− 32–86) respectively. Ferritin lost statistical significance, both in sensitivity analysis and after adjustment for fibrinogen and D-dimer. Conclusion Lower average concentrations of fibrinogen over time were associated with the presence of clinical pulmonary thromboembolism in patients at the Intensive Care, whereas D-dimer, CRP and ferritin were not. Lower concentrations over time may indicate the consumption of fibrinogen related to thrombus formation in the pulmonary vessels. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00286-7.
Collapse
Affiliation(s)
- Mark M G Mulder
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - LIoyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Renée A G Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marcel Koelmann
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Alexander S Streng
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Renske H Olie
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Hester A Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,GROW School of Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Henri M H Spronk
- Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim E Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Care and Public Health Research Institute, Maastricht University Medical Centre+, Maastricht, The Netherlands
| |
Collapse
|
17
|
Baggerman MR, van Dijk DPJ, Winkens B, Schnabel RM, van Gassel RJJ, Bol ME, Bakers FC, Olde Damink SWM, van de Poll MCG. Edema in critically ill patients leads to overestimation of skeletal muscle mass measurements using computed tomography scans. Nutrition 2021; 89:111238. [PMID: 33895558 DOI: 10.1016/j.nut.2021.111238] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/28/2021] [Accepted: 02/28/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Changes in muscle mass and quality are important targets for nutritional intervention in critical illness. Effects of such interventions may be assessed using sequential computed tomography (CT) scans. However, fluid and lipid infiltration potentially affects muscle area measurements. The aim of this study was to evaluate changes in muscle mass and quality in critical illness with special emphasis on the influence of edema on this assessment. METHODS Changes in skeletal muscle area index (SMI) and radiation attenuation (RA) at the level of vertebra L3 were analyzed using sequential CT scans of 77 patients with abdominal sepsis. Additionally, the relation between these changes and disease severity using the maximum Sequential Organ Failure Assessment (SOFA) score and change in edema were studied. RESULTS SMI declined on average 0.35%/d (±1.22%; P = 0.013). However, SMI increased in 41.6% of the study population. Increasing edema formation was significantly associated with increased SMI and with a higher SOFA score. Muscle RA decreased during critical illness, but was not significantly associated with changes in SMI or changes in edema. CONCLUSION In critically ill patients, edema affects skeletal muscle area measurements, which leads to an overestimation of skeletal muscle area. A higher SOFA score was associated with edema formation. Because both edema and fat infiltration may affect muscle RA, the separate effects of these on muscle quality are difficult to distinguish. When using abdominal CT scans to changes in muscle mass and quality in critically ill patients, researchers must be aware and careful with the interpretation of the results.
Collapse
Affiliation(s)
- Michelle R Baggerman
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Intensive Care Medicine, Laurentius hospital, Roermond, the Netherlands.
| | - David P J van Dijk
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rob J J van Gassel
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martine E Bol
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Frans C Bakers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| |
Collapse
|
18
|
Heijnen NFL, Hagens LA, Smit MR, Schultz MJ, van der Poll T, Schnabel RM, van der Horst ICC, Dickson RP, Bergmans DCJJ, Bos LDJ. Biological subphenotypes of acute respiratory distress syndrome may not reflect differences in alveolar inflammation. Physiol Rep 2021; 9:e14693. [PMID: 33547768 PMCID: PMC7865405 DOI: 10.14814/phy2.14693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 12/12/2022] Open
Abstract
Biological subphenotypes have been identified in acute respiratory distress syndrome (ARDS) based on two parsimonious models: the "uninflamed" and "reactive" subphenotype (cluster-model) and "hypo-inflammatory" and "hyper-inflammatory" (latent class analysis (LCA) model). The distinction between the subphenotypes is mainly driven by inflammatory and coagulation markers in plasma. However, systemic inflammation is not specific for ARDS and it is unknown whether these subphenotypes also reflect differences in the alveolar compartment. Alveolar inflammation and dysbiosis of the lung microbiome have shown to be important mediators in the development of lung injury. This study aimed to determine whether the "reactive" or "hyper-inflammatory" biological subphenotype also had higher concentrations of inflammatory mediators and enrichment of gut-associated bacteria in the lung. Levels of alveolar inflammatory mediators myeloperoxidase (MPO), surfactant protein D (SPD), interleukin (IL)-1b, IL-6, IL-10, IL-8, interferon gamma (IFN-ƴ), and tumor necrosis factor-alpha (TNFα) were determined in the mini-BAL fluid. Key features of the lung microbiome were measured: bacterial burden (16S rRNA gene copies/ml), community diversity (Shannon Diversity Index), and community composition. No statistically significant differences between the "uninflamed" and "reactive" ARDS subphenotypes were found in a selected set of alveolar inflammatory mediators and key features of the lung microbiome. LCA-derived subphenotypes and stratification based on cause of ARDS (direct vs. indirect) showed similar profiles, suggesting that current subphenotypes may not reflect the alveolar host response. It is important for future research to elucidate the pulmonary biology within each subphenotype properly, which is arguably a target for intervention.
