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Eck RJ, van de Leur JJCM, Wiersema R, Cox EGM, Bult W, Spanjersberg AJ, van der Horst ICC, Lukens MV, Gans ROB, Meijer K, Keus F. Trough anti-Xa activity after intermediate dose nadroparin for thrombosis prophylaxis in critically ill patients with COVID-19 and acute kidney injury. Sci Rep 2022; 12:17408. [PMID: 36257974 PMCID: PMC9579123 DOI: 10.1038/s41598-022-21560-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/28/2022] [Indexed: 01/12/2023] Open
Abstract
Our objective was to assess the incidence of drug bioaccumulation in critically ill COVID-19 patients with AKI receiving intermediate dose nadroparin for thrombosis prophylaxis. We conducted a Prospective cohort study of critically ill COVID-19 patients. In patients on intermediate dose nadroparin (5700 IU once daily) we assessed the incidence of bioaccumulation (trough anti-Xa level > 0.2 IU/mL) stratified according to presence of AKI. We quantified this association using multilevel analyses. To assess robustness of our observations, we explored the association between AKI and anti-Xa activity in patients receiving high dose nadroparin (> 5700 IU). 108 patients received intermediate dose nadroparin, of whom 24 had AKI during 36 anti-Xa measurements. One patient with AKI (4.2% [95%CI 0.1-21%]) and 1 without (1.2% [95%CI 0.03-6.5%]) developed bioaccumulation (p = 0.39). Development of AKI was associated with a mean increase of 0.04 (95%CI 0.02-0.05) IU/ml anti-Xa activity. There was no statistically significant association between anti-Xa activity and AKI in 51 patients on high dose nadroparin. There were four major bleeding events, all in patients on high dose nadroparin. In conclusion, Bioaccumulation of an intermediate dose nadroparin did not occur to a significant extent in critically ill patients with COVID-19 complicated by AKI. Dose adjustment in AKI may be unnecessary.
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Affiliation(s)
- R. J. Eck
- grid.4830.f0000 0004 0407 1981Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - J. J. C. M. van de Leur
- grid.452600.50000 0001 0547 5927Department of Laboratory Medicine and Thrombosis Expertise Centre, Isala, Zwolle, The Netherlands
| | - R. Wiersema
- grid.4830.f0000 0004 0407 1981Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - E. G. M. Cox
- grid.4830.f0000 0004 0407 1981Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W. Bult
- grid.4830.f0000 0004 0407 1981Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands ,grid.4494.d0000 0000 9558 4598Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - A. J. Spanjersberg
- grid.452600.50000 0001 0547 5927Department of Anesthesiology and Intensive Care, Isala, Zwolle, The Netherlands
| | - I. C. C. van der Horst
- grid.412966.e0000 0004 0480 1382Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M. V. Lukens
- grid.4830.f0000 0004 0407 1981Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - R. O. B. Gans
- grid.4830.f0000 0004 0407 1981Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - K. Meijer
- grid.4830.f0000 0004 0407 1981Department of Haematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - F. Keus
- grid.4830.f0000 0004 0407 1981Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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2
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Vos ME, Cox EGM, Schagen MR, Hiemstra B, Wong A, Koeze J, van der Horst ICC, Wiersema R. Right ventricular strain measurements in critically ill patients: an observational SICS sub-study. Ann Intensive Care 2022; 12:92. [PMID: 36190597 PMCID: PMC9530097 DOI: 10.1186/s13613-022-01064-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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is common in critically ill patients and is associated with poor outcomes. RV function is usually evaluated by Tricuspid Annular Plane Systolic Excursion (TAPSE) which can be obtained using critical care echocardiography (CCE). Myocardial deformation imaging, measuring strain, is suitable for advanced RV function assessment and has widely been studied in cardiology. However, it is relatively new for the Intensive Care Unit (ICU) and little is known about RV strain in critically ill patients. Therefore, the objectives of this study were to evaluate the feasibility of RV strain in critically ill patients using tissue-Doppler imaging (TDI) and explore the association between RV strain and conventional CCE measurements representing RV function. METHODS This is a single-center sub-study of two prospective observational cohorts (Simple Intensive Care Studies (SICS)-I and SICS-II). All acutely admitted adults with an expected ICU stay over 24 h were included. CCE was performed within 24 h of ICU admission. In patients in which CCE was performed, TAPSE, peak systolic velocity at the tricuspid annulus (RV s') and TDI images were obtained. RV free wall longitudinal strain (RVFWSL) and RV global four-chamber longitudinal strain (RV4CSL) were measured during offline analysis. RESULTS A total of 171 patients were included. Feasibility of RVFWSL and RV4CSL was, respectively, 62% and 56% in our population; however, when measurements were performed, intra- and inter-rater reliability based on the intraclass correlation coefficient were good to excellent. RV dysfunction based on TAPSE or RV s' was found in 56 patients (33%) and 24 patients (14%) had RV dysfunction based on RVFWSL or RV4CSL. In 14 patients (8%), RVFWSL, RV4CSL, or both were reduced, despite conventional RV function measurements being preserved. These patients had significantly higher severity of illness scores. Sensitivity analysis with fractional area change showed similar results. CONCLUSIONS TDI RV strain imaging in critically ill patients is challenging; however, good-to-excellent reproducibility was shown when measurements were adequately obtained. Future studies are needed to elucidate the diagnostic and prognostic value of RV strain in critically ill patients, especially to outweigh the difficulty and effort of imaging against the clinical value.
