Contrast induced acute kidney injury prevention during angiographic procedure with early renal replacement therapy

Background and purpose

Post-angiography renal replacement therapy (RRT) has shown protective effects from Ci-AKI (contrast induced acute kidney injury) in patients with pre-existing advanced renal disfunction. We analysed a series of 1095 continuative patients who undergone coronary or peripheral angiography in our center. In non-haemodialyzed patients with eGFR <20ml/min/1.73m2 or with poor renal reserve we performed an “early” RRT, starting during angiography procedure and applied for at least 6 h after procedure, thus diverging from previous literature data based only on post-procedure hours delayed RRT application. The RRT modality chosen was CVVHDF (continous veno-venous hemodiafiltration).

Methods

We considered following subjects variability: age, sex, weight, presence of hypertension, dyslipidaemia, diabetes, smoking habitude, left ventricular ejection fraction, amount of contrast media given and shock or infection occurrence during hospital stay. We evaluate statistic significative of serum creatine (SCr) variation in patients receiving RRT from pre-procedure time (T0), at 24h (T1), 48h (T2), 72h (T3) after procedure and at 3–8 weeks follow-up (T4). Quantitative data were compared with Student T test, qualitative data with Chi Square test, considering statistically significant p value <0.05 with two tails. Ci-AKI was defined as serum creatinine rise ≥0.3 mg/dL at 48h from contrast media administration, following KDIGO (kidney disease improving global outcomes) guidelines definition.

Results

26 patients received RRT. Medium SCr at T0 was 3.37 mg/dl and showed a significative reduction (see figure) at T1 (−0.88mg/dl = −20.6%, p=0.003) and T2 (−0.96mg/dl = −18.33%, p=0.029) and a trend towards reduction at T3 (−0.78mg/dl, p=0.174) and at T4 (−0.28mg/dl, p=0.568).

Between 26 pts, 6 pts (23%) developed Ci-AKI. Only contrast media amount significatively diverge between two groups (183 ml in the group with Ci-AKI vs 162 ml in pts with no Ci-AKI, p=0.03), showing also a trend towards significance for infection occurrence (83.3% pts Ci-AKI vs 40% pts no Ci-AKI, p=0.06) and shock onset (33.3%pts Ci-AKI vs 5% pts no Ci-AKI, p=0.06).

Average SCr diverge at T2 (3.18mg/dl Ci-AKI vs 2.04mg/dl no Ci-AKI, p=0.01) and at T3 (3.33mg/dl CI-AKI vs 2.31mg/dl no CI-AKI, p=0.06); we also found a trend towards progressive increase of SCr for Ci-AKI pts (T0-T1: +0.17mg/dl, p=ns; T0-T2: +0.41mg/dl, p=ns; T0-T3: +0.57mg/dl, p=ns; T0-T4: +1.35mg/dl, p=ns) and a significative reduction in SCr for no Ci-AKI pts (T0-T1: −1.23mg/dl = −29.32% p=0.001; T0-T2: −1.46mg/dl = −30.78%, p=0.01; T0-T4: −0.41mg/dl = −15.5%, p=0.05).

Conclusions

Early RRT with CVVHDF modality results effective in 77% of patients in avoiding Ci-AKI, with a significative SCr reduction at 24 and 48h. An increased amount of contrast media is significatively related to Ci-AKI incidence. Ci-AKI development could also possibly be related to shock and infection occurrence.

Figure 1

Funding Acknowledgement

Type of funding source: None

How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism

BACKGROUND

Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism.

CASE REPORT

A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection.

CONCLUSION

Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.

P2815Antiplatelet therapy with cangrelor in patients undergoing surgery after coronary stent implantation: a real-world bridging protocol experience

Background

Perioperative management of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients deemed at high thrombotic risk undergoing non-deferrable surgery remains poorly defined. Cangrelor represents a potential treatment option as a “bridge” from discontinuation of oral P2Y12 receptor antagonists to surgical procedures, but data in this setting are still scant.