Collapse
Affiliation(s)
- Nanon F. L. Heijnen
- Department of Intensive CareMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Laura A. Hagens
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marry R. Smit
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marcus J. Schultz
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A)Academic Medical CentersLocation Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Mahidol‐Oxford Tropical Medicine Research Unit (MORU)Mahidol UniversityBangkokThailand
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Tom van der Poll
- Center for Experimental and Molecular MedicineAmsterdam University Medical CentersLocation Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Division of Infectious DiseasesAmsterdam University Medical CentersLocation Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Ronny M. Schnabel
- Department of Intensive CareMaastricht University Medical Center+MaastrichtThe Netherlands
| | | | - Robert P. Dickson
- Division of Pulmonary and Critical Care MedicineDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMIUSA
- Department of Microbiology and ImmunologyUniversity of Michigan Medical SchoolAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical CareAnn ArborMIUSA
| | | | - Lieuwe D. J. Bos
- Department of Intensive CareAmsterdam University Medical CentersLocation Academic Medical CenterAmsterdamThe Netherlands
| | | |
Collapse
|
19
|
Hagens LA, Heijnen NFL, Smit MR, Schultz MJ, Bergmans DCJJ, Schnabel RM, Bos LDJ. Systematic review of diagnostic methods for acute respiratory distress syndrome. ERJ Open Res 2021; 7:00504-2020. [PMID: 33532455 PMCID: PMC7836439 DOI: 10.1183/23120541.00504-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/18/2020] [Indexed: 01/10/2023] Open
Abstract
Rationale Acute respiratory distress syndrome (ARDS) is currently diagnosed by the Berlin definition, which does not include a direct measure of pulmonary oedema, endothelial permeability or pulmonary inflammation. We hypothesised that biomarkers of these processes have good diagnostic accuracy for ARDS. Methods Medline and Scopus were searched for original diagnostic studies using minimally invasive testing. Primary outcome was the diagnostic accuracy per test and was categorised by control group. The methodological quality was assessed with QUADAS-2 tool. Biomarkers that had an area under the receiver operating characteristic curve (AUROCC) of >0.75 and were studied with minimal bias against an unselected control group were considered to be promising. Results Forty-four articles were included. The median AUROCC for all evaluated tests was 0.80 (25th to 75th percentile: 0.72–0.88). The type of control group influenced the diagnostic accuracy (p=0.0095). Higher risk of bias was associated with higher diagnostic accuracy (AUROCC 0.75 for low-bias, 0.77 for intermediate-bias and 0.84 for high-bias studies; p=0.0023). Club cell protein 16 and soluble receptor for advanced glycation end-products in plasma and two panels with biomarkers of oxidative stress in breath showed good diagnostic accuracy in low-bias studies that compared ARDS patients to an unselected intensive care unit (ICU) population. Conclusion This systematic review revealed only four diagnostic tests fulfilling stringent criteria for a promising biomarker in a low-bias setting. For implementation into the clinical setting, prospective studies in a general unselected ICU population with good methodological quality are needed. Accuracy of diagnosis of acute respiratory distress syndrome (ARDS) is associated with risk of bias. There is a lack of validated diagnostic tests in an unbiased setting, emphasising the need for quality driven diagnostic research in ARDS.https://bit.ly/2GfPAvf
Collapse
Affiliation(s)
- Laura A Hagens
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon F L Heijnen
- Dept of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marry R Smit
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Dennis C J J Bergmans
- Dept of Intensive Care, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Lieuwe D J Bos
- Dept of Intensive Care, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Dept of Respiratory Medicine, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
20
|
Driessen RGH, Latten BGH, Bergmans DCJJ, Hulsewe RPMG, Holtkamp JWM, van der Horst ICC, Kubat B, Schnabel RM. Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study. Virchows Arch 2020; 478:1173-1178. [PMID: 33306143 PMCID: PMC8203528 DOI: 10.1007/s00428-020-02984-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Abstract
Early death in sepsis occurs frequently; however, specific causes are largely unknown. An autopsy can contribute to ascertain causes of death. The objective of the study was to determine discrepancies in clinical diagnosis and postmortem findings in septic intensive care unit (ICU) patients deceased within 48 h after ICU admission. All septic ICU patients who deceased within 48 h after ICU admission were identified and included. Four intensivists determined the clinical cause of death by medical record review. An autopsy was performed within 24 h of death. Clinical diagnosis and postmortem findings were compared and classified as autopsy-identified missed clinical diagnoses and autopsy-refuted diagnoses. Class I and II missed major diagnoses using the Goldman criteria were scored. Between 2012 and 2017, 1107 septic patients were admitted to ICU. Of these, 344 patients (31%) died, of which 97 patients (28%) deceased within 48 h. In 32 (33%) early deceased patients, an autopsy was agreed. There were 26 autopsy-identified missed clinical diagnoses found, mostly myocardial infarction (n = 4) and pneumonia (n = 4). In four patients (13%), a class I discrepancy was found. In fourteen patients (42%), a class II discrepancy was found. In conclusion, an autopsy is an important diagnostic tool that can identify definite causes of death. These diagnoses deviate from diagnoses established during admission in early deceased sepsis patients.
