1
|
Heinen A, Erlebach R, Schrimpf C, Bonani M, Ganter CC, David S, Andermatt R. [OCT, Triple H or anything else?]. Inn Med (Heidelb) 2024; 65:176-179. [PMID: 37407743 PMCID: PMC10830584 DOI: 10.1007/s00108-023-01559-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/07/2023]
Abstract
Hyperammonemia is a life-threatening condition, the prognosis of which depends on a rapid reduction of ammonia. If a hepatic cause is excluded, the differential diagnosis is broad and even in adulthood includes hereditary metabolic diseases. Here, the case of a 25-year-old female patient with severe hyperammonemia refractory to standard therapy is described and the relevance of extracorporeal elimination of ammonia emphasized.
Collapse
Affiliation(s)
- Anna Heinen
- Institut für Intensivmedizin, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - Rolf Erlebach
- Institut für Intensivmedizin, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - Claudia Schrimpf
- Klinik für Gefässchirurgie, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - Marco Bonani
- Klinik für Nephrologie, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - Christoph C Ganter
- Institut für Intensivmedizin, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| | - Sascha David
- Institut für Intensivmedizin, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz.
| | - Rea Andermatt
- Institut für Intensivmedizin, Universitätsspital Zürich, Rämistr. 100, 8091, Zürich, Schweiz
| |
Collapse
|
2
|
Müller MM, Caspar L, Sazpinar O, Hofmaenner DA, Erlebach R, Andermatt R, Ganter CC, Schuepbach RA, Wendel-Garcia PD, David S. Metabolic disturbances potentially attributable to clogging during continuous renal replacement therapy. Intensive Care Med Exp 2023; 11:99. [PMID: 38127207 PMCID: PMC10739685 DOI: 10.1186/s40635-023-00581-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Clogging is characterized by a progressive impairment of transmembrane patency in renal replacement devices and occurs due to obstruction of pores by unknown molecules. If citrate-based anti-coagulation is used, clogging can manifest as a metabolic alkalosis accompanied by hypernatremia and hypercalcemia, primarily a consequence of Na3Citrate infusion. An increased incidence of clogging has been observed during the COVID-19 pandemic. However, precise factors contributing to the formation remain uncertain. This investigation aimed to analyze its incidence and assessed time-varying trajectories of associated factors in critically ill patients on continuous renal replacement therapy (CRRT). METHODS In this retrospective, single-center data analysis, we evaluated COVID-19 patients undergoing CRRT and admitted to critical care between March 2020 and December 2021. We assessed the proportional incidence of clogging surrogates in the overall population and subgroups based on the specific CRRT devices employed at our institution, including multiFiltrate (Fresenius Medical Care) and Prismaflex System (Baxter). Moderate and severe clogging were defined as Na > 145 or ≥ 150 mmol/l and HCO3- > 28.0 or ≥ 30 mmol/l, respectively, with a total albumin-corrected calcium > 2.54 mmol/l. A mixed effect model was introduced to investigate factors associated with development of clogging. RESULTS Fifty-three patients with 240 CRRT runs were analyzed. Moderate and severe clogging occurred in 15% (8/53) and 19% (10/53) of patients, respectively. Twenty-seven percent (37/136) of CRRTs conducted with a multiFiltrate device met the criteria for clogging, whereas no clogging could be observed in patients dialyzed with the Prismaflex System. Occurrence of clogging was associated with elevated triglyceride plasma levels at filter start (p = 0.013), amount of enteral nutrition (p = 0.002) and an increasing white blood cell count over time (p = 0.002). CONCLUSIONS Clogging seems to be a frequently observed phenomenon in critically ill COVID-19 patients. The presence of hypertriglyceridemia, combined with systemic inflammation, may facilitate the development of an impermeable secondary membrane within filters, thereby contributing to compromised membrane patency.