Purpose

We sought to describe a real-world experience of a bridging protocol using cangrelor for patients referred to relevant bleeding risk surgery requiring withdrawal of DAPT.

Methods

We collected data from 7 Italian centers on patients with previous PCI, still on DAPT, undergoing non-deferrable surgery which required discontinuation of one or both antiplatelet agents. A standardized bridging protocol using cangrelor infusion before and eventually after surgery was applied (Figure 1).

Results

Between December 2017 and January 2019, a total of 18 patients (mean age 70±10 years; male 85%) were enrolled. In the majority (89%) of patients, the index PCI was performed due to acute coronary syndrome (ACS) and 2±1.7 stents per patient were implanted. All patients required non-deferrable, intermediate-high bleeding risk surgery as pulmonary lobectomy, colectomy, endoscopic bladder surgery, paranasal sinus surgery, coronary artery by-pass surgery and valvular repair, hip replacement, endoscopy sphincterotomy. High thrombotic risk categories included PCI time <1 month, SCA time <3 months, stent failure occurrence, previous Absorb BVS implantation. Due to the surgical bleeding risk, discontinuation of P2Y12 inhibitor was required 5 days before surgery (ticagrelor, n=13; prasugrel=1; clopidogrel, n=5). All patients but 1 maintained aspirin through the perioperative phase. Cangrelor infusion was started at a bridging dose (0.75 mcg/kg/min) 3 days before planned surgery and was discontinued 6.9±1.5 hours before. After surgery, drainages were left in all patients but 3. In 56% of patients, cangrelor was resumed within 24 hours from surgery (mean time 9±7 hours) for a mean of 36±38 hours. Drainages were removed after discontinuation of cangrelor, in order to reduce bleeding complications. Within 2 hours from post-operative cangrelor discontinuation, a 300 mg clopidogrel loading dose was administered. No major ischemic adverse outcomes occurred during hospital stay and up to 30 days follow-up. The mean Hb drop was 2±1.8 g/dl, 7 patients received blood transfusions consistent with the type of surgeries and no life-threatening or fatal bleeding occurred.

Figure 1. Standardized bridging protocol.

Conclusions

Peri-operative bridge therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk referred to non-deferrable surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.

Langerhans' cells histiocytosis

Langerhans cell histiocytosis (LCH) is a rare disorder of unknown cause, characterized by the proliferation of histiocytic cells in various tissues and organs. The role of the otolaryngologist is important in the early and accurate evaluation, staging and diagnosis of LCH, because it may mimic more common diseases such as otitis externa and acute mastoiditis. We discuss a case report of bilateral mastoid involvement in a child with a history of otalgia unresponsive to medical therapy.

Effect of sample volume location on Doppler-derived transmitral inflow velocity values in 288 normal subjects 20 to 80 years old: an echocardiographic, two-dimensional color Doppler cooperative study

The aims of the study were to evaluate in a population of 288 normal subjects 20 to 80 years old (1) the normal values of the indexes of the mitral flow velocity pattern measured either at the tips of the mitral leaflets or at the annulus; (2) whether there was a significant difference between the values obtained at the tips compared with those measured at the mitral annulus; (3) the correlation with aging between the indexes measured in the two different positions; and (4) whether certain physiological variables have different effects on diastolic function measured in the two different positions. The highest values were always measured at the tips of the mitral leaflets (p < 0.05); only atrial filling fraction, E acceleration time, and E deceleration velocity had higher values when measured at the level of the annulus (p < 0.05). The A-wave peak velocity had the same mean value when measured at both the tips and at the annulus. A significant difference in the correlation between parameters measured at the tips of the mitral leaflets with age and at the annulus (with age) was observed for the following parameters: (1) peak E velocity, E integral, total integral and E acceleration showed better correlation with age when measured at the annulus (p < 0.02); (2) peak A velocity and A integral showed better correlation with age when measured at the tips of the mitral leaflets (p < 0.001). Multivariate analysis showed that age was the variable that had the most influence on diastolic function parameters; heart rate had less influence on the diastolic function indexes.

