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Coxwell Matthewman M, Yanase F, Costa-Pinto R, Jones D, Karalapillai D, Modra L, Radford S, Ukor IF, Warrillow S, Bellomo R. Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome. Aust Crit Care 2024; 37:391-399. [PMID: 37160405 PMCID: PMC10063572 DOI: 10.1016/j.aucc.2023.03.006] [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: 06/13/2022] [Revised: 03/10/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.
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Affiliation(s)
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
| | | | - Daryl Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Lucy Modra
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Sam Radford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ida-Fong Ukor
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia; Department of Critical Care, Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
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Chow JWY, Al-Bassam W, Yanase F, O'Brien Z, Bassam A, Hadzakis S, Chaba A, Maeda A, Bellomo R, Serpa Neto A. P0.1 During Pressure Support Ventilation. Am J Respir Crit Care Med 2024; 209:590-592. [PMID: 37991405 DOI: 10.1164/rccm.202307-1314le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023] Open
Affiliation(s)
- Joanna W Y Chow
- Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Wisam Al-Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | | | - Zachary O'Brien
- Austin Health and
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Ahmad Bassam
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - Stefanos Hadzakis
- Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | | | | | - Rinaldo Bellomo
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; and
| | - Ary Serpa Neto
- Austin Health and
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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3
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Nadkarni A, Costa-Pinto R, Hensman T, Harman EV, Yanase F, Lister BG, Nickson CP, Thomas JS. Evaluating an inquiry-based learning program. Adv Physiol Educ 2023; 47:930-939. [PMID: 37823188 DOI: 10.1152/advan.00050.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/05/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
Inquiry-based learning (IBL) is a promising educational framework that is understudied in graduate medical education. To determine participant satisfaction and engagement with phases of an IBL postgraduate education program, a mixed-methods study collected data via survey statements and open-ended responses. The authors included participants attending an intensive care medicine (ICM) IBL program from May to November 2020. Quantitative outcomes included participants' satisfaction with the IBL format and impact of engagement with IBL on the learning experience. Qualitative outcomes explored determinants of engagement with IBL phases and the impact on the learning experience. Of 378 attendees, 167 submitted survey responses (44.2%). There was strong agreement relating to overall satisfaction (93.4%). Responses indicated engagement with "orientation" (94.6%), "conceptualization" (97.3%), "discussion" (91.1%), and "conclusion" (91.0%) but limited engagement with the "investigation" phase (48.1%). Greater engagement with IBL phases had positive impacts, with repeat attenders having clearer learning objectives (79.1% vs. 56.6%, P < 0.05) and enhanced learning through collaborative discussion (65.9% vs. 48.7%, P < 0.05). Qualitative analysis showed that ICM learners value active learning principles, clear objectives, and a safe environment to expand their "knowledge base." Sessions facilitated "clinically relevant learning," with application of theoretical knowledge. Learners transformed and "reframed their understanding," using the input of others' experiences. ICM learners were highly satisfied with the IBL format and reported valuable learning. Participants engaged strongly with all IBL phases except the investigation phase during the sessions. IBL facilitated learners' active construction of meaning, facilitating a constructivist approach to learning.NEW & NOTEWORTHY An inquiry-based learning (IBL) program was launched as part of a novel binational intensive care medicine education program. Postgraduate intensive care medicine practitioners participated in this education intervention, where facilitated group discussions explored core intensive care medicine concepts. Survey responses indicated overall satisfaction, engagement with the IBL format, and a constructivist approach to learning. This study provided new insights into the benefits and challenges of an IBL program in the context of practicing clinicians.
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Affiliation(s)
- Aniket Nadkarni
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Austin Hospital, Austin Health, Heidelberg, Victoria, Australia
- College of Intensive Care Medicine of Australia and New Zealand, Prahran, Victoria, Australia
| | - Rahul Costa-Pinto
- Austin Hospital, Austin Health, Heidelberg, Victoria, Australia
- College of Intensive Care Medicine of Australia and New Zealand, Prahran, Victoria, Australia
| | - Tamishta Hensman
- Austin Hospital, Austin Health, Heidelberg, Victoria, Australia
- College of Intensive Care Medicine of Australia and New Zealand, Prahran, Victoria, Australia
| | - Emily V Harman
- Austin Hospital, Austin Health, Heidelberg, Victoria, Australia
- College of Intensive Care Medicine of Australia and New Zealand, Prahran, Victoria, Australia
| | - Fumitaka Yanase
- Austin Hospital, Austin Health, Heidelberg, Victoria, Australia
| | - Bruce G Lister
- College of Intensive Care Medicine of Australia and New Zealand, Prahran, Victoria, Australia
| | - Christopher P Nickson
- Alfred Hospital, Alfred Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Josephine S Thomas
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
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Yanase F, Spano S, Maeda A, Chaba A, Naorungroj T, Ow CPC, Lankadeva YR, May CN, Betrie AH, Lane DJR, Eastwood GM, Plummer MP, Bellomo R. Mega-dose sodium ascorbate: a pilot, single-dose, physiological effect, double-blind, randomized, controlled trial. Crit Care 2023; 27:371. [PMID: 37828547 PMCID: PMC10571252 DOI: 10.1186/s13054-023-04644-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/09/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Mega-dose sodium ascorbate (NaAscorbate) appears beneficial in experimental sepsis. However, its physiological effects in patients with septic shock are unknown. METHODS We conducted a pilot, single-dose, double-blind, randomized controlled trial. We enrolled patients with septic shock within 24 h of diagnosis. We randomly assigned them to receive a single mega-dose of NaAscorbate (30 g over 1 h followed by 30 g over 5 h) or placebo (vehicle). The primary outcome was the total 24 h urine output (UO) from the beginning of the study treatment. Secondary outcomes included the time course of the progressive cumulative UO, vasopressor dose, and sequential organ failure assessment (SOFA) score. RESULTS We enrolled 30 patients (15 patients in each arm). The mean (95% confidence interval) total 24-h UO was 2056 (1520-2593) ml with placebo and 2948 (2181-3715) ml with NaAscorbate (mean difference 891.5, 95% confidence interval [- 2.1 to 1785.2], P = 0.051). Moreover, the progressive cumulative UO was greater over time on linear mixed modelling with NaAscorbate (P < 0.001). Vasopressor dose and SOFA score changes over time showed faster reductions with NaAscorbate (P < 0.001 and P = 0.042). The sodium level, however, increased more over time with NaAscorbate (P < 0.001). There was no statistical difference in other clinical outcomes. CONCLUSION In patients with septic shock, mega-dose NaAscorbate did not significantly increase cumulative 24-h UO. However, it induced a significantly greater increase in UO and a greater reduction in vasopressor dose and SOFA score over time. One episode of hypernatremia and one of hemolysis were observed in the NaAscorbate group. These findings support further cautious investigation of this novel intervention. Trial registration Australian New Zealand Clinical Trial Registry (ACTRN12620000651987), Date registered June/5/2020.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | | | - Connie Pei Chen Ow
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Yugeesh R Lankadeva
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Clive N May
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Ashenafi H Betrie
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Darius J R Lane
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark P Plummer
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
- Department of Critical Care, University of Melbourne, Melbourne, Australia.
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia.
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.
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Dahan A, Farina S, Holmes NE, Kachel S, McDonald CF, Lewis JE, Marhoon N, Yanase F, Yang N, Bellomo R. Subsegmental pulmonary embolism and anticoagulant therapy: the impact of clinical context. Intern Med J 2023; 53:1435-1443. [PMID: 35499105 DOI: 10.1111/imj.15789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 04/18/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anticoagulation for subsegmental pulmonary embolism (SSPE) is controversial. AIM To assess the impact of clinical context on anticoagulation and outcomes of SSPE. METHODS We electronically searched computed tomography pulmonary angiogram reports to identify SSPE. We extracted demographic, risk factor, investigations and outcome data from the electronic medical record. We stratified patients according to anticoagulation and no anticoagulation. RESULTS From 1 January 2017 to 31 December 2019, we identified 166 patients with SSPE in 5827 pulmonary angiogram reports. Of these, 123 (74%) received anticoagulation. Compared with non-anticoagulated patients, such patients had a different clinical context: higher rates of previous venous thromboembolism (11% vs 0%; P = 0.019), more recent surgery (26% vs 9%; P = 0.015), more elevated serum D-dimer (22% vs 5%; P = 0.004), more lung parenchymal abnormalities (76% vs 61%; P = 0.037) and were almost twice as likely to require inpatient care (76% vs 42%; P < 0.001). Such patients also had twice the all-cause mortality at 1 year (32% vs 16%). CONCLUSIONS SSPE is diagnosed in almost 3% of pulmonary angiograms and is associated with high mortality, regardless of anticoagulation, due to coexistent disease processes rather than SSPE. Anticoagulation appears dominant but markedly affected by the clinical context of risk factors, alternative indications and illness severity. Thus, the controversy is partly artificial because anticoagulation after SSPE is clinically contextual with SSPE as only one of several factors.
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Affiliation(s)
- Ariel Dahan
- Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Sergio Farina
- Department of Haematology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Natasha E Holmes
- Data Analytics Research and Evaluation, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Stefan Kachel
- Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Jane E Lewis
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Nada Marhoon
- Data Analytics Research and Evaluation, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Natalie Yang
- Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Data Analytics Research and Evaluation, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
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Belletti A, Lee DK, Yanase F, Naorungroj T, Eastwood GM, Bellomo R, Weinberg L. Changes in SedLine-derived processed electroencephalographic parameters during hypothermia in patients undergoing cardiac surgery with cardiopulmonary bypass. Front Cardiovasc Med 2023; 10:1084426. [PMID: 37469479 PMCID: PMC10352607 DOI: 10.3389/fcvm.2023.1084426] [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: 10/30/2022] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Objective Processed electroencephalography (pEEG) is used to monitor depth-of-anesthesia during cardiopulmonary bypass (CPB). The SedLine device has been recently introduced for pEEG monitoring. However, the effect of hypothermia on its parameters during CPB is unknown. Accordingly, we aimed to investigate temperature-induced changes in SedLine-derived pEEG parameters during CPB. Design Prospective observational study. Setting Cardiac surgery operating theatre. Participants 28 patients undergoing elective cardiac surgery with CPB. Interventions We continuously measured patient state index (PSI), suppression ratio (SR), bilateral spectral edge frequency (SEF) and temperature. We used linear mixed modelling with fixed and random effects to study the interactions between pEEG parameters and core temperature. Measurements and main results During CPB maintenance, the median temperature was 32.1°C [interquartile range (IQR): 29.8-33.6] at the end of cooling and 32.8°C (IQR: 30.1-34.0) at rewarming initiation. For each degree Celsius change in temperature during cooling and rewarming the PSI either decreased by 0.8 points [95% confidence interval (CI): 0.7-1.0; p < 0.001] or increased by 0.7 points (95% CI: 0.6-0.8; p < 0.001). The SR increased by 2.9 (95% CI: 2.3-3.4); p < 0.001) during cooling and decreased by 2.2 (95% CI: 1.7-2.7; p < 0.001) during rewarming. Changes in the SEF were not related to changes in temperature. Conclusions During hypothermic CPB, temperature changes led to concordant changes in the PSI. The SR increased during cooling and decreased during rewarming. Clinicians using SedLine for depth-of-anesthesia monitoring should be aware of these effects when interpreting the PSI and SR values.