Collapse
Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands. .,Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | | | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Riquette P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Johanna W M Holtkamp
- Department of Intensive Care Medicine, St. Jans Gasthuis, Weert, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bela Kubat
- Department of Pathology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
21
|
Smit MR, de Vos J, Pisani L, Hagens LA, Almondo C, Heijnen NFL, Schnabel RM, van der Horst ICC, Bergmans DCJJ, Schultz MJ, Bos LDJ. Comparison of Linear and Sector Array Probe for Handheld Lung Ultrasound in Invasively Ventilated ICU Patients. Ultrasound in Medicine & Biology 2020; 46:3249-3256. [PMID: 32962892 DOI: 10.1016/j.ultrasmedbio.2020.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/31/2020] [Accepted: 08/13/2020] [Indexed: 06/11/2023]
Abstract
International guidelines do not recommend a specific probe for assessment of lung aeration using lung ultrasound (LUS). The aim of this study was to assess the concordance between linear and sector array probes of a handheld ultrasound device in assessment of lung aeration in invasively ventilated intensive care unit patients. This study included intensive care unit patients who were expected to be ventilated for longer than 24 h. A 12-region LUS exam was performed with a linear and a sector array probe. In each image, the LUS aeration score and number of B-lines were determined. Adding the LUS aeration scores of all regions resulted in a global LUS aeration score. Agreement between the two probes was calculated using intra-class correlation coefficients (ICCs). A total of 30 LUS exams were performed in 19 patients, resulting in a total of 328 pairs of images. Twenty-nine pairs of images were excluded from analysis because the images from the linear probe could not be scored. ICCs calculated for the remaining images revealed good concordance the LUS aeration scores for individual images (ICC = 0.73, 95% confidence interval 0.67-0.78), number of B-lines (ICC = 0.79, 95% confidence interval 0.72-0.83) and global LUS aeration score (ICC = 0.74, 95% confidence interval 0.52-0.87). In conclusion, there is good concordance between linear and sector array probes of a handheld ultrasound device in assessment of lung aeration patterns in mechanically ventilated intensive care unit patients. However, in roughly 10% of the images acquired using the linear probe, the aeration pattern could not be scored.
Collapse
Affiliation(s)
- Marry R Smit
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Juliette de Vos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Luigi Pisani
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Laura A Hagens
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Chiara Almondo
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, the Netherlands
| | | | | | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lieuwe D J Bos
- Department of Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
22
|
Bels JLM, van Kuijk SMJ, Ghossein-Doha C, Tijssen FH, van Gassel RJJ, Tas J, Collaborators M, Schnabel RM, Aries MJH, van de Poll MCG, Bergmans DCJJ, Meex SJR, van Mook WNKA, van der Horst ICC, van Bussel BCT. Decreased serial scores of severe organ failure assessments are associated with survival in mechanically ventilated patients; the prospective Maastricht Intensive Care COVID cohort. J Crit Care 2020; 62:38-45. [PMID: 33246196 PMCID: PMC7669472 DOI: 10.1016/j.jcrc.2020.11.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/04/2020] [Accepted: 11/10/2020] [Indexed: 01/08/2023]
Abstract
Background The majority of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are admitted to the Intensive Care Unit (ICU) for mechanical ventilation. The role of multi-organ failure during ICU admission as driver for outcome remains to be investigated yet. Design and setting Prospective cohort of mechanically ventilated critically ill with SARS-CoV-2 infection. Participants and methods 94 participants of the MaastrICCht cohort (21% women) had a median length of stay of 16 days (maximum of 77). After division into survivors (n = 59) and non-survivors (n = 35), we analysed 1555 serial SOFA scores using linear mixed-effects models. Results Survivors improved one SOFA score point more per 5 days (95% CI: 4–8) than non-survivors. Adjustment for age, sex, and chronic lung, renal and liver disease, body-mass index, diabetes mellitus, cardiovascular risk factors, and Acute Physiology and Chronic Health Evaluation II score did not change this result. This association was stronger for women than men (P-interaction = 0.043). Conclusions The decrease in SOFA score associated with survival suggests multi-organ failure involvement during mechanical ventilation in patients with SARS-CoV-2. Surviving women appeared to improve faster than surviving men. Serial SOFA scores may unravel an unfavourable trajectory and guide decisions in mechanically ventilated patients with SARS-CoV-2.
Collapse
Affiliation(s)
- Julia L M Bels
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Chahinda Ghossein-Doha
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Department of Cardiology, Maastricht University Medical Centre+, Maastricht, the Netherlands; School for Oncology & Developmental Biology (GROW), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Fabian H Tijssen
- Department of Anaesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Rob J J van Gassel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - MaastrICCht Collaborators
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands.
| | - Marcel J H Aries
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| | - Dennis C J J Bergmans
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands.
| | - Steven J R Meex
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands.
| | - Walther N K A van Mook
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; School of Health Professions Education, Maastricht University, Universiteitssingel 60, 6229 ER Maastricht, the Netherlands.