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Affiliation(s)
- Madelon E Vos
- University Medical Center Groningen, Department of Anaesthesiology, University of Groningen, Groningen, The Netherlands.
| | - Eline G M Cox
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - Maaike R Schagen
- Erasmus Medical Center, Department of Internal Medicine, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Bart Hiemstra
- Department of Anaesthesiology, Location VU Medical Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Jacqueline Koeze
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University of Maastricht, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Renske Wiersema
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands.,Department of Cardiology, Erasmus University Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands
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Cox EGM, Koeze J, van der Horst ICC, Wiersema R. Calculated left ventricular outflow tract diameter for critically ill patients. J Intensive Care 2022; 10:31. [PMID: 35729661 PMCID: PMC9210692 DOI: 10.1186/s40560-022-00623-6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/13/2022] [Indexed: 11/21/2022] Open
Abstract
A fast and reliable left ventricular outflow diameter (LVOTd) estimation may aid in quickly estimating cardiac output. However, obtaining a correct LVOTd can be difficult in intensive care patients, potentially leading to errors and a cardiac output deviation. In this study, the measured LVOTd was compared with the expected LVOTd when estimated using an existing formula in 1177 critically ill patients. We show that estimated LVOTd based on baseline data can aid when obtaining LVOTd is difficult or impossible and simplified estimation based on a formula may allow for more reliable and accessible measurement of cardiac output.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University, Maastricht University Medical Centre+ Maastricht, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Cox EGM, Onrust M, Vos ME, Paans W, Dieperink W, Koeze J, van der Horst ICC, Wiersema R. The simple observational critical care studies: estimations by students, nurses, and physicians of in-hospital and 6-month mortality. Crit Care 2021; 25:393. [PMID: 34782000 PMCID: PMC8591867 DOI: 10.1186/s13054-021-03809-w] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/21/2021] [Indexed: 12/01/2022] Open
Abstract
Background Prognostic assessments of the mortality of critically ill patients are frequently performed in daily clinical practice and provide prognostic guidance in treatment decisions. In contrast to several sophisticated tools, prognostic estimations made by healthcare providers are always available and accessible, are performed daily, and might have an additive value to guide clinical decision-making. The aim of this study was to evaluate the accuracy of students’, nurses’, and physicians’ estimations and the association of their combined estimations with in-hospital mortality and 6-month follow-up. Methods The Simple Observational Critical Care Studies is a prospective observational single-center study in a tertiary teaching hospital in the Netherlands. All patients acutely admitted to the intensive care unit were included. Within 3 h of admission to the intensive care unit, a medical or nursing student, a nurse, and a physician independently predicted in-hospital and 6-month mortality. Logistic regression was used to assess the associations between predictions and the actual outcome; the area under the receiver operating characteristics (AUROC) was calculated to estimate the discriminative accuracy of the students, nurses, and physicians. Results In 827 out of 1,010 patients, in-hospital mortality rates were predicted to be 11%, 15%, and 17% by medical students, nurses, and physicians, respectively. The estimations of students, nurses, and physicians were all associated with in-hospital mortality (OR 5.8, 95% CI [3.7, 9.2], OR 4.7, 95% CI [3.0, 7.3], and OR 7.7 95% CI [4.7, 12.8], respectively). Discriminative accuracy was moderate for all students, nurses, and physicians (between 0.58 and 0.68). When more estimations were of non-survival, the odds of non-survival increased (OR 2.4 95% CI [1.9, 3.1]) per additional estimate, AUROC 0.70 (0.65, 0.76). For 6-month mortality predictions, similar results were observed. Conclusions Based on the initial examination, students, nurses, and physicians can only moderately predict in-hospital and 6-month mortality in critically ill patients. Combined estimations led to more accurate predictions and may serve as an example of the benefit of multidisciplinary clinical care and future research efforts. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03809-w.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Marisa Onrust