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Affiliation(s)
- Alessandro Belletti
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and The Austin Hospital, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Anaesthesia, Austin Hospital, Heidelberg, VIC, Australia
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Mårtensson J, Cutuli SL, Osawa EA, Yanase F, Toh L, Cioccari L, Luethi N, Maeda A, Bellomo R. Sodium glucose co-transporter-2 inhibitors in intensive care unit patients with type 2 diabetes: a pilot case control study. Crit Care 2023; 27:189. [PMID: 37194077 DOI: 10.1186/s13054-023-04481-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Sodium glucose co-transporter-2 (SGLT2) inhibitors improve long-term cardiovascular and renal outcomes in individuals with type 2 diabetes. However, the safety of SGLT2 inhibitors in ICU patients with type 2 diabetes is uncertain. We aimed to perform a pilot study to assess the relationship between empagliflozin therapy and biochemical, and clinical outcomes in such patients. METHODS We included 18 ICU patients with type 2 diabetes receiving empagliflozin (10 mg daily) and insulin to target glucose range of 10-14 mmol/l according to our liberal glucose control protocol for patients with diabetes (treatment group). Treatment group patients were matched on age, glycated hemoglobin A1c, and ICU duration with 72 ICU patients with type 2 diabetes exposed to the same target glucose range but who did not receive empagliflozin (control group). We compared changes in electrolyte and acid-base parameters, hypoglycemia, ketoacidosis, worsening kidney function, urine culture findings, and hospital mortality between the groups. RESULTS Median (IQR) maximum increase in sodium and chloride levels were 3 (1-10) mmol/l and 3 (2-8) mmol/l in the control group and 9 (3-12) mmol/l and 8 (3-10) mmol/l in the treatment group (P = 0.045 for sodium, P = 0.059 for chloride). We observed no differences in strong ion difference, pH or base excess. Overall, 6% developed hypoglycemia in each group. No patient in the treatment group and one patient in the control group developed ketoacidosis. Worsening kidney function occurred in 18% and 29% of treatment and control group patients, respectively (P = 0.54). Urine cultures were positive in 22% of treatment group patients and 13% of control group patients (P = 0.28). Overall, 17% of treatment group patients and 19% of control group patients died in hospital (P = 0.79). CONCLUSIONS In our pilot study of ICU patients with type 2 diabetes, empagliflozin therapy was associated with increases in sodium and chloride levels but was not significantly associated with acid-base changes, hypoglycemia, ketoacidosis, worsening kidney function, bacteriuria, or mortality.
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Affiliation(s)
- Johan Mårtensson
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden.
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, L.Go F. Vito 1, 00168, Rome, Italy
| | - Eduardo A Osawa
- Cardiology Intensive Care Unit, Hospital DF-Star, Brasília, Brazil
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Lisa Toh
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Luca Cioccari
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Nora Luethi
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Mårtensson J, Cutuli S, Yanase F, Ancona P, Toh L, Osawa E, Bellomo R. Glycemic control and blood gas sampling frequency during continuous glucose monitoring in the intensive care unit: A before-and-after study. Acta Anaesthesiol Scand 2023; 67:86-93. [PMID: 36263915 PMCID: PMC10092568 DOI: 10.1111/aas.14159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/21/2022] [Accepted: 10/16/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Whether subcutaneous continuous glucose monitoring (CGM) can safely replace intermittent arterial blood gas glucose analyses in intensive care unit (ICU) patients remains uncertain. We aimed to compare CGM to blood gas glucose values and assess whether CGM use reduces blood gas sampling frequency and glucose variability in ICU patients with type 2 diabetes managed with liberal glucose control. METHODS We used the FreeStyle Libre CGM in 15 ICU patients and compared their blood glucose metrics with a pre-CGM control population of 105 ICU patients with type 2 diabetes. Both groups received insulin to target glucose range of 10-14 mmol/L. We used linear regression analysis adjusted for illness severity to assess the association of CGM use with blood gas sampling frequency and glucose variability. We used mean absolute relative difference (MARD) and Clarke error grid analysis to assess accuracy of matched CGM-blood glucose values overall, across glucose stata (<10, 10-14, >14 mmol/L), and over time (≤48, 48-96, >96 h). RESULTS We analyzed 483 matched glucose values. Overall MARD was 11.5 (95% CI, 10.7-12.3)% with 99% of readings in Clarke zones A and B. MARD was 15.5% for glucose values <10 mmol/L, 11.1% at 10-14 mmol/L, and 11.4% >14 mmol/L. MARD was 13.8% in the first 48 h, 10.9% at 48-96 h, and 8.9% beyond 96 h. CGM use was associated with 30% reduction in blood gas sampling frequency. CGM use was not associated with glucose variability as determined by glycemic lability index or standard deviation of blood glucose. CONCLUSIONS In our cohort of ICU patients with type 2 diabetes receiving liberal glycemic control, CGM showed acceptable accuracy and was associated with a reduction in blood gas sampling frequency without compromising glucose control. Lowest accuracy was observed at glucose values below 10 mmol/L and during the first 48 h of CGM use.
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Affiliation(s)
- Johan Mårtensson
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden.,Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Salvatore Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Lisa Toh
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Eduardo Osawa
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Center, Austin Hospital, Melbourne, Victoria, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Weinberg L, Yanase F, Tosif S, Riedel B, Bellomo R, Hahn RG. Trajectory of plasma syndecan-1 and heparan sulphate during major surgery: A retrospective observational study. Acta Anaesthesiol Scand 2023; 67:4-11. [PMID: 36112130 PMCID: PMC10087164 DOI: 10.1111/aas.14150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/01/2022] [Accepted: 09/10/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical trauma-induced inflammation during major surgery may disrupt endothelial integrity and affect plasma concentrations of glycocalyx constituents, such as syndecan-1 and heparan sulphate. To date, no studies have focused on their perioperative temporal changes. METHODS As part of a trial, we obtained plasma and urine specimens sampled during the perioperative period in 72 patients undergoing major abdominal surgery. The plasma concentration of syndecan-1 and heparan sulphate was measured on five occasions, from baseline to the second postoperative day. Plasma and urinary creatinine and urinary syndecan-1 concentrations were measured before surgery and on the first postoperative morning. RESULTS We observed three different temporal patterns of plasma syndecan-1 concentration. Group 1 'low' (64% of patients) showed only minor changes from baseline despite a median heparan sulphate increase of 67% (p < .005). Group 2 'increase' (21% of patients) showed a marked increase in median plasma syndecan-1 from 27 μg/L to 118 μg/L during the first postoperative day (p < .001) with a substantial (+670%; p < .005) increase in median plasma heparan sulphate from 279 to 2196 μg/L. Group 3 'high' (14% of patients) showed a constant elevation of plasma syndecan-1 to >100 μg/L, but low heparan sulphate levels. The plasma C-reactive protein concentration did not differ across the three groups and 90% of colon surgeries occurred in Group 1. Treatment with dexamethasone was similar across the three groups. Surgical blood loss, duration of surgery and liver resection were greatest in Group 2. CONCLUSION Changes in syndecan-1 and heparan sulphate after surgery appear to show three different patterns, with the greatest increases in those patients with greater blood loss, more liver surgery and longer operations. These observations suggest that increases in syndecan-1 and heparan sulphate reflect the degree of surgical injury.
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Affiliation(s)
- Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Shervin Tosif
- Department of Anaesthesia, Austin Hospital, Melbourne, Australia
| | - Bernhard Riedel
- Department of Critical Care, The University of Melbourne, Melbourne, Australia.,Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and the Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Robert G Hahn
- Karolinska Institute at Danderyd's Hospital (KIDS), Stockholm, Sweden.,Department of Research, Södertälje Hospital, Södertälje, Sweden
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10
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Costa-Pinto R, Yanase F, Kennedy LM, Talbot LJ, Flanagan JP, Opdam HI, Ellard LM, Bellomo R, Jones DA. Characteristics and outcomes of surgical patients admitted to an overnight intensive recovery unit: A retrospective observational study. Anaesth Intensive Care 2023; 51:29-37. [PMID: 36217293 DOI: 10.1177/0310057x221105299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Postoperative 'enhanced care' models that sit between critical care and ward-based care may allow for more cost-effective and efficient utilisation of resources for high-risk surgical patients. In this retrospective observational study, we describe an overnight intensive recovery model in a tertiary hospital, termed 'recovery high dependency unit', and the characteristics, treatment, disposition at discharge and in-hospital outcomes of patients admitted to this unit. We included all adult patients (≥18 years) admitted to the recovery high dependency unit for at least one hour between July 2017 and June 2020. Over this three-year period, 1257 patients were included in the study. The median length of stay in the recovery high dependency unit was 12.6 (interquartile range 9.1-15.9) hours and the median length of hospital stay was 8.3 (interquartile range 5.0-17.3) days. Hospital discharge data showed that 1027 (81.7%) patients were discharged home and that 37 (2.9%) patients died. Non-invasive ventilation was delivered to 59 (4.7%) patients and 290 (23.1%) required vasopressor support. A total of 164 patients (13.0%) were admitted to the intensive care unit following their recovery high dependency unit admission. Of the 1093 patients who were discharged to the ward, 70 patients (6.4%) had a medical emergency team call within 24 hours of discharge from the recovery high dependency unit. In this study of a recovery high dependency unit patient cohort, there was a relatively low need for intensive care unit admission postoperatively and a very low incidence of medical emergency team calls post-discharge to the ward. Other institutions may consider the introduction and evaluation of this model in the care of their higher risk surgical patients.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lucy M Kennedy
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
| | - Lachie J Talbot
- Melbourne Medical School, University of Melbourne, Parkville, Australia
| | | | - Helen I Opdam
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia
| | - Louise M Ellard
- Department of Anaesthesia, 96043Austin Hospital, Heidelberg, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Parkville, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Daryl A Jones
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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11
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Osawa EA, Cutuli SL, Yanase F, Iguchi N, Bitker L, Maciel AT, Lankadeva YR, May CN, Evans RG, Eastwood GM, Bellomo R. Effects of changes in inspired oxygen fraction on urinary oxygen tension measurements. Intensive Care Med Exp 2022; 10:52. [PMID: 36504004 PMCID: PMC9742069 DOI: 10.1186/s40635-022-00479-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Continuous measurement of urinary PO2 (PuO2) is being applied to indirectly monitor renal medullary PO2. However, when applied to critically ill patients with shock, its measurement may be affected by changes in FiO2 and PaO2 and potential associated O2 diffusion between urine and ureteric or bladder tissue. We aimed to investigate PuO2 measurements in septic shock patients with a fiberoptic luminescence optode inserted into the urinary catheter lumen in relation to episodes of FiO2 change. We also evaluated medullary and urinary oxygen tension values in Merino ewes at two different FiO2 levels. RESULTS In 10 human patients, there were 32 FiO2 decreases and 31 increases in FiO2. Median pre-decrease FiO2 was 0.36 [0.30, 0.39] and median post-decrease FiO2 was 0.30 [0.23, 0.30], p = 0.006. PaO2 levels decreased from 83 mmHg [77, 94] to 72 [62, 80] mmHg, p = 0.009. However, PuO2 was 23.2 mmHg [20.5, 29.0] before and 24.2 mmHg [20.6, 26.3] after the intervention (p = 0.56). The median pre-increase FiO2 was 0.30 [0.21, 0.30] and median post-increase FiO2 was 0.35 [0.30, 0.40], p = 0.008. PaO2 levels increased from 64 mmHg [58, 72 mmHg] to 71 mmHg [70, 100], p = 0.04. However, PuO2 was 25.0 mmHg [IQR: 20.7, 26.8] before and 24.3 mmHg [IQR: 20.7, 26.3] after the intervention (p = 0.65). A mixed linear regression model showed a weak correlation between the variation in PaO2 and the variation in PuO2 values. In 9 Merino ewes, when comparing oxygen tension levels between FiO2 of 0.21 and 0.40, medullary values did not differ (25.1 ± 13.4 mmHg vs. 27.9 ± 15.4 mmHg, respectively, p = 0.6766) and this was similar to urinary oxygen values (27.1 ± 6.17 mmHg vs. 29.7 ± 4.41 mmHg, respectively, p = 0.3192). CONCLUSIONS Changes in FiO2 and PaO2 within the context of usual care did not affect PuO2. Our findings were supported by experimental data and suggest that PuO2 can be used as biomarker of medullary oxygenation irrespective of FiO2.