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands.
| | - Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Centre+, P. Debyelaan 25, 6202 AZ Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, the Netherlands.
| |
Collapse
|
23
|
Brüggemann RAG, Spaetgens B, Gietema HA, Brouns SHA, Stassen PM, Magdelijns FJ, Rennenberg RJ, Henry RMA, Mulder MMG, van Bussel BCT, Schnabel RM, van der Horst ICC, Wildberger JE, Stehouwer CDA, Ten Cate H. The prevalence of pulmonary embolism in patients with COVID-19 and respiratory decline: A three-setting comparison. Thromb Res 2020; 196:486-490. [PMID: 33091701 PMCID: PMC7557291 DOI: 10.1016/j.thromres.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The risk of pulmonary embolism (PE) in patients with Coronavirus Disease 2019 (COVID-19) is recognized. The prevalence of PE in patients with respiratory deterioration at the Emergency Department (ED), the regular ward, and the Intensive Care Unit (ICU) are not well-established. OBJECTIVES We aimed to investigate how often PE was present in individuals with COVID-19 and respiratory deterioration in different settings, and whether or not disease severity as measured by CT-severity score (CTSS) was related to the occurrence of PE. PATIENTS/METHODS Between April 6th and May 3rd, we enrolled 60 consecutive adult patients with confirmed COVID-19 from the ED, regular ward and ICU who met the pre-specified criteria for respiratory deterioration. RESULTS A total of 24 (24/60: 40% (95% CI: 28-54%)) patients were diagnosed with PE, of whom 6 were in the ED (6/23: 26% (95% CI: 10-46%)), 8 in the regular ward (8/24: 33% (95% CI: 16-55%)), and 10 in the ICU (10/13: 77% (95% CI: 46-95%)). CTSS (per unit) was not associated with the occurrence of PE (age and sex-adjusted OR 1.06 (95%CI 0.98-1.15)). CONCLUSION The number of PE diagnosis among patients with COVID-19 and respiratory deterioration was high; 26% in the ED, 33% in the regular ward and 77% in the ICU respectively. In our cohort CTSS was not associated with the occurrence of PE. Based on the high number of patients diagnosed with PE among those scanned we recommend a low threshold for performing computed tomography angiography in patients with COVID-19 and respiratory deterioration.
Collapse
Affiliation(s)
- Renée A G Brüggemann
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | - Bart Spaetgens
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Hester A Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands; Grow school of Oncology and Developmental biology, Maastricht, the Netherlands
| | - Steffie H A Brouns
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Patricia M Stassen
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Fabienne J Magdelijns
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Roger J Rennenberg
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ronald M A Henry
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark M G Mulder
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Coen D A Stehouwer
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands; Thrombosis Expert Centre Maastricht and Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| |
Collapse
|
24
|
Tas J, van Gassel RJJ, Heines SJH, Mulder MMG, Heijnen NFL, Acampo-de Jong MJ, Bels JLM, Bennis FC, Koelmann M, Groven RVM, Donkers MA, van Rosmalen F, Hermans BJM, Meex SJ, Mingels A, Bekers O, Savelkoul P, Oude Lashof AML, Wildberger J, Tijssen FH, Buhre W, Sels JWEM, Ghossein-Doha C, Driessen RGH, Kubben PL, Janssen MLF, Nicolaes GAF, Strauch U, Geyik Z, Delnoij TSR, Walraven KHM, Stehouwer CDA, Verbunt JAMCF, Van Mook WNKA, van Santen S, Schnabel RM, Aries MJH, van de Poll MCG, Bergmans D, van der Horst ICC, van Kuijk S, van Bussel BCT. Serial measurements in COVID-19-induced acute respiratory disease to unravel heterogeneity of the disease course: design of the Maastricht Intensive Care COVID cohort (MaastrICCht). BMJ Open 2020; 10:e040175. [PMID: 32994259 PMCID: PMC7526030 DOI: 10.1136/bmjopen-2020-040175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The course of the disease in SARS-CoV-2 infection in mechanically ventilated patients is unknown. To unravel the clinical heterogeneity of the SARS-CoV-2 infection in these patients, we designed the prospective observational Maastricht Intensive Care COVID cohort (MaastrICCht). We incorporated serial measurements that harbour aetiological, diagnostic and predictive information. The study aims to investigate the heterogeneity of the natural course of critically ill patients with a SARS-CoV-2 infection. METHODS AND ANALYSIS Mechanically ventilated patients admitted to the intensive care with a SARS-CoV-2 infection will be included. We will collect clinical variables, vital parameters, laboratory variables, mechanical ventilator settings, chest electrical impedance tomography, ECGs, echocardiography as well as other imaging modalities to assess heterogeneity of the course of a SARS-CoV-2 infection in critically ill patients. The MaastrICCht is also designed to foster various other studies and registries and intends to create an open-source database for investigators. Therefore, a major part of the data collection is aligned with an existing national intensive care data registry and two international COVID-19 data collection initiatives. Additionally, we create a flexible design, so that additional measures can be added during the ongoing study based on new knowledge obtained from the rapidly growing body of evidence. The spread of the COVID-19 pandemic requires the swift implementation of observational research to unravel heterogeneity of the natural course of the disease of SARS-CoV-2 infection in mechanically ventilated patients. Our study design is expected to enhance aetiological, diagnostic and prognostic understanding of the disease. This paper describes the design of the MaastrICCht. ETHICS AND DISSEMINATION Ethical approval has been obtained from the medical ethics committee (Medisch Ethische Toetsingscommissie 2020-1565/3 00 523) of the Maastricht University Medical Centre+ (Maastricht UMC+), which will be performed based on the Declaration of Helsinki. During the pandemic, the board of directors of Maastricht UMC+ adopted a policy to inform patients and ask their consent to use the collected data and to store serum samples for COVID-19 research purposes. All study documentation will be stored securely for fifteen years after recruitment of the last patient. The results will be published in peer-reviewed academic journals, with a preference for open access journals, while particularly considering deposition of the manuscripts on a preprint server early. TRIAL REGISTRATION NUMBER The Netherlands Trial Register (NL8613).