Collapse
Affiliation(s)
- Mattia M Müller
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Larina Caspar
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Onur Sazpinar
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Daniel A Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Christoph C Ganter
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
- Department of Nephrology, Hannover Medical School, Hanover, Germany.
| |
Collapse
|
3
|
Erlebach R, Wild LC, Seeliger B, Rath AK, Andermatt R, Hofmaenner DA, Schewe JC, Ganter CC, Müller M, Putensen C, Natanov R, Kühn C, Bauersachs J, Welte T, Hoeper MM, Wendel-Garcia PD, David S, Bode C, Stahl K. Outcomes of patients with acute respiratory failure on veno-venous extracorporeal membrane oxygenation requiring additional circulatory support by veno-venoarterial extracorporeal membrane oxygenation. Front Med (Lausanne) 2022; 9:1000084. [PMID: 36213640 PMCID: PMC9539450 DOI: 10.3389/fmed.2022.1000084] [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: 07/21/2022] [Accepted: 09/05/2022] [Indexed: 12/05/2022] Open
Abstract
Objective Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the V-V ECMO with an additional arterial return cannula (termed V-VA ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality. Design Multicenter, retrospective analysis between January 2008 and September 2021. Setting Three tertiary care ECMO centers in Germany (Hannover, Bonn) and Switzerland (Zurich). Patients Seventy-three V-V ECMO patients with ARDS and additional acute cardio-circulatory deterioration required an upgrade to V-VA ECMO were included in this study. Measurements and main results Fifty-three patients required an upgrade from V-V to V-VA and 20 patients were directly triple cannulated. Median (Interquartile Range) age was 49 (28–57) years and SOFA score was 14 (12–17) at V-VA ECMO upgrade. Vasoactive-inotropic score decreased from 53 (12–123) at V-VA ECMO upgrade to 9 (3–37) after 24 h of V-VA ECMO support. Weaning from V-VA and V-V ECMO was successful in 47 (64%) and 40 (55%) patients, respectively. Duration of ECMO support was 12 (6–22) days and ICU length of stay was 32 (16–46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). The vast majority of patients was free from higher degree persistent organ dysfunction at follow-up. A SOFA score > 14 and higher lactate concentrations at the day of V-VA upgrade were independent predictors of mortality in the multivariate regression analysis. Conclusion In this analysis, the use of V-VA ECMO in patients with ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score > 14 and elevated lactate levels at the day of V-VA upgrade predict unfavorable outcome.
Collapse
Affiliation(s)
- Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Lennart C. Wild
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
| | - Ann-Kathrin Rath
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Daniel A. Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jens-Christian Schewe
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christoph C. Ganter
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Mattia Müller
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | - Johann Bauersachs
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
- Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | - Marius M. Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- *Correspondence: Sascha David,
| | - Christian Bode
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany
| |
Collapse
|
4
|
Maibach MA, Allam A, Hilty MP, Perez Gonzalez NA, Buehler PK, Wendel Garcia PD, Brugger SD, Ganter CC, Krauthammer M, Schuepbach RA, Bartussek J. How to Synchronize Longitudinal Patient Data With the Underlying Disease Progression: A Pilot Study Using the Biomarker CRP for Timing COVID-19. Front Med (Lausanne) 2021; 8:607594. [PMID: 34307391 PMCID: PMC8295502 DOI: 10.3389/fmed.2021.607594] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/07/2021] [Indexed: 01/29/2023] Open
Abstract
The continued digitalization of medicine has led to an increased availability of longitudinal patient data that allows the investigation of novel and known diseases in unprecedented detail. However, to accurately describe any underlying pathophysiology and allow inter-patient comparisons, individual patient trajectories have to be synchronized based on temporal markers. In this pilot study, we use longitudinal data from critically ill ICU COVID-19 patients to compare the commonly used alignment markers “onset of symptoms,” “hospital admission,” and “ICU admission” with a novel objective method based on the peak value of the inflammatory marker C-reactive protein (CRP). By applying our CRP-based method to align the progression of neutrophils and lymphocytes, we were able to define a pathophysiological window that improved mortality risk stratification in our COVID-19 patient cohort. Our data highlights that proper synchronization of longitudinal patient data is crucial for accurate interpatient comparisons and the definition of relevant subgroups. The use of objective temporal disease markers will facilitate both translational research efforts and multicenter trials.