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Affiliation(s)
- Eduardo A. Osawa
- Imed Group Research Department, Sao Paulo, Brazil ,grid.477346.5Intensive Care Unit, Hospital Sao Camilo, Unidade Pompeia, Sao Paulo, Brazil ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084 Australia
| | - Salvatore L. Cutuli
- grid.414603.4Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy ,grid.8142.f0000 0001 0941 3192Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fumitaka Yanase
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084 Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Naoya Iguchi
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084 Australia ,grid.136593.b0000 0004 0373 3971Department of Anaesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan ,grid.418025.a0000 0004 0606 5526Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC Australia
| | - Laurent Bitker
- grid.413306.30000 0004 4685 6736Service de Médecine Intensive – Réanimation, Hôpital de La Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Alexandre T. Maciel
- Imed Group Research Department, Sao Paulo, Brazil ,grid.477346.5Intensive Care Unit, Hospital Sao Camilo, Unidade Pompeia, Sao Paulo, Brazil
| | - Yugeesh R. Lankadeva
- grid.418025.a0000 0004 0606 5526Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC Australia
| | - Clive N. May
- grid.418025.a0000 0004 0606 5526Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC Australia
| | - Roger G. Evans
- grid.418025.a0000 0004 0606 5526Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Glenn M. Eastwood
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084 Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084 Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDepartment of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC Australia
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12
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Naorungroj T, Yanase F, Bittar I, Eastwood G, Bellomo R. The Relationship between Nephrocheck® Test Values, Outcomes, and Urinary Output in Critically Ill Patients at Risk of Acute Kidney Injury. Acta Anaesthesiol Scand 2022; 66:1219-1227. [DOI: 10.1111/aas.14133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/31/2022] [Accepted: 08/08/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care Austin Hospital Melbourne Australia
- Department of Intensive Care, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | - Fumitaka Yanase
- Department of Intensive Care Austin Hospital Melbourne Australia
- ANZICS–Research Centre, Melbourne, Australia, Monash University School and Public Health and Preventive Medicine, Monash University
| | | | - Glenn Eastwood
- Department of Intensive Care Austin Hospital Melbourne Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Hospital Melbourne Australia
- ANZICS–Research Centre, Melbourne, Australia, Monash University School and Public Health and Preventive Medicine, Monash University
- Department of Critical Care University of Melbourne Melbourne Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital Melbourne Australia
- Department of Intensive Care Royal Melbourne Hospital Melbourne Australia
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13
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Hu R, Yanase F, McCall P, Evans R, Raman J, Bellomo R. The effects of targeted changes in systemic blood flow and mean arterial pressure on urine oximetry during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2022; 36:3551-3560. [DOI: 10.1053/j.jvca.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/11/2022]
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14
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Chan JW, Yanase F, See E, McCue C, Yong ZT, Talbot LJ, Flanagan JP, Eastwood GM. A pilot study of the pharmacokinetics of continuous magnesium infusion in critically ill patients. CRIT CARE RESUSC 2022; 24:29-38. [PMID: 38046838 PMCID: PMC10692660 DOI: 10.51893/2022.1.oa4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The pharmacokinetics and haemodynamic effect of continuous magnesium infusion in non-cardiac intensive care unit (ICU) patients are poorly understood. We aimed to measure serum and urine magnesium levels during bolus and continuous infusion in critically ill adults, compare serum levels with those of a control population, and assess its haemodynamic effect. Design: Pharmacokinetic study Setting: A single tertiary adult ICU. Participants: Mechanically ventilated adults requiring vasopressor support. Intervention: A 10 mmol bolus of magnesium sulfate followed by 1.5-3 mmol/h infusion for 24 hours. Main outcome measures: The primary outcome was the change in total serum magnesium concentration. The main secondary outcome was mean arterial pressure (MAP)- adjusted vasopressor dose. Results: We matched 31 treated patients with 93 controls. Serum total magnesium concentration increased from a median 0.94 mmol/L (interquartile range [IQR], 0.83-1.10 mmol/L) to 1.38 mmol/L (IQR, 1.25-1.69 mmol/L; P < 0.001) and stabilised between a median 1.64 mmol/L (IQR, 1.38-1.88 mmol/L) at 7 hours and 1.77 mmol/L (IQR, 1.53-1.85 mmol/L) at 25 hours. This was significantly greater than in the control group (P < 0.001). The MAP-adjusted vasopressor dose decreased during magnesium infusion (P < 0.001). Conclusion: In critically ill patients, a magnesium sulfate bolus followed by continuous infusion achieved moderately elevated levels of total serum magnesium with a decrease in MAP-adjusted vasopressor dose. Trial registration number: ACTRN12619000925145.
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Affiliation(s)
- Jian Wen Chan
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emily See
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Claire McCue
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Zhen-Ti Yong
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Lachlan J. Talbot
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | | | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
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15
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Hahn RG, Yanase F, Zdolsek JH, Tosif SH, Bellomo R, Weinberg L. Serum Creatinine Levels and Nephrocheck® Values With and Without Correction for Urine Dilution-A Multicenter Observational Study. Front Med (Lausanne) 2022; 9:847129. [PMID: 35252280 PMCID: PMC8894808 DOI: 10.3389/fmed.2022.847129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background The Nephrocheck® test is a single-use cartridge designed to measure the concentrations of two novel cell-cycle arrest biomarkers of acute kidney injury, namely tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor binding protein 7 (IGFBP7). Correlations of serum creatine values and TIMP-2 and IGFBP7 with and without correction for urine dilution have not been previously undertaken in patients undergoing major abdominal surgery. We hypothesized that the Nephrocheck® values would be significantly different with and without correction for urine dilution in patients with elevated creatinine values post major abdominal surgery. Methods We performed a post hoc analysis of serum and urine specimens sampled preoperatively and postoperatively in 72 patients undergoing major abdominal surgery. Thirty samples were measured from patients with the greatest decrease and the greatest increase in postoperative serum creatinine values. Urine was analyzed with the Nephrocheck to predict the risk of acute kidney injury (AKIRisk™). We then examined the relationship between serum creatinine and the urinary excretion of TIMP-2 and IGFBP7 as measured by the Nephrocheck test. The AKIRisk between the groups with and without correction for urine dilution was assessed. Results The median perioperative change in serum creatinine in the two groups was −19% and +57%, respectively. The uncorrected median baseline AKIRisk decreased from 0.70 (25th−75th percentiles, 0.09–1.98) to 0.35 (0.19–0.57) (mg/L)2 in the first group and rose from 0.57 (0.22–1.53) to 0.85 (0.67–2.20) (mg/L)2 in the second group. However, when corrected for the squared urine dilution, the AKIRisk™ in patients with postoperative increases in serum creatinine was not indicative of kidney injury; the corrected AKIRisk was 8.0 (3.2–11.7) μg2/mmol2 before surgery vs.6.9 (5.3–11.0) μg2/mmol2 after the surgery (P = 0.69). Conclusion In the setting of major abdominal surgery, after correction of TIMP-2 and IGFBP7 for urine dilution, the Nephrocheck AKIRisk scores were significantly different from the uncorrected values. These finding imply that the AKIRisk index is a function of urine flow in addition to an increased release of the biomarkers.
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Affiliation(s)
- Robert G. Hahn
- Karolinska Institute at Danderyd's Hospital (KIDS), Stockholm, Sweden
- Department of Research, Sodertalje Hospital, Sodertalje, Sweden
| | - Fumitaka Yanase
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Joachim H. Zdolsek
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Shervin H. Tosif
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Laurence Weinberg
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16
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Costa-Pinto R, Yong ZT, Yanase F, Young C, Brown A, Udy A, Young PJ, Eastwood G, Bellomo R. A pilot, feasibility, randomised controlled trial of midodrine as adjunctive vasopressor for low-dose vasopressor-dependent hypotension in intensive care patients: The MAVERIC study. J Crit Care 2022; 67:166-171. [PMID: 34801917 DOI: 10.1016/j.jcrc.2021.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/15/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the feasibility and physiological efficacy of adjunctive midodrine in patients with vasopressor-dependent hypotension. MATERIALS AND METHODS This was a pilot, open label, randomised controlled trial. Patients were enrolled from two tertiary intensive care units on low dose intravenous vasopressor therapy for more than 24 h. We randomly assigned patients to receive either adjunctive midodrine (10 mg every 8 h) or usual care. The primary efficacy outcome was time to cessation of intravenous vasopressor therapy. Secondary outcomes included protocol compliance, ICU and hospital length of stay. RESULTS We screened 381 patients over 22-months and enrolled 62 (32 in midodrine group, 30 in usual care group). Median time to cessation of vasopressor infusion was 16.5 h for midodrine vs 19 h for usual care (p = 0.22). Time in ICU (50 [25.50, 74.00] hours for midodrine v 59 [38.50, 93.25] hours for usual care, p = 0.14) and hospital length of stay (9 days vs. 7.5 days, p = 0.92) were similar. Protocol compliance was 96.9%. One patient ceased midodrine early due to symptomatic bradycardia. CONCLUSIONS Adjunctive midodrine therapy was feasible with acceptable compliance, duration of therapy, and safety profile. However, at the chosen dose, there was no evidence of physiological or clinical efficacy.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
| | - Zhen-Ti Yong
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Chelsea Young
- Department of Intensive Care, Wellington Regional Hospital, 49 Riddiford Street, Newtown, Wellington, New Zealand
| | - Alastair Brown
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, 49 Riddiford Street, Newtown, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Medical Research Institute of New Zealand, Private Bag, 7902, Wellington, New Zealand; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
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17
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Fujii T, Salanti G, Belletti A, Bellomo R, Carr A, Furukawa TA, Luethi N, Luo Y, Putzu A, Sartini C, Tsujimoto Y, Udy AA, Yanase F, Young PJ. Effect of adjunctive vitamin C, glucocorticoids, and vitamin B1 on longer-term mortality in adults with sepsis or septic shock: a systematic review and a component network meta-analysis. Intensive Care Med 2022; 48:16-24. [PMID: 34750650 PMCID: PMC8724116 DOI: 10.1007/s00134-021-06558-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/13/2021] [Indexed: 01/15/2023]
Abstract
We aimed to compare the effects of vitamin C, glucocorticoids, vitamin B1, combinations of these drugs, and placebo or usual care on longer-term mortality in adults with sepsis or septic shock. MEDLINE, Embase, CENTRAL, ClinicalTrials.gov and WHO-ICTRP were searched. The final search was carried out on September 3rd, 2021. Multiple reviewers independently selected randomized controlled trials (RCTs) comparing very-high-dose vitamin C (≥ 12 g/day), high-dose vitamin C (< 12, ≥ 6 g/day), vitamin C (< 6 g/day), glucocorticoid (< 400 mg/day of hydrocortisone), vitamin B1, combinations of these drugs, and placebo/usual care. We performed random-effects network meta-analysis and, where applicable, a random-effects component network meta-analysis. We used the Confidence in Network Meta-Analysis framework to assess the degree of treatment effect certainty. The primary outcome was longer-term mortality (90-days to 1-year). Secondary outcomes were severity of organ dysfunction over 72 h, time to cessation of vasopressor therapy, and length of stay in intensive care unit (ICU). Forty-three RCTs (10,257 patients) were eligible. There were no significant differences in longer-term mortality between treatments and placebo/usual care or between treatments (10 RCTs, 7,096 patients, moderate to very-low-certainty). We did not find any evidence that vitamin C or B1 affect organ dysfunction or ICU length of stay. Adding glucocorticoid to other treatments shortened duration of vasopressor therapy (incremental mean difference, - 29.8 h [95% CI - 44.1 to - 15.5]) and ICU stay (incremental mean difference, - 1.3 days [95% CI - 2.2 to - 0.3]). Metabolic resuscitation with vitamin C, glucocorticoids, vitamin B1, or combinations of these drugs was not significantly associated with a decrease in longer-term mortality.