Collapse
Affiliation(s)
- Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Rob J J van Gassel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Serge J H Heines
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Mark M G Mulder
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Melanie J Acampo-de Jong
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Julia L M Bels
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Frank C Bennis
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marcel Koelmann
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Rald V M Groven
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Moniek A Donkers
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Frank van Rosmalen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Ben J M Hermans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Steven Jr Meex
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Alma Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Otto Bekers
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Astrid M L Oude Lashof
- Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Radiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Fabian H Tijssen
- Department of Anesthesiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Wolfgang Buhre
- Department of Anesthesiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Chahinda Ghossein-Doha
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Rob G H Driessen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Pieter L Kubben
- Department of Neurosurgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marcus L F Janssen
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Gerry A F Nicolaes
- Department of Biochemistry, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ulrich Strauch
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Zafer Geyik
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Kim H M Walraven
- Department of Pulmonology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Coen DA Stehouwer
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jeanine A M C F Verbunt
- Department of Rehabilitation Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Walther N K A Van Mook
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Susanne van Santen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marcel J H Aries
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Dennis Bergmans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
25
|
Driessen RGH, Heijnen NFL, Hulsewe RPMG, Holtkamp JWM, Winkens B, van de Poll MCG, van der Horst ICC, Bergmans DCJJ, Schnabel RM. Early ICU-mortality in sepsis - causes, influencing factors and variability in clinical judgement: a retrospective cohort study. Infect Dis (Lond) 2020; 53:61-68. [PMID: 32930619 DOI: 10.1080/23744235.2020.1821912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Sepsis is a global health care problem with a high mortality. Early death seems common; however, data are sparse. The objective of the present study was to report causes and influencing factors of early death in sepsis and septic shock. METHODS All septic ICU patients were included from 2012 to 2017. Early death was predefined as occurring within 48 h. Causes and factors leading up to death were reported by a panel of four intensivists, independently reviewing the medical files. Following factors were assessed: (1) delay in ICU admission; (2) futile ICU treatment; (3) missed diagnosis or inadequate treatment on the ICU. Fleiss kappa was used to assess inter-observer agreement. RESULTS 1107 septic patients (APACHE II score 25 ± 8) were included. 344 patients died of which 97 (28%) within 48 h. In 33% an autopsy was performed. Primary causes of early death were multiple organ failure, mesenteric ischaemia and death after cardio-pulmonary resuscitation (CPR). Delay in ICU admission was scored in 32% of early deaths with slight agreement (κ = 0.180), futile ICU treatment in 29% with moderate agreement (κ = 0.415) and missed diagnosis or treatment in 7% of cases with slight agreement (κ = 0.122). CONCLUSIONS Early death after ICU admission in sepsis is common and primarily caused by multiple organ failure, mesenteric ischaemia and death after unsuccessful CPR. Influencing factors were delay in ICU admission and futile ICU admission. Fleiss kappa indicates substantial variability in clinical judgement between intensivists, strengthening the necessity for shared decision making.
Collapse
Affiliation(s)
- Rob G H Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Riquette P M G Hulsewe
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Johanna W M Holtkamp
- Department of Intensive Care Medicine, St. Jans Gasthuis, Weert, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Maastricht University (CAPHRI), Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands.,Department of Surgery, Maastricht University Medical Center +, Maastricht, The Netherlands.,School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Center +, Maastricht, The Netherlands
| |
Collapse
|
26
|
Cuijpers ACM, Coolsen MME, Schnabel RM, van Santen S, Olde Damink SWM, van de Poll MCG. Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery. World J Surg 2020; 44:4060-4069. [PMID: 32864720 PMCID: PMC7599195 DOI: 10.1007/s00268-020-05742-5] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2020] [Indexed: 12/25/2022]
Abstract
Background Postoperative outcome prediction in elderly is based on preoperative physical status but its predictive value is uncertain. The goal was to evaluate the value of risk assessment performed perioperatively in predicting outcome in case of admission to an intensive care unit (ICU). Methods A total of 108 postsurgical patients were retrospectively selected from a prospectively recorded database of 144 elderly septic patients (>70 years) admitted to the ICU department after elective or emergency abdominal surgery between 2012 and 2017. Perioperative risk assessment scores including Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM) and American Society of Anaesthesiologists Physical Status classification (ASA) were determined. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) was obtained at ICU admission. Results In-hospital mortality was 48.9% in elderly requiring ICU admission after elective surgery (n = 45), compared to 49.2% after emergency surgery (n = 63). APACHE IV significantly predicted in-hospital mortality after complicated elective surgery [area under the curve 0.935 (p < 0.001)] where outpatient ASA physical status and P-POSSUM did not. In contrast, P-POSSUM and APACHE IV significantly predicted in-hospital mortality when based on current physical state in elderly requiring emergency surgery (AUC 0.769 (p = 0.002) and 0.736 (p = 0.006), respectively). Conclusions Perioperative risk assessment reflecting premorbid physical status of elderly loses its value when complications occur requiring unplanned ICU admission. Risks in elderly should be re-assessed based on current clinical condition prior to ICU admission, because outcome prediction is more reliable then.