Collapse
Affiliation(s)
- Martina A Maibach
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Ahmed Allam
- Department of Quantitative Biomedicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Matthias P Hilty
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Nicolas A Perez Gonzalez
- Department of Quantitative Biomedicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp K Buehler
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Pedro D Wendel Garcia
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Silvio D Brugger
- Department of Infectious Diseases and Hospital Epidemiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Christoph C Ganter
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland
| | | | | | - Michael Krauthammer
- Department of Quantitative Biomedicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Reto A Schuepbach
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan Bartussek
- Institute for Intensive Care Medicine, University and University Hospital Zurich, Zurich, Switzerland.,Department of Quantitative Biomedicine, University and University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
5
|
Frei P, Minder EI, Corti N, Muellhaupt B, Geier A, Adams H, Dutertre JP, Rudiger A, Dutkowski P, Maggiorini M, Ganter CC. Liver Transplantation because of Acute Liver Failure due to Heme Arginate Overdose in a Patient with Acute Intermittent Porphyria. Case Rep Gastroenterol 2012; 6:190-6. [PMID: 22649331 PMCID: PMC3362186 DOI: 10.1159/000338354] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
In acute attacks of acute intermittent porphyria, the mainstay of treatment is glucose and heme arginate administration. We present the case of a 58-year-old patient with acute liver failure requiring urgent liver transplantation after erroneous 6-fold overdose of heme arginate during an acute attack. As recommended in the product information, albumin and charcoal were administered and hemodiafiltration was started, which could not prevent acute liver failure, requiring super-urgent liver transplantation after 6 days. The explanted liver showed no preexisting liver cirrhosis, but signs of subacute liver injury and starting regeneration. The patient recovered within a short time. A literature review revealed four poorly documented cases of potential hepatic and/or renal toxicity of hematin or heme arginate. This is the first published case report of acute liver failure requiring super-urgent liver transplantation after accidental heme arginate overdose. The literature and recommendations in case of heme arginate overdose are summarized. Knowledge of a potentially fatal course is important for the management of future cases. If acute liver failure in case of heme arginate overdose is progressive, super-urgent liver transplantation has to be evaluated.
Collapse
Affiliation(s)
- Pascal Frei
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Wyler von Ballmoos M, Takala J, Roeck M, Porta F, Tueller D, Ganter CC, Schröder R, Bracht H, Baenziger B, Jakob SM. Pulse-pressure variation and hemodynamic response in patients with elevated pulmonary artery pressure: a clinical study. Crit Care 2010; 14:R111. [PMID: 20540730 PMCID: PMC2911757 DOI: 10.1186/cc9060] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Revised: 03/15/2010] [Accepted: 06/11/2010] [Indexed: 02/06/2023]
Abstract
Introduction Pulse-pressure variation (PPV) due to increased right ventricular afterload and dysfunction may misleadingly suggest volume responsiveness. We aimed to assess prediction of volume responsiveness with PPV in patients with increased pulmonary artery pressure. Methods Fifteen cardiac surgery patients with a history of increased pulmonary artery pressure (mean pressure, 27 ± 5 mm Hg (mean ± SD) before fluid challenges) and seven septic shock patients (mean pulmonary artery pressure, 33 ± 10 mm Hg) were challenged with 200 ml hydroxyethyl starch boli ordered on clinical indication. PPV, right ventricular ejection fraction (EF) and end-diastolic volume (EDV), stroke volume (SV), and intravascular pressures were measured before and after volume challenges. Results Of 69 fluid challenges, 19 (28%) increased SV > 10%. PPV did not predict volume responsiveness (area under the receiver operating characteristic curve, 0.555; P = 0.485). PPV was ≥13% before 46 (67%) fluid challenges, and SV increased in 13 (28%). Right ventricular EF decreased in none of the fluid challenges, resulting in increased SV, and in 44% of those in which SV did not increase (P = 0.0003). EDV increased in 28% of fluid challenges, resulting in increased SV, and in 44% of those in which SV did not increase (P = 0.272). Conclusions Both early after cardiac surgery and in septic shock, patients with increased pulmonary artery pressure respond poorly to fluid administration. Under these conditions, PPV cannot be used to predict fluid responsiveness. The frequent reduction in right ventricular EF when SV did not increase suggests that right ventricular dysfunction contributed to the poor response to fluids.