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Affiliation(s)
- Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Department of Health Promotion and Human Behaviour, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Anitra Carr
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behaviour, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nora Luethi
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Yan Luo
- Department of Health Promotion and Human Behaviour, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Alessandro Putzu
- Division of Anesthesiology, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yasushi Tsujimoto
- Department of Health Promotion and Human Behaviour, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, The Alfred, Melbourne, VIC, Australia
| | - Fumitaka Yanase
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, VIC, Australia
| | - Paul J Young
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
- Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
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18
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Nadkarni A, Costa-Pinto R, Hensman T, Harman E, Yanase F, Lister B, Nickson C, Thomas J. The inquiry-based learning program – Evaluation of a national online intensive care teaching curriculum. Aust Crit Care 2022. [DOI: 10.1016/j.aucc.2022.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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Yanase F, Naorungroj T, Cutuli SL, Eastwood GM, Bellomo R. Rapid 500 mL albumin bolus versus rapid 200 mL bolus followed by slower continuous infusion in post-cardiac surgery patients: a pilot before-and-after study. CRIT CARE RESUSC 2021; 23:320-328. [PMID: 38046079 PMCID: PMC10692547 DOI: 10.51893/2021.3.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To evaluate the haemodynamic effects of rapid fluid bolus therapy (FBT) (500 mL of 4% albumin over several minutes) versus combined FBT (rapid 200 mL FBT followed by a 300 mL infusion over 30 minutes). Design: Single centre, prospective, before-and-after trial. Setting: A tertiary intensive care unit in Australia. Participants: Fifty mechanically ventilated post-cardiac surgery patients. Interventions: Rapid 4% albumin FBT versus combined FBT. Main outcome measures: We recorded haemodynamic parameters from before FBT to 30 minutes after FBT. A mean arterial pressure (MAP) response was defined by a MAP increase > 10%, and a cardiac index (CI) response was defined by a CI increase > 15%. Results: Immediately after rapid FBT versus combined FBT, there was a CI response in 13 patients (52%) compared with five patients (20%) respectively (P = 0.038), and a MAP response in 11 patients (44%) in each group. However, from FBT administration to 30 minutes, there was a time and group interaction such that MAP was higher in the rapid FBT group (P = 0.003), as was the case for central venous pressure (P = 0.002) and mean pulmonary artery pressure (P < 0.001). Body temperature fell immediately and was lower with rapid FBT but became warmer than with combined FBT later (P < 0.001). At 30 minutes, a MAP response was seen in ten patients (40%) compared with nine patients (36%) (P < 0.99) and a CI response was present in eight patients (32%) compared with 11 patients (44%) (P = 0.56) in the rapid versus combined FBT groups respectively. Conclusion: Rapid FBT was superior to combined FBT in terms of mean MAP levels and immediate CI response. However, the number of MAP responders or CI responders was similar at 30 minutes.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salvatore L. Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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20
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Yanase F, Cutuli SL, Naorungroj T, Bitker L, Wilson A, Eastwood GM, Bellomo R. A comparison of the hemodynamic effects of fluid bolus therapy with crystalloids vs. 4% albumin and vs. 20% albumin in patients after cardiac surgery. Heart Lung 2021; 50:870-876. [PMID: 34403891 DOI: 10.1016/j.hrtlng.2021.07.014] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/16/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Crystalloids, 4% albumin and 20% albumin are used for fluid bolus therapy (FBT) in patients after cardiac surgery. However, their detailed early (30 min) hemodynamic effects remain unstudied. METHODS In a comparative prospective observational trial of 120 ventilated, we studied post cardiac surgery patients who received crystalloid 500 ml FBT, 4% albumin 500 ml FBT or 20% albumin 100 ml FBT (40 per group). We recorded second-by-second hemodynamic parameters and 15-minutely cardiac index (CI) data before and for 30 min after FBT. We compared the crystalloid group (reference) vs. the 4% albumin group, and vs. the 20% albumin group. RESULTS Immediately after FBT, the mean (standard deviation) CI increase was 0.4 (0.4) L/min/m2 with crystalloids, 0.4 (0.5) L/min/m2 with 4% albumin and 0.3 (0.4) L/min/m2 with 20% albumin, despite the much smaller FBT volume with 20% albumin. Mean arterial pressure (MAP) increase was 11 (10), 12 (9) and 9 (6) mm Hg, respectively. There was no group effect or interaction for changes in CI. However, there were time-group interactions for MAP changes such that crystalloid FBT had faster MAP reduction than 4% (p<0.001) or 20% albumin (p < 0.001). Moreover, patients treated with crystalloid FBT showed a faster decline in central venous pressure, perfusion pressure than the two groups. Finally, 20% albumin attenuated the fall in temperature induced by FBT. CONCLUSION In postoperative cardiac surgery patients, after a similar initial CI and MAP response, the MAP effect of crystalloid FBT dissipates faster than that of 4% or 20% albumin FBT. These findings can be used to inform clinical practice.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Australia
| | - Salvatore L Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Service de médecine intensive et réanimation, hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Australia; Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Parkville, Victoria, Australia.
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21
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Deane AM, Jiang A, Tascone B, Clancy A, Finnis ME, Collie JT, Greaves R, Byrne KM, Fujii T, Douglas JS, Nichol A, Udy AA, Young M, Russo G, Fetterplace K, Maiden MJ, Plummer MP, Yanase F, Bellomo R, Ali Abdelhamid Y. A multicenter randomized clinical trial of pharmacological vitamin B1 administration to critically ill patients who develop hypophosphatemia during enteral nutrition (The THIAMINE 4 HYPOPHOSPHATEMIA trial). Clin Nutr 2021; 40:5047-5052. [PMID: 34388414 DOI: 10.1016/j.clnu.2021.07.024] [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] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/02/2021] [Accepted: 07/17/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hypophosphatemia may be a useful biomarker to identify thiamine deficiency in critically ill enterally-fed patients. The objective was to determine whether intravenous thiamine affects blood lactate, biochemical and clinical outcomes in this group. METHOD This randomized clinical trial was conducted across 5 Intensive Care Units. Ninety critically ill adult patients with a serum phosphate ≤0.65 mmol/L within 72 h of commencing enteral nutrition were randomized to intravenous thiamine (200 mg every 12 h for up to 14 doses) or usual care (control). The primary outcome was blood lactate over time and data are median [IQR] unless specified. RESULTS Baseline variables were well balanced (thiamine: lactate 1.2 [1.0, 1.6] mmol/L, phosphate 0.56 [0.44, 0.64] mmol/L vs. control: lactate 1.0 [0.8, 1.3], phosphate 0.54 [0.44, 0.61]). Patients randomized to the intervention received a median of 11 [7.5, 13.5] doses for a total of 2200 [1500, 2700] mg of thiamine. Blood lactate over the entire 7 days of treatment was similar between groups (mean difference = -0.1 (95 % CI -0.2 to 0.1) mmol/L; P = 0.55). The percentage change from lactate pre-randomization to T = 24 h was not statistically different (thiamine: -32 (-39, -26) vs. control: -24 (-31, -16) percent, P = 0.09). Clinical outcomes were not statistically different (days of vasopressor administration: thiamine 2 [1, 4] vs. control 2 [0, 5.5] days; P = 0.37, and deaths 9 (21 %) vs. 5 (11 %); P = 0.25). CONCLUSIONS In critically ill enterally-fed patients who developed hypophosphatemia, intravenous thiamine did not cause measurable differences in blood lactate or clinical outcomes. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ACTRN12619000121167).
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Affiliation(s)
- Adam M Deane
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia.
| | - Alice Jiang
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Brianna Tascone
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Annabelle Clancy
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Mark E Finnis
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; The University of Adelaide, Discipline of Acute Care Medicine, Adelaide, Australia
| | - Jake T Collie
- RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia
| | - Ronda Greaves
- RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia; Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kathleen M Byrne
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Tomoko Fujii
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - James S Douglas
- Department of Intensive Care, Western Health, Melbourne, Australia
| | - Alistair Nichol
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Andrew A Udy
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Meredith Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Giovanni Russo
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Kate Fetterplace
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew J Maiden
- The University of Adelaide, Discipline of Acute Care Medicine, Adelaide, Australia; Intensive Care Unit, Barwon Health, Geelong, Australia
| | - Mark P Plummer
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
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22
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Yanase F, Raman S, Naorungroj T, McCarthy A, Cree M, Schlapbach LJ, Bellomo R. Efficacy and Safety of Parenteral High-Dose Vitamin C Therapy in Pediatric Patients: A Scoping Review. Pediatr Crit Care Med 2021; 22:561-571. [PMID: 33729732 DOI: 10.1097/pcc.0000000000002686] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Recently, several adult trials have investigated the potential benefit of high-dose vitamin C therapy in critically ill patients. In pediatric patients, little is known on the efficacy, safety, and risk of high-dose vitamin C therapy. We aimed to review the efficacy and potential harm associated with high-dose vitamin C treatment. DATA SOURCES We searched MEDLINE, EMBASE, Cochrane Library, and National Institute of Health Clinical Trials Register. STUDY SELECTION We included studies in neonatal and pediatric patients who received IV or intra-arterial high-dose vitamin C (ascorbic acid) defined as greater than or equal to 75 mg/kg/d. DATA EXTRACTION Two independent investigators screened articles and extracted data. DATA SYNTHESIS We found 1,364 articles, assessed 193 full texts for eligibility, and identified 12 eligible studies. These studies included 855 patients, with 194 receiving high-dose vitamin C. The age of patients who received high-dose vitamin C ranged from 2 hours after delivery to 8.4 years (median 2.4 yr), and the vitamin C dose ranged from 100 to 1,500 mg/kg/d (median 260.5 mg/kg/d). Four studies were double-blind randomized controlled trials, and no clinical efficacy outcome was reported in favor of or against vitamin C. Furthermore, no adverse event or signal of harm was reported with high-dose vitamin C. CONCLUSIONS In 12 studies with 194 children treated with parenteral high-dose vitamin C, there was no evidence of clinical efficacy or inferior clinical outcomes in double-blind randomized controlled trials, and no reported harmful effects. These findings justify further investigations of this treatment in children.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Sainath Raman
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Avril McCarthy
- Department of Anaesthesia, Northern Health, Epping, VIC, Australia
| | - Michele Cree
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Department of Pharmacy, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
- Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine and Radiology, Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC, Australia
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23
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Naorungroj T, Neto AS, Zwakman-Hessels L, Yanase F, Eastwood G, Murugan R, Kellum JA, Bellomo R. Early net ultrafiltration rate and mortality in critically ill patients receiving continuous renal replacement therapy. Nephrol Dial Transplant 2021. [PMID: 32259841 DOI: 10.1093/ndt/gfaa032.] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND In patients treated with continuous renal replacement therapy (CRRT), early net ultrafiltration (NUF) rates may be associated with differential outcomes. We tested whether higher early NUF rates are associated with increased mortality in CRRT patients. METHODS We performed a retrospective, observational study of all patients treated with CRRT within 14 days of intensive care unit admission. We defined the early (first 48 h) NUF rate as the volume of fluid removed per hour adjusted for patient body weight and analysed as a categorical variable (>1.75, 1.01-1.75 and <1.01 mL/kg/h). The primary outcome was 28-day mortality. To deal with competing risk, we also compared different time epochs. RESULTS We studied 347 patients {median age 64 [interquartile range (IQR) 53-71] years and Acute Physiology and Chronic Health Evaluation III score 73 [IQR 54-90]}. Compared with NUF rates <1.01 mL/kg/h, NUF rates >1.75 mL/kg/h were associated with greater mortality rates in each epoch: Days 0-5, adjusted hazard ratio (aHR) 1.27 [95% confidence interval (CI) 1.21-1.33]; Days 6-10, aHR 1.62 (95% CI 1.55-1.68); Days 11-15, aHR 1.87 (95% CI 1.79-1.94); Days 16-26, aHR 1.92 (95% CI 1.84-2.01) and Days 27-28, aHR 4.18 (95% CI 3.98-4.40). For every 0.5 mL/kg/h NUF rate increase, mortality similarly increased during these epochs. CONCLUSION Compared with early NUF rates <1.01 mL/kg/h, NUF rates >1.75 mL/kg/h are associated with increased mortality. These observations provide the rationale for clinical trials to confirm or refute these findings.
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Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lara Zwakman-Hessels
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School and Public Health and Preventive Medicine, Monash University, Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Raghavan Murugan
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre
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Bitker L, Cutuli SL, Yanase F, Wilson A, Osawa EA, Lucchetta L, Cioccari L, Canet E, Glassford N, Eastwood GM, Bellomo R. The hemodynamic effects of warm versus room-temperature crystalloid fluid bolus therapy in post-cardiac surgery patients. Perfusion 2021; 37:613-623. [PMID: 33960224 DOI: 10.1177/02676591211012204] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The contribution of fluid temperature to the effect of crystalloid fluid bolus therapy (FBT) in post-cardiac surgery patients is unknown. We evaluated the hemodynamic effects of FBT with fluid warmed to 40°C (warm FBT) versus room-temperature fluid. METHODS In this single centre prospective before-and-after study, we evaluated the effects of 500 ml of warm versus room-temperature compound sodium lactate administered over <30 minutes, in 50 cardiac surgery patients admitted to ICU. We recorded hemodynamics continuous before and for 30 minutes after the first FBT. We defined CI responsiveness (CI-R) as an CI increase >15% of baseline immediately after FBT and effect dissipation if the CI returned to <5% of baseline and MAP responsiveness as >10% increase and dissipation as return to <3 mmHg of baseline. RESULTS Hypotension (56%) and low CI (40%) typically triggered FBT. Temperature decreased >0.3°C in 13 (52%) patients after room-temperature FBT versus 0 (0%) after warm FBT (p < 0.01). CI and MAP responsiveness was similar (16 [64%] versus 11 [44%], p = 0.15 and 15 [60%] versus 17 [68%], p = 0.77, respectively). Among CI responders, CI increased more with room-temperature FBT (+0.6 [IQR, 0.5-1.1] versus +0.5 [IQR, 0.4-0.6] L/min/m2, p = 0.01). However, dissipation was more common after room-temperature versus warm FBT (9/16 [56%] versus 1/11 [9%], p = 0.02). CONCLUSION In postoperative cardiac surgery patients, warm FBT preserved core temperature and induced smaller but more sustained CI increases among responders. Fluid temperature appears to impact both core temperature and the duration of CI response.