Collapse
Affiliation(s)
- Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands. .,Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Marielle M E Coolsen
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands
| | - Susanne van Santen
- Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Surgery, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.,Intensive Care Department, Maastricht University Medical Centre+, Postbus 5800, 6202 AZ, Maastricht, The Netherlands.,Faculty of Health Medicine and Life Sciences, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| |
Collapse
|
27
|
Baggerman MR, van Dijk DPJ, Winkens B, van Gassel RJJ, Bol ME, Schnabel RM, Bakers FC, Olde Damink SWM, van de Poll MCG. Muscle wasting associated co-morbidities, rather than sarcopenia are risk factors for hospital mortality in critical illness. J Crit Care 2019; 56:31-36. [PMID: 31805466 DOI: 10.1016/j.jcrc.2019.11.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Low skeletal muscle mass on intensive care unit admission is related to increased mortality. It is however unknown whether this association is influenced by co-morbidities that are associated with skeletal muscle loss. The aim of this study was to investigate whether sarcopenia is an independent risk factor for hospital mortality in critical illness in the presence of co-morbidities associated with muscle wasting. METHODS Data of 155 patients with abdominal sepsis were retrospectively analyzed. Skeletal muscle area was assessed using CT-scans at the level of vertebra L3. Demographic and clinical data were retrieved from electronic patient files. Sarcopenia was defined as a muscle area index below the 5th percentile of the general population. Uni- and multivariable analyses were performed to assess the association between sarcopenia and hospital mortality, correcting for age and comorbidities. RESULTS The prevalence of sarcopenia was higher in patients that did not survive until hospital discharge. However, it appeared that this relation was confounded by the presence of chronic renal insufficiency and cancer. These were independent risk factors for hospital mortality, whereas sarcopenia was not. CONCLUSION In critically ill patients with abdominal sepsis, muscle wasting associated co-morbidities rather than sarcopenia were risk factors for hospital mortality.
Collapse
Affiliation(s)
- Michelle R Baggerman
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands.
| | - David P J van Dijk
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Rob J J van Gassel
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martine E Bol
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Frans C Bakers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Steven W M Olde Damink
- School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| |
Collapse
|
28
|
Heijnen NFL, Bergmans DCJJ, Schnabel RM, Bos LDJ. Targeted treatment of acute respiratory distress syndrome with statins-a commentary on two phenotype stratified re-analysis of randomized controlled trials. J Thorac Dis 2019; 11:S296-S299. [PMID: 30997202 DOI: 10.21037/jtd.2019.01.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nanon F L Heijnen
- Department of Intensive Care, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Ronny M Schnabel
- Department of Intensive Care, Maastricht UMC+, Maastricht, The Netherlands
| | - Lieuwe D J Bos
- Department of Intensive Care, UMC Amsterdam, Location AMC, Amsterdam, The Netherlands
| |
Collapse
|
29
|
Driessen RGH, van de Poll MCG, Mol MF, van Mook WNKA, Schnabel RM. The influence of a change in septic shock definitions on intensive care epidemiology and outcome: comparison of sepsis-2 and sepsis-3 definitions. Infect Dis (Lond) 2017; 50:207-213. [PMID: 28950786 DOI: 10.1080/23744235.2017.1383630] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Clear definitions for septic shock assist clinicians regarding recognition, treatment and standardized reporting of characteristics and outcome of this entity. Sepsis-3 definition of septic shock incorporates a new criterion, a lactate level >2 mmol/L. Differences in epidemiology and outcome of septic shock based upon both definitions were studied in an intensive care (ICU) population of septic patients. METHODS We analyzed a prospectively collected cohort of data in the ICU of the Maastricht University Medical Centre. 632 septic patients were included. ICU mortality was compared between the patient group fulfilling Sepsis-3 definition for septic shock and those that met Sepsis-2 definition. Furthermore, association between lactate levels and ICU mortality was studied. RESULTS Of 632 septic patients, 482 (76.3%) had septic shock according to Sepsis-2 and 300 patients (48.4%) according to Sepsis-3 definition, respectively. Patients meeting Sepsis-3 definition had a higher mortality than patients meeting Sepsis-2 definition (38.9 vs. 34.0%). Serum lactate levels between 2 and 4 mmol/L (25.0 vs. 26.2%, OR 0.94 (0.5-1.5)) and between 4 and 6 mmol/L (23.8 vs. 26.2%, OR 0.88 (0.4-1.7)) compared to levels ≤2 mmol/L were not associated with significantly higher ICU mortality. Serum lactate values ≥6 mmol/L, were significantly associated with increased ICU mortality. CONCLUSION Patients classified according to Sepsis-3 criteria had a higher ICU mortality compared with Sepsis-2 criteria. Lactate levels <6 mmol/L were not able to identify patients with increased ICU mortality. Lactate threshold of 2 mmol/L may be too low to point out patients with actual increased ICU mortality.