Collapse
Affiliation(s)
- Moritz Wyler von Ballmoos
- Department of Intensive Care Medicine, Bern University Hospital and University of Bern Inselspital, Freiburgstrasse 10, 3010 Bern, Switzerland.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Stricker KH, Takala J, Hullin R, Ganter CC. When Drugs Disappear from the Patient: Elimination of Intravenous Medication by Hemodiafiltration. Anesth Analg 2009; 109:1640-3. [DOI: 10.1213/ane.0b013e3181b9db63] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
8
|
Ganter CC, Ganter CG, Jakob SM, Takala J. Pulmonary capillary pressure. A review. Minerva Anestesiol 2006; 72:21-36. [PMID: 16407804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Pulmonary capillary pressure (Pcap) is the predominant force that drives fluid out of the pulmonary capillaries into the interstitium. Increasing hydrostatic capillary pressure is directly proportional to the lung's transvascular filtration rate, and in the extreme leads to pulmonary edema. In the pulmonary circulation, blood flow arises from the transpulmonary pressure gradient, defined as the difference between pulmonary artery (diastolic) pressure and left atrial pressure. The resistance across the pulmonary vasculature consists of arterial and venous components, which interact with the capacitance of the compliant pulmonary capillaries. In pathological states such as acute respiratory distress syndrome, sepsis, and high altitude or neurogenic lung edema, the longitudinal distribution of the precapillary arterial and the postcapillary venous resistance varies. Subsequently, the relationship between Pcap and pulmonary artery occlusion pressure (PAOP) is greatly variable and Pcap can no longer be predicted from PAOP. In clinical practice, PAOP is commonly used to guide fluid therapy, and Pcap as a hemodynamic target is rarely assessed. This approach is potentially misleading. In the presence of a normal PAOP and an increased pressure gradient between Pcap and PAOP, the tendency for fluid leakage in the capillaries and subsequent edema development may substantially be underestimated. Tho-roughly validated methods have been developed to assess Pcap in humans. At the bedside, measurement of Pcap can easily be determined by analyzing a pressure transient after an acute pulmonary artery occlusion with the balloon of a Swan-Ganz catheter.
Collapse
Affiliation(s)
- C C Ganter
- Department of Intensive Care Medicine, University Hospital (Inselspital), Bern, Switzerland
| | | | | | | |
Collapse
|
9
|
Kaim AH, Burger C, Ganter CC, Goerres GW, Kamel E, Weishaupt D, Dizendorf E, Schaffner A, von Schulthess GK. PET-CT-guided percutaneous puncture of an infected cyst in autosomal dominant polycystic kidney disease: case report. Radiology 2001; 221:818-21. [PMID: 11719684 DOI: 10.1148/radiol.2213010445] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An infected cyst in autosomal dominant polycystic kidney disease was identified with a combined positron emission tomographic (PET) and computed tomographic (CT) system, an experimental setup mimicking an integrated CT-PET scanner. Image fusion of fluorine 18 fluorodeoxyglucose PET and CT images allowed exact localization of the infected cyst among many cysts identified on previous CT and magnetic resonance images. Confirmation was obtained instantly, followed by CT-guided percutaneous puncture. Integrated imaging systems hold promise for direct PET-guided puncture of areas of increased fluorodeoxyglucose uptake by using the anatomic accuracy of CT.
Collapse
Affiliation(s)
- A H Kaim
- Department of Nuclear Medicine, University Hospital of Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.
| | | | | | | | | | | | | | | | | |
Collapse
|