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Affiliation(s)
- Laurent Bitker
- Department of Intensive Care, Austin hospital, Melbourne, Australia.,Service de Médecine Intensive - Réanimation, hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Salvatore L Cutuli
- Department of Intensive Care, Austin hospital, Melbourne, Australia.,Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia "A. Gemelli", Rome, Italy
| | - Fumitaka Yanase
- Department of Intensive Care, Austin hospital, Melbourne, Australia
| | - Anthony Wilson
- Department of Intensive Care, Austin hospital, Melbourne, Australia
| | - Eduardo A Osawa
- Department of Intensive Care, Austin hospital, Melbourne, Australia
| | - Luca Lucchetta
- Department of Intensive Care, Austin hospital, Melbourne, Australia
| | - Luca Cioccari
- Department of Intensive Care, Austin hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Melbourne, Australia.,Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emmanuel Canet
- Department of Intensive Care, Austin hospital, Melbourne, Australia
| | - Neil Glassford
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin hospital, Melbourne, Australia.,Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Australia.,University of Melbourne, Parkville, VIC, Australia
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25
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Yanase F, Cutuli SL, Naorungroj T, Bitker L, Belletti A, Wilson A, Eastwood GM, Bellomo R. Temperature and haemodynamic effects of a 100 mL bolus of 20% albumin at room versus body temperature in cardiac surgery patients. CRIT CARE RESUSC 2021; 23:14-23. [PMID: 38046386 PMCID: PMC10692526 DOI: 10.51893/2021.1.oa1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To study the temperature and haemodynamic effects of room versus body temperature 20% albumin fluid bolus therapy (FBT). Design: Single-centre, prospective, before-after trial. Setting: A tertiary intensive care unit (ICU) in Australia. Participants: Sixty ventilated post-cardiac surgery patients. Intervention: Room versus body temperature 100 mL 20% albumin FBT. Main outcome measures: We recorded haemodynamic data from FBT start to 30 minutes after FBT. The cardiac index (CI) response was defined by a CI increase > 15%, and the mean arterial pressure (MAP) response was defined by a MAP increase > 10%. Outcomes: Immediately after FBT, median blood temperature decreased by -0.1°C (interquartile range [IQR], -0.1 to 0.0°C) with room temperature albumin versus 0.0°C (IQR, -0.1 to 0.0°C) with body temperature albumin (P < 0.001). The CI or MAP responses were similar. There was, however, a time and study group interaction for blood temperature (P < 0.001) for absolute and relative changes. In addition, mean pulmonary arterial pressure (PAP) (P = 0.002) increased more with body temperature albumin and remained higher for most of the observation period. Conclusion: Compared with room temperature albumin FBT, body temperature 20% albumin FBT prevents FBT-associated blood temperature fall and increases mean PAP. However, CI and MAP changes were the similar between the two groups, implying that fluid temperature has limited haemodynamic effects in these patients.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Salvatore L. Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Dipartimento di Scienze dell’emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Alessandro Belletti
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Adult Critical Care, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, VIC, Australia
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Lankadeva YR, Peiris RM, Okazaki N, Birchall IE, Trask-Marino A, Dornom A, Vale TAM, Evans RG, Yanase F, Bellomo R, May CN. Reversal of the Pathophysiological Responses to Gram-Negative Sepsis by Megadose Vitamin C. Crit Care Med 2021; 49:e179-e190. [PMID: 33239507 PMCID: PMC7803449 DOI: 10.1097/ccm.0000000000004770] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Oxidative stress appears to initiate organ failure in sepsis, justifying treatment with antioxidants such as vitamin C at megadoses. We have therefore investigated the safety and efficacy of megadose sodium ascorbate in sepsis. DESIGN Interventional study. SETTING Research Institute. SUBJECTS Adult Merino ewes. INTERVENTIONS Sheep were instrumented with pulmonary and renal artery flow-probes, and laser-Doppler and oxygen-sensing probes in the kidney. Conscious sheep received an infusion of live Escherichia coli for 31 hours. At 23.5 hours of sepsis, sheep received fluid resuscitation (30 mL/kg, Hartmann solution) and were randomized to IV sodium ascorbate (0.5 g/kg over 0.5 hr + 0.5 g/kg/hr for 6.5 hr; n = 5) or vehicle (n = 5). Norepinephrine was titrated to restore mean arterial pressure to baseline values (~80 mm Hg). MEASUREMENTS AND MAIN RESULTS Sepsis-induced fever (41.4 ± 0.2°C; mean ± se), tachycardia (141 ± 2 beats/min), and a marked deterioration in clinical condition in all cases. Mean arterial pressure (86 ± 1 to 67 ± 2 mm Hg), arterial Po2 (102.1 ± 3.3 to 80.5 ± 3.4 mm Hg), and renal medullary tissue Po2 (41 ± 5 to 24 ± 2 mm Hg) decreased, and plasma creatinine doubled (71 ± 2 to 144 ± 15 µmol/L) (all p < 0.01). Direct observation indicated that in all animals, sodium ascorbate dramatically improved the clinical state, from malaise and lethargy to a responsive, alert state within 3 hours. Body temperature (39.3 ± 0.3°C), heart rate (99.7 ± 3 beats/min), and plasma creatinine (32.6 ± 5.8 µmol/L) all decreased. Arterial (96.5 ± 2.5 mm Hg) and renal medullary Po2 (48 ± 5 mm Hg) increased. The norepinephrine dose was decreased, to zero in four of five sheep, whereas mean arterial pressure increased (to 83 ± 2 mm Hg). We confirmed these physiologic findings in a coronavirus disease 2019 patient with shock by compassionate use of 60 g of sodium ascorbate over 7 hours. CONCLUSIONS IV megadose sodium ascorbate reversed the pathophysiological and behavioral responses to Gram-negative sepsis without adverse side effects. Clinical studies are required to determine if such a dose has similar benefits in septic patients.
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Affiliation(s)
- Yugeesh R Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, VIC, Australia
| | - Rachel M Peiris
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Nobuki Okazaki
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Ian E Birchall
- Neuropathology Laboratory, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Anton Trask-Marino
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Anthony Dornom
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Tom A M Vale
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
| | - Roger G Evans
- Department of Physiology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University, VIC, Australia
| | - Fumitaka Yanase
- School of Medicine, University of Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, VIC, Australia
- School of Medicine, University of Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Clive N May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, VIC, Australia
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27
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Naorungroj T, Serpa Neto A, Yanase F, Bittar I, Eastwood GM, Bellomo R. NephroCheck® Quality Test. Blood Purif 2020; 50:489-491. [PMID: 33291111 DOI: 10.1159/000511727] [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: 09/18/2020] [Accepted: 09/19/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The acute kidney injury (AKI) risk score helps detect moderate and severe AKI in the next 12-24 h. However, inappropriate urine collection may impact its results. AIM The aim of this study was to evaluate the stability of NephroCheck® after urine storage at different temperatures. METHODS The urine sample was centrifuged and split into 3 tubes. One was tested as soon as possible by the laboratory. The other 2 samples were frozen at -20 and -80°C, and the NephroCheck® test was performed 8 weeks later. RESULTS The mean values of the AKI risk score were 1.19 ± 0.93, 1.15 ± 1.14, and 1.20 ± 1.11 (ng/mL)2/1,000 for fresh urine, -20, and -80°C, respectively (p = 0.70). Spearman's rank correlation for -20 and -80°C versus immediate processing was strong with a rho of 0.82 and 0.98, respectively. CONCLUSION The AKI risk score was relatively stable. Urine could be collected without dry ice or liquid nitrogen and kept for up to 8 weeks with either -20 or -80°C freezing with stable NephroCheck® results.
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Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.,Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
| | - Intissar Bittar
- Department of Pathology, Austin Hospital, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia, .,Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Victoria, Australia, .,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia, .,Data Analytics Research and Evaluation (DARE) Centre, The University of Melbourne, Melbourne, Victoria, Australia,
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Naorungroj T, Yanase F, Eastwood GM, Baldwin I, Bellomo R. Extracorporeal Ammonia Clearance for Hyperammonemia in Critically Ill Patients: A Scoping Review. Blood Purif 2020; 50:453-461. [PMID: 33279903 DOI: 10.1159/000512100] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 07/20/2020] [Accepted: 10/02/2020] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Hyperammonemia is a life-threatening condition. However, clearance of ammonia via extracorporeal treatment has not been systematically evaluated. METHODS We searched EMBASE and MEDLINE databases. We included all publications reporting ammonia clearance by extracorporeal treatment in adult and pediatric patients with clearance estimated by direct dialysate ammonia measurement or calculated by formula. Two reviewers screened and extracted data independently. RESULTS We found 1,770 articles with 312 appropriate for assessment and 28 studies meeting eligibility criteria. Most of the studies were case reports. Hyperammonemia was typically secondary to inborn errors of metabolisms in children and to liver failure in adult patients. Ammonia clearance was most commonly reported during continuous renal replacement therapy (CRRT) and appeared to vary markedly from <5 mL/min/m2 to >250 mL/min/m2. When measured during intermittent hemodialysis (IHD), clearance was highest and correlated with blood flow rate (R2 = 0.853; p < 0.001). When measured during CRRT, ammonia clearance could be substantial and correlated with effluent flow rate (EFR; R2 = 0.584; p < 0.001). Neither correlated with ammonia reduction. Peritoneal dialysis (PD) achieved minimal clearance, and other extracorporeal techniques were rarely studied. CONCLUSIONS Extracorporeal ammonia clearance varies widely with sometimes implausible values. Treatment modality, blood flow, and EFR, however, appear to affect such clearance with IHD achieving the highest values, PD achieving minimal values, and CRRT achieving substantial values especially at high EFRs. The role of other techniques remains unclear. These findings can help inform practice and future studies.
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Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Monash University School and Public Health and Preventive Medicine, ANZICS-RC, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Ian Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia, .,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia, .,Data Analytics Research and Evaluation (DARE) Centre, The University of Melbourne and Austin Health, Melbourne, Victoria, Australia,
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29
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, University of Melbourne, Melbourne, Australia
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Yanase F, Bitker L, Lucchetta L, Naorungroj T, Cutuli SL, Osawa EA, Canet E, Wilson A, Eastwood GM, Bailey M, Bellomo R. Comparison of the Hemodynamic and Temperature Effects of a 500-mL Bolus of 4% Albumin at Room Versus Body Temperature in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2020; 35:499-507. [PMID: 32654806 DOI: 10.1053/j.jvca.2020.06.045] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare the hemodynamic effect of room temperature (cold) 4% albumin fluid bolus therapy (FBT) with body temperature (warm) albumin FBT. DESIGN Prospective, before-after trial. SETTING A tertiary intensive care unit (ICU). PARTICIPANTS Sixty ventilated, post-cardiac surgery patients prescribed with 4% albumin FBT. INTERVENTION Cold or warm 4% albumin 500 ml FBT. MEASUREMENTS AND MAIN RESULTS We recorded hemodynamic parameters before and for 30 minutes after FBT. Cardiac index (CI) and mean arterial pressure (MAP) responses were defined by a CI increase >15% and a MAP increase >10%, respectively. Immediately after FBT, median [interquartile range] core temperature changed by -0.3 [-0.4; -0.3] °C with cold albumin vs. 0.0 [0.0; 0.1]°C with warm albumin (P<0.001). The median CI increase was 0.3 [0.0; 0.5] L/min/m2 with 14 CI-responders (47%) in both groups (P>0.99). The median immediate MAP increase was 9 [3; 15] mmHg with cold albumin vs. 11 [5; 13] mmHg with warm albumin (P=0.79), with a MAP-response in 16 vs. 17 patients (P=0.99). There was an interaction between group and time for MAP (P=0.002), mean pulmonary artery pressure (PAP) (P=0.002) and core temperature (P<0.001). In the cold albumin group, after the initial response, MAP and mean PAP decreased more slowly than with warm albumin and, after the initial fall, core temperature increased toward baseline. CONCLUSION In postoperative cardiac surgery patients, warm albumin FBT prevents the decrease in core temperature and, after an initial similar increase, is associated with a faster return of MAP and mean PAP toward baseline.