Collapse
Affiliation(s)
- Rob G H Driessen
- a Department of Intensive Care Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands.,b Department of Cardiology , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Marcel C G van de Poll
- a Department of Intensive Care Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands.,c Department of Surgery , Maastricht University Medical Centre , Maastricht , The Netherlands.,d School of Nutrition and Translational Research in Metabolism (NUTRIM) , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Marianne F Mol
- a Department of Intensive Care Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Walther N K A van Mook
- a Department of Intensive Care Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Ronny M Schnabel
- a Department of Intensive Care Medicine , Maastricht University Medical Centre , Maastricht , The Netherlands
| |
Collapse
|
30
|
Schnabel RM, Boumans MLL, Smolinska A, Stobberingh EE, Kaufmann R, Roekaerts PMHJ, Bergmans DCJJ. Electronic nose analysis of exhaled breath to diagnose ventilator-associated pneumonia. Respir Med 2015; 109:1454-9. [PMID: 26440675 DOI: 10.1016/j.rmed.2015.09.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 09/21/2015] [Accepted: 09/25/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Exhaled breath analysis is an emerging technology in respiratory disease and infection. Electronic nose devices (e-nose) are small and portable with a potential for point of care application. Ventilator-associated pneumonia (VAP) is a common nosocomial infection occurring in the intensive care unit (ICU). The current best diagnostic approach is based on clinical criteria combined with bronchoalveolar lavage (BAL) and subsequent bacterial culture analysis. BAL is invasive, laborious and time consuming. Exhaled breath analysis by e-nose is non-invasive, easy to perform and could reduce diagnostic time. Aim of this study was to explore whether an e-nose can be used as a non-invasive in vivo diagnostic tool for VAP. METHODS Seventy-two patients met the clinical diagnostic criteria of VAP and underwent BAL. In thirty-three patients BAL analysis confirmed the diagnosis of VAP [BAL+(VAP+)], in thirty-nine patients the diagnosis was rejected [BAL-]. Before BAL was performed, exhaled breath was sampled from the expiratory limb of the ventilator into sterile Tedlar bags and subsequently analysed by an e-nose with metal oxide sensors (DiagNose, C-it, Zutphen, The Netherlands). From further fifty-three patients without clinical suspicion of VAP or signs of respiratory disease exhaled breath was collected to serve as a control group [control(VAP-]). The e-nose data from exhaled breath were analysed using logistic regression. RESULTS The ROC curve comparing [BAL+(VAP+)] and [control(VAP-)] patients had an area under the curve (AUC) of 0.82 (95% CI 0.73-0.9). The sensitivity was 88% with a specificity of 66%. The comparison of [BAL+(VAP+)] and [BAL-] patients revealed an AUC of 0.69; 95% CI 0.57-0.81) with a sensitivity of 76% with a specificity of 56%. CONCLUSION E-nose lacked sensitivity and specificity in the diagnosis of VAP in the present study for current clinical application. Further investigation into this field is warranted to explore the diagnostic possibilities of this promising new technique.
Collapse
Affiliation(s)
- R M Schnabel
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands.
| | - M L L Boumans
- Medical Microbiology, Maastricht University Medical Centre, The Netherlands
| | - A Smolinska
- Department of Pharmacology and Toxicology, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Centre, The Netherlands
| | - E E Stobberingh
- Medical Microbiology, Maastricht University Medical Centre, The Netherlands
| | - R Kaufmann
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - P M H J Roekaerts
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| | - D C J J Bergmans
- Departments of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands
| |
Collapse
|
31
|
Schnabel RM, van der Velden K, Osinski A, Rohde G, Roekaerts PMHJ, Bergmans DCJJ. Clinical course and complications following diagnostic bronchoalveolar lavage in critically ill mechanically ventilated patients. BMC Pulm Med 2015; 15:107. [PMID: 26420333 PMCID: PMC4588466 DOI: 10.1186/s12890-015-0104-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 09/21/2015] [Indexed: 12/26/2022] Open
Abstract
Background Flexible, fibreoptic bronchoscopy (FFB) and bronchoalveolar lavage (BAL) have been used for diagnostic purposes in critically ill ventilated patients. The additional diagnostic value compared to tracheal aspirations in ventilator-associated pneumonia (VAP) has been questioned. Nevertheless, BAL can provide extra information for the differential diagnosis of respiratory disease and good antibiotic stewardship. These benefits should outweigh potential hazards caused by the invasiveness of this diagnostic technique. The focus of the present study was on the clinical course and complications of patients following BAL procedures up to 24 h. Methods Hundred sixty-four FFB guided BAL procedures for suspected pneumonia were analysed in an observational study. The clinical course of patients was monitored by respiratory and haemodynamic data before BAL, 1 and 24 h after BAL. Complications were defined and registered. Factors associated with complications were analysed by logistic regression. Results Clinical course: a decrease in average pO2/FiO2 ratio 1 h after BAL from 29 kPa (218 mmHg) to 25 kPa (189 mmHg) (p < 0.05) was observed which fully recovered within 24 h. Respiratory complications: the incidence of procedure related hypo-oxygenation (SaO2 ≤ 88 %) and/or bronchospasm was 9 %; a decrease of >25 % PaO2/FiO2 ratio 1 h after BAL was found in 29 % of patients; no bleeding or pneumothorax were registered. Haemodynamic complications: there were no cases of hypertension and cardiac rhythm disturbances; haemodynamic instability within the first 24 h after BAL was recorded in 22 %; this was correlated with a cardiovascular diagnosis at admission (OR 2.9; 95 % CI 1.2 - 6.7) and the presence of cardiovascular co-morbidity (OR 3.5; 95 % CI 1.5 – 8.3). The incidence of bacteraemia was 7 %. There was no case of procedure related death. Discussion Frequently occurring haemodynamic and respiratory instability but no cases of cardiac rhythm disturbances, bleeding, pneumothorax or procedure related death were attributable to diagnostic FFB and BAL. The procedures should be conducted under careful supervision by experienced physicians. Only a randomized controlled trial that compares diagnostic FFB and BAL with a non-invasive strategy could ultimately establish the safety profile and clinical utility of these procedures in critically ill ventilated patients.