Reduced cardiovascular sympathetic excitatory responses during iloprost infusion in conscious dogs

STUDY OBJECTIVE

The aim was to determine the effects of the stable prostacyclin analogue iloprost (ZK 36374) on systemic haemodynamics and on cardiovascular neural control.

DESIGN

The buffering effect was examined of intravenous and intracoronary iloprost infusion on the excitatory sympathetic reflexes elicited from the heart by (1) intracoronary injections of bradykinin and (2) transient coronary artery occlusion.

SUBJECTS

22 conscious mongrel dogs of either sex, weight 20-25 kg, were used.

MEASUREMENTS AND MAIN RESULTS

ECG, systemic arterial pressure, left atrial pressure, and left ventricular pressure, and contractility (dP/dt) were continuously monitored for the duration of the experiments. Iloprost infusion reduced left ventricular pressure, mean arterial pressure, and dP/dt without causing significant changes in heart rate. Transient non-hypertensive coronary artery occlusion increased heart rate and depressed contractility. During intravenous iloprost infusion, coronary artery occlusion no longer elicited an increase in heart rate, while left ventricular dP/dt was more drastically reduced. This pattern of response was not substantially modified by beta adrenergic blockade, whereas the blockade of muscarinic receptors with atropine was accompanied by hypotension and a greater reduction of dP/dt. The observation of a reduced pressor response to the intracoronary injections of bradykinin during iloprost administration further indicated a restraining effect of iloprost on the sympathetic reflexes elicited from the heart.

CONCLUSIONS

The data suggest the hypothesis that the protective effects on the ischaemic myocardium observed with iloprost infusions may arise not only from its vasodilator and antiplatelet properties, but also from its capacity to blunt excitatory sympathetic reflexes.

Analysis of short-term oscillations of R-R and arterial pressure in conscious dogs

We studied the neural determinants of the second (i.e., high frequency, HF)- and third-order (i.e., low frequency, LF) spontaneous oscillations of heart period (R-R interval) and arterial pressure (AP) in conscious dogs, with the hypothesis that they might furnish quantitative markers of autonomic controlling activities. Spectral analysis of simultaneous R-R and AP variabilities quantified these oscillations that were also evaluated in units normalized by total power to focus on the balance of these two major components. At rest we observed a prevalent HF component (approximately 0.25 Hz) in R-R and AP variabilities that was synchronous with respiration. This HF component of R-R variability disappeared after atropine infusion and can be considered a marker mostly of vagal activity. When baroreceptor unloading, obtained by moderate hypotension, increased sympathetic activity the LF component increased in R-R, systolic, and diastolic AP variabilities. This increase in LF was not present after ganglionic blockade or after chronic arterial baroreceptor denervation. After chronic bilateral stellectomy, hypotension was not accompanied by an increase in LF component of R-R variability, while LF component remained in AP variability. An increase in LF component of R-R and AP variabilities was observed during transient coronary artery occlusion.

Spectral analysis of heart rate variability in the assessment of autonomic diabetic neuropathy

We studied heart rate variability in 49 uncomplicated diabetics (27 with insulin therapy; 22 with oral hypoglycemic agents) and in 40 age-matched controls. An automatic autoregressive algorithm was used to compute the power spectral density (PSD) of beat by beat RR variability derived from the surface ECG. The PSD contains two major components (a low frequency approximately 0.1 Hz (LF) and a high frequency, respiratory linked, approximately 0.25 Hz (HF] that provide, respectively, quantitative markers of sympathetic and vagal modulatory activities and of their balance. As compared to controls, in diabetics, besides a reduced RR variance at rest (2722 +/- 300 and 1436 +/- 241 ms2, respectively), we observed during passive tilt an altered response of spectral indices of sympathetic activation and vagal withdrawal, suggestive of a complex modification in the neural control activities. In addition, we compared this approach to the commonly used clinical tests score, and observed that the latter provides overall results similar to those obtained with spectral changes induced by tilt (r = 0.42; P less than 0.01). Of potential clinical importance is that the data obtained with spectral analysis appear more thoroughly quantifiable and do not require the active collaboration of the patients.