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Affiliation(s)
- Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Service de médecine intensive et réanimation, hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Luca Lucchetta
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salvatore L Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eduardo A Osawa
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Emmanuel Canet
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Parkville, Victoria, Australia.
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Naorungroj T, Neto AS, Zwakman-Hessels L, Yanase F, Eastwood G, Bellomo R. P1460MEDIATORS OF THE IMPACT OF HOURLY NET ULTRAFILTRATION RATE ON MORTALITY IN CRITICALLY ILL PATIENTS RECEIVING CONTINUOUS RENAL REPLACEMENT THERAPY. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p1460] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
During continuous renal replacement therapy (CRRT), a high net ultrafiltration (NUF) rate is associated with increased mortality. However, it is unknown what might mediate its putative effect on mortality. This study aims to investigate whether the relationship between early (first 48h) NUF and mortality is mediated by fluid balance (FB), hemodynamic instability or low potassium or phosphate blood levels.
Method
We performed a retrospective, observational study in patients treated with CRRT within 14 days of ICU admission who survived >48 hours. The primary outcome was hospital mortality. We applied multiple mediation analysis to identify possible mediators of NUF’s putative impact on mortality.
Results
We studied 347 patients [median (interquartile range) age: 64 (53–71) years and Acute Physiology and Chronic Health Evaluation (APACHE) III score: 73 (54–90)]. After adjustment for confounders, compared with a NUF<1.01 ml/kg/h, a NUF rate > 1.75 mL/kg/h was associated with significantly greater mortality (adjusted odds ratio [aOR], 1.15 [95%CI, 1.03 to 1.29]; p = 0.011). Adjusted univariable mediation analysis found no suggestion of a causal mediation effect for blood pressure, vasopressor therapy, or potassium levels, but identified a possible effect for FB (average causal mediation effect (ACME), 0.95 [95%CI, 0.90 to 0.99]; p = 0.062) and percentage of phosphate measurements with hypophosphatemia (ACME, 0.96 [95%CI, 0.92 to 1.00]; p = 0.055). However, on multiple mediator analysis, such variables lost any suggestion of a significant effect. In contrast, NUF rate remained associated with mortality even in their presence (average direct effect, 1.24 [95%CI, 1.11 to 1.40]; p < 0.001).
Conclusion
An early NUF greater than 1.75 mL/kg/h was independently associated with increased hospital mortality. Its putative effect was not mediated by FB, low blood pressure, vasopressor use, hypokalemia or hypophosphatemia.
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Affiliation(s)
- Thummaporn Naorungroj
- Austin Hospital, Intensive Care, Heidelberg, Australia
- Siriraj Hospital, Intensive Care, Bangkok, Thailand
| | - Ary Serpa Neto
- Austin Hospital, Intensive Care, Heidelberg, Australia
- Unidade Morumbi - Hospital Israelita Albert Einstein, Critical Care Medicine, Sao Paulo, Brazil
- Academic Medical Centre, Intensive Care, Amsterdam, Netherlands
| | - Lara Zwakman-Hessels
- Austin Hospital, Intensive Care, Heidelberg, Australia
- University of Groningen, Critical Care, Groningen, Netherlands
| | - Fumitaka Yanase
- Austin Hospital, Intensive Care, Heidelberg, Australia
- ANZICS-Research Center, Monash University School and Public Health and Preventive Medicine, Melbourne, Australia
| | | | - Rinaldo Bellomo
- Austin Hospital, Intensive Care, Heidelberg, Australia
- ANZICS-Research Center, Monash University School and Public Health and Preventive Medicine, Melbourne, Australia
- University of Melbourne, Centre for Integrated Critical Care, Parkville, Australia
- University of Melbourne, Data Analytics Research and Evaluation (DARE) Centre, Parkville, Australia
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Osawa EA, Cutuli SL, Cioccari L, Bitker L, Peck L, Young H, Hessels L, Yanase F, Fukushima JT, Hajjar LA, Seevanayagam S, Matalanis G, Eastwood GM, Bellomo R. Continuous Magnesium Infusion to Prevent Atrial Fibrillation After Cardiac Surgery: A Sequential Matched Case-Controlled Pilot Study. J Cardiothorac Vasc Anesth 2020; 34:2940-2947. [PMID: 32493662 DOI: 10.1053/j.jvca.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/29/2020] [Accepted: 04/03/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The authors aimed to test whether a bolus of magnesium followed by continuous intravenous infusion might prevent the development of atrial fibrillation (AF) after cardiac surgery. DESIGN Sequential, matched, case-controlled pilot study. SETTING Tertiary university hospital. PARTICIPANTS Matched cohort of 99 patients before and intervention cohort of 99 consecutive patients after the introduction of a continuous magnesium infusion protocol. INTERVENTIONS The magnesium infusion protocol consisted of a 10 mmol loading dose of magnesium sulphate followed by a continuous infusion of 3 mmol/h over a maximum duration of 96 hours or until intensive care unit discharge. MEASUREMENTS AND MAIN RESULTS The study groups were balanced except for a lower cardiac index in the intervention cohort. The mean duration of magnesium infusion was 27.93 hours (95% confidence interval [CI]: 24.10-31.76 hours). The intervention group had greater serum peak magnesium levels: 1.72 mmol/L ± 0.34 on day 1, 1.32 ± 0.36 on day 2 versus 1.01 ± 1.14 and 0.97 ± 0.13, respectively, in the control group (p < 0.01). Atrial fibrillation occurred in 25 patients (25.3%) in the intervention group and 40 patients (40.4%) in the control group (odds ratio 0.49, 95% CI, 0.27-0.92; p = 0.023). On a multivariate Cox proportional hazards model, the hazard ratio for the development of AF was significantly less in the intervention group (hazard ratio 0.45, 95% CI, 0.26-0.77; p = 0.004). CONCLUSION The magnesium delivery strategy was associated with a decreased incidence of postoperative AF in cardiac surgery patients. These findings provide a rationale and preliminary data for the design of future randomized controlled trials.
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Affiliation(s)
- Eduardo A Osawa
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Cardiology, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Salvatore L Cutuli
- Department of Anesthesiology and Intensive Care, Fondazione Policlinico Universitario A. Gemelli, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Cioccari
- Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Leah Peck
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Helen Young
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Lara Hessels
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia
| | - Julia T Fukushima
- Department of Cardiology, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ludhmila A Hajjar
- Department of Cardiology, Heart Institute (InCor), Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Siven Seevanayagam
- Department of Cardiac Surgery, Austin Hospital, Heidelberg, Melbourne, Australia
| | - George Matalanis
- Department of Cardiac Surgery, Austin Hospital, Heidelberg, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Centre for Integrated Critical Care, School of Medicine, The University of Melbourne, Melbourne, Australia.
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Naorungroj T, Neto AS, Zwakman-Hessels L, Yanase F, Eastwood G, Murugan R, Kellum JA, Bellomo R. Early net ultrafiltration rate and mortality in critically ill patients receiving continuous renal replacement therapy. Nephrol Dial Transplant 2020; 36:1112-1119. [PMID: 32259841 DOI: 10.1093/ndt/gfaa032] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In patients treated with continuous renal replacement therapy (CRRT), early net ultrafiltration (NUF) rates may be associated with differential outcomes. We tested whether higher early NUF rates are associated with increased mortality in CRRT patients. METHODS We performed a retrospective, observational study of all patients treated with CRRT within 14 days of intensive care unit admission. We defined the early (first 48 h) NUF rate as the volume of fluid removed per hour adjusted for patient body weight and analysed as a categorical variable (>1.75, 1.01-1.75 and <1.01 mL/kg/h). The primary outcome was 28-day mortality. To deal with competing risk, we also compared different time epochs. RESULTS We studied 347 patients {median age 64 [interquartile range (IQR) 53-71] years and Acute Physiology and Chronic Health Evaluation III score 73 [IQR 54-90]}. Compared with NUF rates <1.01 mL/kg/h, NUF rates >1.75 mL/kg/h were associated with greater mortality rates in each epoch: Days 0-5, adjusted hazard ratio (aHR) 1.27 [95% confidence interval (CI) 1.21-1.33]; Days 6-10, aHR 1.62 (95% CI 1.55-1.68); Days 11-15, aHR 1.87 (95% CI 1.79-1.94); Days 16-26, aHR 1.92 (95% CI 1.84-2.01) and Days 27-28, aHR 4.18 (95% CI 3.98-4.40). For every 0.5 mL/kg/h NUF rate increase, mortality similarly increased during these epochs. CONCLUSION Compared with early NUF rates <1.01 mL/kg/h, NUF rates >1.75 mL/kg/h are associated with increased mortality. These observations provide the rationale for clinical trials to confirm or refute these findings.
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Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lara Zwakman-Hessels
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,School and Public Health and Preventive Medicine, Monash University, Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Raghavan Murugan
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre
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34
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Cutuli SL, Bitker L, Osawa EA, O’Brien Z, Canet E, Yanase F, Ancona P, Wilson A, Lucchetta L, Kubicki M, Cronhjort M, Cioccari L, Peck L, Young H, Eastwood GM, Mårtensson J, Glassford NJ, Bellomo R. Haemodynamic effect of a 20% albumin fluid bolus in post-cardiac surgery patients. CRIT CARE RESUSC 2020. [DOI: 10.51893/2020.1.oa2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To study the cardiovascular effect over 30 minutes following the end of fluid bolus therapy (FBT) with 20% albumin in patients after cardiac surgery. Design: Prospective observational study. Setting: Intensive care unit of a tertiary university-affiliated hospital. Participants: Twenty post-cardiac surgery mechanically ventilated patients with a clinical decision to administer FBT. Intervention: FBT with a 100 mL bolus of 20% albumin. Main outcome measures: Cardiac index (CI) response was defined by a 15% increase, while mean arterial pressure (MAP) response was defined by a 10% increase. Results: The most common indication for FBT was hypotension (40%). Median duration of infusion was 7 minutes (interquartile range [IQR], 3–9 min). At the end of FBT, five patients (25%) showed a CI response, which increased to almost half in the following 30 minutes and dissipated in one patient. MAP response occurred in 11 patients (55%) and dissipated in five patients (45%) by a median of 6 minutes (IQR, 6–10 min). CI and MAP responses coexisted in four patients (20%). An intrabolus MAP response occurred in 17 patients (85%) but dissipated in 11 patients (65%) within a median of 7 minutes (IQR, 2–11 min). On regression analysis, faster fluid bolus administration predicted MAP increase at the end of the bolus. Conclusion: In post-cardiac surgery patients, CI response to 20% albumin FBT was not congruous with MAP response over 30 minutes. Although hypotension was the main indication for FBT and a MAP response occurred in most of patients, such response was maximal during the bolus, dissipated in a few minutes, and was dissociated from the CI response.