Collapse
Affiliation(s)
- R M Schnabel
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - K van der Velden
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - A Osinski
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - G Rohde
- Department of Respiratory Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - P M H J Roekaerts
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - D C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre+, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| |
Collapse
|
32
|
Schnabel RM, Scholte JBJ, Van Der Velden KEHM, Roekaerts PMHJ, Bergmans DCJJ. Ventilator-associated pneumonia rates after introducing selective digestive tract decontamination. Infect Dis (Lond) 2015; 47:650-3. [PMID: 25851244 DOI: 10.3109/23744235.2015.1031172] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The incidence of ventilator-associated pneumonia (VAP) before and after the introduction of selective oral decontamination (SOD) only and selective digestive tract decontamination (SDD) in a general intensive care population was examined. SOD as standard of care was introduced in December 2010 and SDD, including SOD, in January 2012 for all patients with an expected length of intensive care unit (ICU) stay of at least 48 h. The diagnosis of VAP was based on clinical criteria and quantitative cultures of bronchoalveolar lavage fluid. A total of 4945 mechanically ventilated patients accounting for 37 554 ventilator days in the period from 2005 to 2013 were analyzed. The incidence of VAP per 1000 ventilator days declined significantly from 4.38 ± 1.64 before to 1.64 ± 0.43 after introduction of SOD/SDD (p = 0.007). Implementation of SOD/SDD as standard of care in ICUs may thus be effective in preventing VAP.
Collapse
Affiliation(s)
- Ronny M Schnabel
- From the Department of Intensive Care Medicine, Maastricht University Medical Centre+ , The Netherlands
| | | | | | | | | |
Collapse
|
33
|
Schnabel RM, Linssen CF, Guion N, van Mook WN, Bergmans DC. Candida pneumonia in intensive care unit? Open Forum Infect Dis 2014; 1:ofu026. [PMID: 25734099 PMCID: PMC4324192 DOI: 10.1093/ofid/ofu026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/24/2014] [Indexed: 01/13/2023] Open
Abstract
It has been questioned if Candida pneumonia exists as a clinical entity. Only histopathology can establish the definite diagnosis. Less invasive diagnostic strategies lack specificity and have been insufficiently validated. Scarcity of this pathomechanism and nonspecific clinical presentation make validation and the development of a clinical algorithm difficult. In the present study, we analyze whether Candida pneumonia exists in our critical care population. We used a bronchoalveolar lavage (BAL) specimen database that we have built in a structural diagnostic approach to ventilator-associated pneumonia for more than a decade consisting of 832 samples. Microbiological data were linked to clinical information and available autopsy data. We searched for critically ill patients with respiratory failure with no other microbiological or clinical explanation than exclusive presence of Candida species in BAL fluid. Five cases could be identified with Candida as the likely cause of pneumonia.
Collapse
Affiliation(s)
| | - Catharina F Linssen
- Medical Microbiology , Maastricht University Medical Centre , Maastricht , The Netherlands
| | | | | | | |
Collapse
|
34
|
Vanspauwen MJ, Schnabel RM, Bruggeman CA, Drent M, van Mook WNKA, Bergmans DCJJ, Linssen CFM. Mimivirus is not a frequent cause of ventilator-associated pneumonia in critically ill patients. J Med Virol 2013; 85:1836-41. [PMID: 23861144 PMCID: PMC7166740 DOI: 10.1002/jmv.23655] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 12/27/2022]
Abstract
Acanthamoeba polyphaga mimivirus (APMV) belongs to the amoebae‐associated microorganisms. Antibodies to APMV have been found in patients with pneumonia suggesting a potential role as a respiratory pathogen. In addition, positive serology for APMV was associated with an increased duration of mechanical ventilation and intensive care unit stay in patients with ventilator‐associated pneumonia. The aim of the present study was to assess the presence of APMV in bronchoalveolar lavage fluid samples of critically ill patients suspected of ventilator‐associated pneumonia. The study was conducted in the intensive care unit of the Maastricht University Medical Centre. All consecutive bronchoalveolar lavage fluid samples obtained between January 2005 and October 2009 from patients suspected of ventilator‐associated pneumonia were eligible for inclusion. All samples were analyzed by real‐time PCR targeting the APMV. A total of 260 bronchoalveolar lavage fluid samples from 214 patients (139 male, 75 female) were included. Bacterial ventilator‐associated pneumonia was confirmed microbiologically in 105 out of 260 (40%) suspected episodes of ventilator‐associated pneumonia (86 patients). The presence of APMV DNA could not be demonstrated in the bacterial ventilator‐associated pneumonia positive or in the bacterial ventilator‐associated pneumonia negative bronchoalveolar lavage fluid samples. Although suspected, APMV appeared not to be present in critically ill patients suspected of ventilator‐associated pneumonia, and APMV does not seem to be a frequent cause of ventilator‐associated pneumonia. J Med. Virol. 85:1836–1841, 2013. © 2013 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- M J Vanspauwen
- Department of Medical Microbiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
35
|
|