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Cutuli SL, Bitker L, Osawa EA, O'Brien Z, Canet E, Yanase F, Ancona P, Wilson A, Lucchetta L, Kubicki M, Cronhjort M, Cioccari L, Peck L, Young H, Eastwood GM, Mårtensson J, Glassford NJ, Bellomo R. Haemodynamic effect of a 20% albumin fluid bolus in post-cardiac surgery patients. CRIT CARE RESUSC 2020; 22:15-25. [PMID: 32102639 PMCID: PMC10692492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To study the cardiovascular effect over 30 minutes following the end of fluid bolus therapy (FBT) with 20% albumin in patients after cardiac surgery. DESIGN Prospective observational study. SETTING Intensive care unit of a tertiary university-affiliated hospital. PARTICIPANTS Twenty post-cardiac surgery mechanically ventilated patients with a clinical decision to administer FBT. INTERVENTION FBT with a 100 mL bolus of 20% albumin. MAIN OUTCOME MEASURES Cardiac index (CI) response was defined by a ≥ 15% increase, while mean arterial pressure (MAP) response was defined by a ≥ 10% increase. RESULTS The most common indication for FBT was hypotension (40%). Median duration of infusion was 7 minutes (interquartile range [IQR], 3-9 min). At the end of FBT, five patients (25%) showed a CI response, which increased to almost half in the following 30 minutes and dissipated in one patient. MAP response occurred in 11 patients (55%) and dissipated in five patients (45%) by a median of 6 minutes (IQR, 6-10 min). CI and MAP responses coexisted in four patients (20%). An intrabolus MAP response occurred in 17 patients (85%) but dissipated in 11 patients (65%) within a median of 7 minutes (IQR, 2-11 min). On regression analysis, faster fluid bolus administration predicted MAP increase at the end of the bolus. CONCLUSION In post-cardiac surgery patients, CI response to 20% albumin FBT was not congruous with MAP response over 30 minutes. Although hypotension was the main indication for FBT and a MAP response occurred in most of patients, such response was maximal during the bolus, dissipated in a few minutes, and was dissociated from the CI response.
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Affiliation(s)
- Salvatore L Cutuli
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Eduardo A Osawa
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Zachary O'Brien
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Emmanuel Canet
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Anthony Wilson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Luca Lucchetta
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Mark Kubicki
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Maria Cronhjort
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Luca Cioccari
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Lea Peck
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Helen Young
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
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Fujii T, Luethi N, Young PJ, Frei DR, Eastwood GM, French CJ, Deane AM, Shehabi Y, Hajjar LA, Oliveira G, Udy AA, Orford N, Edney SJ, Hunt AL, Judd HL, Bitker L, Cioccari L, Naorungroj T, Yanase F, Bates S, McGain F, Hudson EP, Al-Bassam W, Dwivedi DB, Peppin C, McCracken P, Orosz J, Bailey M, Bellomo R. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial. JAMA 2020; 323:423-431. [PMID: 31950979 PMCID: PMC7029761 DOI: 10.1001/jama.2019.22176] [Citation(s) in RCA: 294] [Impact Index Per Article: 73.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock. OBJECTIVE To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock. DESIGN, SETTING, AND PARTICIPANTS Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019. INTERVENTIONS Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days. MAIN OUTCOMES AND MEASURES The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality. RESULTS Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was -0.6 hours (95% CI, -8.3 to 7.2 hours; P = .83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69-2.00). No serious adverse events were reported. CONCLUSIONS AND RELEVANCE In patients with septic shock, treatment with intravenous vitamin C, hydrocortisone, and thiamine, compared with intravenous hydrocortisone alone, did not significantly improve the duration of time alive and free of vasopressor administration over 7 days. The finding suggests that treatment with intravenous vitamin C, hydrocortisone, and thiamine does not lead to a more rapid resolution of septic shock compared with intravenous hydrocortisone alone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03333278.
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Affiliation(s)
- Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nora Luethi
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Paul J. Young
- Intensive Care Unit, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Daniel R. Frei
- Department of Anaesthesia and Pain Medicine, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Glenn M. Eastwood
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Craig J. French
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Anaesthesia, Pain, and Perioperative Medicine, Footscray Hospital, Western Health, Footscray, Melbourne, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - Adam M. Deane
- Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Parkville, Australia
| | - Yahya Shehabi
- Critical Care and Perioperative Services, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Victoria, Australia
- Clinical School of Medicine, University of New South Wales, Sydney, Australia
| | | | - Gisele Oliveira
- Cancer Institute of the State of Sao Paulo, Sao Paulo, Brazil
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Neil Orford
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, Victoria, Australia
- School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia
| | - Samantha J. Edney
- Intensive Care Unit, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Anna L. Hunt
- Intensive Care Unit, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Harriet L. Judd
- Intensive Care Unit, Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
| | - Laurent Bitker
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
- Service de médecine intensive et réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Luca Cioccari
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland
| | - Thummaporn Naorungroj
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Fumitaka Yanase
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Samantha Bates
- Department of Intensive Care, Anaesthesia, Pain, and Perioperative Medicine, Footscray Hospital, Western Health, Footscray, Melbourne, Victoria, Australia
| | - Forbes McGain
- Department of Intensive Care, Anaesthesia, Pain, and Perioperative Medicine, Footscray Hospital, Western Health, Footscray, Melbourne, Victoria, Australia
| | - Elizabeth P. Hudson
- Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Wisam Al-Bassam
- Critical Care and Perioperative Services, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Dhiraj Bhatia Dwivedi
- Critical Care and Perioperative Services, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Chloe Peppin
- Critical Care and Perioperative Services, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Phoebe McCracken
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Judit Orosz
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
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Yanase F, Bitker L, Hessels L, Osawa E, Naorungroj T, Cutuli SL, Young PJ, Ritzema J, Hill G, Latimer-Bell C, Hunt A, Eastwood GM, Hilton A, Bellomo R. A Pilot, Double-Blind, Randomized, Controlled Trial of High-Dose Intravenous Vitamin C for Vasoplegia After Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:409-416. [DOI: 10.1053/j.jvca.2019.08.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/17/2019] [Accepted: 08/19/2019] [Indexed: 01/06/2023]
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Naorungroj T, Neto AS, Zwakman-Hessels L, Yanase F, Eastwood G, Bellomo R. Hourly Fluid Balance in Patients Receiving Continuous Renal Replacement Therapy. Blood Purif 2019; 49:93-101. [PMID: 31846982 DOI: 10.1159/000503771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/28/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Little is known about early (first 48 h) hourly and cumulative fluid balance (FB) during continuous renal replacement therapy (CRRT). OBJECTIVES To study the characteristics and outcome associations of early hourly and cumulative FB. METHODS We studied FB in CRRT patients (2016-2018). RESULTS Among 350 patients, mean hourly FB became negative after 20 CRRT hours, but within 6 CRRT hours in patients with baseline fluid overload. A negative early FB was never achieved in patients receiving vasopressor therapy (p < 0.001). Mortality was 31%. The percentage of hourly negative FB was independently associated with decreased ICU mortality. A time-weighted hourly FB between 18.5 and -33 mL/h was also significantly and independently associated with decreased mortality. CONCLUSIONS In CRRT patients, an early FB conservative approach is possible, modulated by patient characteristics, and associated with a low mortality. Moreover, avoidance of an early positive FB is associated with decreased mortality.
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Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Lara Zwakman-Hessels
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Fumitaka Yanase
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Center, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Victoria, Australia, .,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia, .,Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Health, Melbourne, Victoria, Australia,
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Hudson EP, Collie JT, Fujii T, Luethi N, Udy AA, Doherty S, Eastwood G, Yanase F, Naorungroj T, Bitker L, Abdelhamid YA, Greaves RF, Deane AM, Bellomo R. Pharmacokinetic data support 6-hourly dosing of intravenous vitamin C to critically ill patients with septic shock. CRIT CARE RESUSC 2019; 21:236-242. [PMID: 31778629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To study vitamin C pharmacokinetics in septic shock. DESIGN Prospective pharmacokinetic study. SETTING Two intensive care units. PARTICIPANTS Twenty-one patients with septic shock enrolled in a randomised trial of high dose vitamin C therapy in septic shock. INTERVENTION Patients received 1.5 g intravenous vitamin C every 6 hours. Plasma samples were obtained before and at 1, 4 and 6 hours after drug administration, and vitamin C concentrations were measured by high performance liquid chromatography. MAIN OUTCOME MEASURES Clearance, volume of distribution, and half-life were calculated using noncompartmental analysis. Data are presented as median (interquartile range [IQR]). RESULTS Of the 11 participants who had plasma collected before any intravenous vitamin C administration, two (18%) were deficient (concentrations < 11 μmol/L) and three (27%) had hypovitaminosis C (concentrations between 11 and 23 μmol/L), with a median concentration 28 μmol/L (IQR, 11-44 μmol/L). Volume of distribution was 23.3 L (IQR, 21.9-27.8 L), clearance 5.2 L/h (IQR, 3.3-5.4 L/h), and half-life 4.3 h (IQR, 2.6-7.5 h). For the participants who had received at least one dose of intravenous vitamin C before sampling, T0 concentration was 258 μmol/L (IQR, 162- 301 μmol/L). Pharmacokinetic parameters for subsequent doses were a median volume of distribution 39.9 L (IQR, 31.4-44.4 L), clearance 3.6 L/h (IQR, 2.6-6.5 L/h), and half-life 6.9 h (IQR, 5.7-8.5 h). CONCLUSION Intravenous vitamin C (1.5 g every 6 hours) corrects vitamin C deficiency and hypovitaminosis C and provides an appropriate dosing schedule to achieve and maintain normal or elevated vitamin C levels in septic shock.
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Affiliation(s)
- Elizabeth P Hudson
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Jake Tb Collie
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Nora Luethi
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Sarah Doherty
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Fumitaka Yanase
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Thummaporn Naorungroj
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Laurent Bitker
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | | | - Ronda F Greaves
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Adam M Deane
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia.
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Matsunaga W, Sanui M, Sasabuchi Y, Kobayashi Y, Kitajima A, Yanase F, Takisawa Y, Lefor AK. Large volume infusions of hydroxyethyl starch during cardiothoracic surgery may be associated with postoperative kidney injury: propensity-matched analysis. Perioper Med (Lond) 2019; 8:13. [PMID: 31695909 PMCID: PMC6822348 DOI: 10.1186/s13741-019-0125-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/09/2019] [Indexed: 12/23/2022] Open
Abstract
Background The safety of intraoperative administration of hydroxyethyl starch (HES) has been debated. We hypothesized that intraoperative use of HES is associated with postoperative acute kidney injury (AKI) following cardiopulmonary bypass (CPB). Materials and methods Patients who underwent cardiothoracic surgery using CPB between 2007 and 2014 were retrospectively reviewed. The incidence of AKI within 7 days after surgery, defined by the Kidney Disease Improving Global Outcome criteria, was compared for patients who did or did not receive 6% (70/0.5) or 6% (130/0.4) HES for anesthesia management before or after CPB. Multivariable logistic regression and propensity matching analysis were performed to examine whether use of HES is associated with postoperative AKI. Outcomes comparing patients receiving HES ≥ 1000 mL and < 1000 mL were also compared. Results Data from 1976 patients were reviewed. All patients received 70/0.5 HES as a part of the priming solution for CPB. The incidence of postoperative AKI was 28.2% in patients who received HES and 26.0% in patients who did not (p = 0.33). In multivariable analysis, there was no correlation between the use of HES and the incidence of AKI (odds ratio 0.87, 95% CI 0.30–2.58, p = 0.81). Propensity matching showed that the incidence of AKI was not significantly different between 481 patients administered with HES and 962 patients (26.6% vs. 26.9%, p = 0.95) who did not receive HES for anesthesia management. However, peak creatinine levels, needed for renal replacement therapy, and in-hospital mortality were higher, and 28-day hospital-free days were lower in patients receiving HES ≥ 1000 mL than those receiving HES < 1000 mL (p < 0.05). Conclusions Intraoperative use of HES was not associated with postoperative AKI following CPB. However, administration of large volumes of HES may be associated with kidney-related adverse clinical outcomes.
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Affiliation(s)
- Wataru Matsunaga
- 1Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Centre, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama 330-8503 Japan
| | - Masamitsu Sanui
- 1Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Centre, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama 330-8503 Japan
| | - Yusuke Sasabuchi
- 2Data Science Centre, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498 Japan
| | - Yasuma Kobayashi
- 1Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Centre, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama 330-8503 Japan
| | - Asuka Kitajima
- 1Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Centre, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama 330-8503 Japan
| | - Fumitaka Yanase
- 1Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Centre, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama 330-8503 Japan
| | - Yutaka Takisawa
- 1Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Centre, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama 330-8503 Japan
| | - Alan Kawarai Lefor
- 3Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi 329-0498 Japan
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Kobayashi D, Kuriyama N, Yanase F, Takahashi O, Aoki K, Komatsu Y. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use prior to medical intensive care unit admission and in-hospital mortality: propensity score-matched cohort study. J Nephrol 2019; 32:595-603. [PMID: 30937855 DOI: 10.1007/s40620-019-00603-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) use prior to medical intensive care unit (ICU) admission was associated with in-hospital mortality and length of ICU stay. METHODS A propensity score-matched cohort study was conducted at single center from 2004 to 2016. We included all adult patients who were admitted to the ICU due to internal medicine-related conditions. We compared patients who had used ACEIs/ARBs prior to ICU admission to patients who had not. Our primary and secondary outcomes were in-hospital mortality and length of stay among survivors and the deceased. Propensity scores were calculated via logistic regression analyses with forward stepwise selection. An odds ratio (OR) for primary outcome was calculated via logistic regression. Sensitivity analyses were performed using conditional logistic regression models including different sets of covariates to confirm our results. RESULTS 3095 patients were admitted to the ICU. Overall, 693 patients were identified via matching, 231 of whom had used ACEIs/ARBs and 462 of whom had not. None of the baseline characteristics differed significantly between groups. Among them, 131 (18.9%) died. Those who had used ACEIs/ARBs had a lower rate of mortality (p < 0.01). Length of ICU stay did not differ significantly between those with ACEIs/ARBs and those without among survivors (p = 0.43) and the deceased (p = 0.14). The OR for mortality was 0.51 (95% confidence interval 0.32-0.79). The results of the sensitivity analyses confirmed the results (ORs 0.4 6-0.53; all were statistically significant). CONCLUSION Prior ACEI/ARB use may be related to in-hospital mortality among medical ICU patients.
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Affiliation(s)
- Daiki Kobayashi
- Division of General Internal Medicine, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan. .,Fujita Health University, Toyoake, Japan.
| | - Nagato Kuriyama
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumitaka Yanase
- Department of Intensive Care Unit, Saitama Medical Center Jichi Medical University, Omiya, Japan
| | - Osamu Takahashi
- Division of General Internal Medicine, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuhiro Aoki
- Department of Anesthesia and Intensive Care Unit, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Komatsu
- Division of Nephrology, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
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Miyazawa K, Kobayashi Y, Yanase F, Nakatomi T, Kajiura A, Ohtsuka Y, Ishiguro Y. [Two Cases of Large Gynecological Tumor Complicated by Preoperative Deep Vein Thromboembolism and Pulmonary Thromboembolism-Should We Use Inferior Vena Cava Filters ?-]. Masui 2017; 66:415-419. [PMID: 30382645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We experienced two cases of large gynecological tumor resection with co-existing deep vein thrombo- embolism (VTE) and pulmonary thromboembolism (PTE). Despite perioperative anticoagulation, one of the two patients developed dyspnea with massive PTE postoperatively, although the other patient did not have any postoperative complications. To prevent fatal mas- sive PTE, temporary inferior vena cava (IVC) filter might have been effective during perioperative period in these cases. Since there are wide variations among institutes regarding the perioperative application of temporary IVC filters for patients with co-existing VTE and/or PTE before surgery, guidelines or recom- mendations for appropriate usage of perioperative IVC filter are necessary.
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Yanase F, Kato M, Matsumoto R, Horaguchi T, Kinoshita H. Postoperative muscular cramp caused by lower limb ischemia related to the unilateral popliteal arteriovenous fistula. J Clin Anesth 2016; 34:143-4. [PMID: 27687361 DOI: 10.1016/j.jclinane.2016.03.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Fumitaka Yanase
- Department of Anesthesiology and Intensive Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Japan.
| | - Masato Kato
- Department of Anesthesiology, International University of Health and Welfare Shioya Hospital, Tochigi, Japan
| | - Ryutaro Matsumoto
- Department of Anesthesiology, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Tetsu Horaguchi
- Department of Vascular Surgery, International University of Health and Welfare Hospital, Tochigi, Japan
| | - Hiroyuki Kinoshita
- Department of Anesthesiology, Aichi Medical University School of Medicine, Aichi, Japan
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Aoyama H, Yanase F, Otsuka Y, Itoh S, Okamura H. Transesophageal Echocardiographic Guidance for Concomitant Bypass With the Right Gastroepiploic Artery to the Superior Mesenteric Artery for Visceral Ischemia Subsequent to Acute Type-A Aortic Dissection Surgery. J Cardiothorac Vasc Anesth 2016; 31:207-210. [PMID: 27498265 DOI: 10.1053/j.jvca.2016.03.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Hiroki Aoyama
- Departments of Anesthesia and Intensive Care Medicine, Saitama Medical Center Jichi Medical University, Saitama, Japan.
| | - Fumitaka Yanase
- Departments of Anesthesia and Intensive Care Medicine, Saitama Medical Center Jichi Medical University, Saitama, Japan
| | - Yuji Otsuka
- Departments of Anesthesia and Intensive Care Medicine, Saitama Medical Center Jichi Medical University, Saitama, Japan
| | - Satoshi Itoh
- Cardiovascular Surgery, Saitama Medical Center Jichi Medical University, Saitama, Japan
| | - Homare Okamura
- Cardiovascular Surgery, Saitama Medical Center Jichi Medical University, Saitama, Japan
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Ishioka H, Sanui M, Tsutsumi Y, Yanase F, Shiotsuka J. Low prevalence of active cytomegalovirus infection in a cardiovascular intensive care unit. J Intensive Care 2014; 2:12. [PMID: 25520828 PMCID: PMC4267559 DOI: 10.1186/2052-0492-2-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 10/11/2013] [Accepted: 01/28/2014] [Indexed: 11/19/2022] Open
Abstract
Active cytomegalovirus infection is not uncommon in critically ill non-immunosuppressed patients. We conducted a preliminary observational study to determine the prevalence of active cytomegalovirus infection in cardiovascular surgical patients. One hundred patients admitted to the intensive care unit following cardiovascular surgery were enrolled between January 2010 and May 2010. Four patients (4%) were positive for serum pp65 antigens, though cytomegalovirus-positive serology (immunoglobulin G, IgG) was found in 98 patients (98%) including those four patients. Active cardiac diseases and their operative procedures including cardiopulmonary bypass may not be significant risk factors for active cytomegalovirus infection unless systemic derangements are also present.
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Affiliation(s)
- Haruhiko Ishioka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama, 330-8503 Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama, 330-8503 Japan
| | - Yusuke Tsutsumi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama, 330-8503 Japan ; Division of Molecular Epidemiology, Jikei University School of Medicine, Nishishimbashi, Minato-ku, Tokyo, 105-8461 Japan
| | - Fumitaka Yanase
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama, 330-8503 Japan
| | - Junji Shiotsuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama, 330-8503 Japan
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Abstract
A 76-year-old man presented with a two-month history of angina pectoris. Computed tomography (CT) revealed a serial enlargement of the supraclavicular and mediastinal lymph nodes compressing the heart, pulmonary artery and aorta. CT angiography (CTA) showed stenosis of the coronary arteries as a result of compression by the enlarged lymph nodes. First-pass contrast-enhanced cardiac magnetic resonance imaging (MRI) at rest revealed a perfusion defect, thus indicating myocardial ischemia. Diffuse large B-cell lymphoma was diagnosed and multidrug combination chemotherapy led to prompt improvement of the symptoms. Relief of the stenosis in the coronary arteries and improvements in myocardial perfusion were noted on follow-up CTA and MRI.
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Affiliation(s)
- Yuki Nagasako
- Division of Hematology, St. Luke's International Hospital, Japan
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Ikehata H, Saito Y, Yanase F, Mori T, Nikaido O, Ono T. Frequent recovery of triplet mutations in UVB-exposed skin epidermis of Xpc-knockout mice. DNA Repair (Amst) 2007; 6:82-93. [PMID: 17049932 DOI: 10.1016/j.dnarep.2006.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Revised: 09/11/2006] [Accepted: 09/11/2006] [Indexed: 10/24/2022]
Abstract
Mutations of the Xpc gene cause a deficiency in global genome repair, a subpathway of nucleotide excision repair (NER), in mammalian cells. We used transgenic mice harboring the lambda-phage-based lacZ mutational reporter gene to study the effect of an Xpc null mutation (Xpc-/-) on damage induction, repair and mutagenesis in mouse skin epidermis after UVB irradiation. UVB induced equal amounts of cyclobutane pyrimidine dimers (CPDs) and pyrimidine(6-4)pyrimidone photoproducts (64PPs) in mouse skin epidermis of Xpc-/- and wild-type mice. CPDs were not significantly removed in either of the mouse genotypes by 12h after irradiation, whereas removal of 64PPs was observed in the wild-type. Irradiation with 300 and 400J/m2 UVB increased the lacZ mutant frequency in the Xpc-/- epidermis to at least twice as high as in the wild-type. Ninety-nine lacZ mutants isolated from the UVB-exposed epidermis of Xpc(-/-)mice were analyzed and compared with mutant sequences from irradiated wild-type mice. The spectra of the mutations in the two genotypes were both highly UV-specific and similar in the dominance of C-->T transitions at dipyrimidine sites; however, Xpc-/- mice had a higher frequency of two-base tandem substitutions, including CC-->TT mutations, three-base tandem substitutions and double base substitutions that were separated by one unchanged base in a three-base sequence (alternating mutations). These tandem/alternating mutations included a remarkably large number of triplet mutations, a recently reported, novel type of UV-specific mutation, characterized by multiple base substitutions or frameshifts within a three-nucleotide sequence containing a dipyrimidine. We concluded that the triplet mutation is a UV-specific mutation that preferably occurs in NER deficient genetic backgrounds.
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Affiliation(s)
- Hironobu Ikehata
- Department of Cell Biology, Graduate School of Medicine, Tohoku University, Sendai 980-8575, Japan.
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Ikehata H, Yanase F, Mori T, Nikaido O, Tanaka K, Ono T. Mutation spectrum in UVB-exposed skin epidermis of Xpa-knockout mice: frequent recovery of triplet mutations. Environ Mol Mutagen 2007; 48:1-13. [PMID: 17163503 DOI: 10.1002/em.20262] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Knockout mutations in both alleles of the Xpa gene give rise to a complete deficiency in nucleotide excision repair (NER) in mammalian cells. We used transgenic mice harboring the lambda-phage-based lacZ mutational reporter gene to study the effect of Xpa null mutation (Xpa(-/-)) on damage induction, repair, and mutagenesis in mouse skin epidermis after UVB irradiation. UVB induced equal amounts of cyclobutane pyrimidine dimers (CPDs) and pyrimidine(6-4)pyrimidone photoproducts (64PPs) in mouse skin epidermis of Xpa(-/-) and wild-type mice. Neither photolesion was removed in the Xpa(-/-) epidermis by 12 hr after irradiation whereas removal of 64PPs was observed in the epidermis of wild-type mice. Irradiation with 200 and 300 J/m(2) UVB increased the lacZ mutant frequency in the epidermis of Xpa(-/-) mice, but the induced mutant frequencies were not significantly different from those previously determined for wild-type mice. One-hundred lacZ mutants isolated from the UVB-exposed epidermis of Xpa(-/-) mice were analyzed and compared with mutant sequences previously determined for irradiated wild-type mice. The distribution of the mutations along the lacZ transgene and the preferred dipyrimidine context of the UV-specific mutations were similar in mutants from the Xpa(-/-) and wild-type mice. The spectra of the mutations in the two genotypes were both highly UV-specific and similar in a dominance of C --> T transitions at dipyrimidine sites; however, Xpa(-/-) mice had a higher frequency than wild-type mice of two-base tandem substitutions, including CC --> TT mutations, three-base tandem mutations and double base substitutions that were separated by one unchanged base in a three-base sequence (alternating mutations). These tandem/alternating mutations included a remarkably large number of triplet mutations, a recently reported, novel type of UV-specific mutation, characterized by multiple base substitutions or frameshifts within a three-nucleotide sequence containing a dipyrimidine. We conclude that the triplet mutation is a UV-specific mutation that preferably occurs in NER-deficient genetic backgrounds.
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Affiliation(s)
- Hironobu Ikehata
- Department of Cell Biology, Graduate School of Medicine, Tohoku University, Seiryo-machi, Sendai 980-8575, Japan.
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