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Madelon E Vos
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wolter Paans
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Research Group Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Research Group Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University Medical Center Maastricht+, University of Maastricht, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.,Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
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5
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Törnblom S, Wiersema R, Prowle JR, Haapio M, Pettilä V, Vaara ST. Fluid balance-adjusted creatinine in diagnosing acute kidney injury in the critically ill. Acta Anaesthesiol Scand 2021; 65:1079-1086. [PMID: 33959961 PMCID: PMC8453932 DOI: 10.1111/aas.13841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/17/2021] [Accepted: 04/29/2021] [Indexed: 12/29/2022]
Abstract
Background Acute kidney injury (AKI) is often diagnosed based on plasma creatinine (Cr) only. Adjustment of Cr for cumulative fluid balance due to potential dilution of Cr and subsequently missed Cr‐based diagnosis of AKI has been suggested, albeit the physiological rationale for these adjustments is questionable. Furthermore, whether these adjustments lead to a different incidence of AKI when used in conjunction with urine output (UO) criteria is unknown. Methods This was a post hoc analysis of the Finnish Acute Kidney Injury study. Hourly UO and daily plasma Cr were measured during the first 5 days of intensive care unit admission. Cr values were adjusted following the previously used formula and combined with the UO criteria. Resulting incidences and mortality rates were compared with the results based on unadjusted values. Results In total, 2044 critically ill patients were analyzed. The mean difference between the adjusted and unadjusted Cr of all 7279 observations was 5 (±15) µmol/L. Using adjusted Cr in combination with UO and renal replacement therapy criteria resulted in the diagnosis of 19 (1%) additional AKI patients. The absolute difference in the incidence was 0.9% (95% confidence interval [CI]: 0.3%‐1.6%). Mortality rates were not significantly different between the reclassified AKI patients using the full set of Kidney Disease: Improving Global Outcomes criteria. Conclusion Fluid balance‐adjusted Cr resulted in little change in AKI incidence, and only minor differences in mortality between patients who changed category after adjustment and those who did not. Using adjusted Cr values to diagnose AKI does not seem worthwhile in critically ill patients.
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Affiliation(s)
- Sanna Törnblom
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Renske Wiersema
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
- Department of Critical Care University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - John R. Prowle
- Critical Care and Perioperative Medicine Research Group William Harvey Research InstituteQueen Mary University of London London UK
| | - Mikko Haapio
- Department of Nephrology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Ville Pettilä
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Suvi T. Vaara
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
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6
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Eck RJ, Hulshof L, Wiersema R, Thio CHL, Hiemstra B, van den Oever NCG, Gans ROB, van der Horst ICC, Meijer K, Keus F. Incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients: data from two prospective cohort studies. Crit Care 2021; 25:27. [PMID: 33436012 PMCID: PMC7801861 DOI: 10.1186/s13054-021-03457-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/01/2021] [Indexed: 12/24/2022]
Abstract
Background The objective of this study was to describe the prevalence, incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients receiving contemporary thrombosis prophylaxis. Methods We conducted a pooled analysis of two prospective cohort studies. The outcomes of interest were in-hospital pulmonary embolism or lower extremity deep vein thrombosis (PE-LDVT), in-hospital nonleg deep vein thrombosis (NLDVT), and 90-day mortality. Multivariable logistic regression analysis was used to evaluate the association between predefined baseline prognostic factors and PE-LDVT or NLDVT. Cox regression analysis was used to evaluate the association between PE-LDVT or NLDVT and 90-day mortality. Results A total of 2208 patients were included. The prevalence of any venous thromboembolism during 3 months before ICU admission was 3.6% (95% CI 2.8–4.4%). Out of 2166 patients, 47 (2.2%; 95% CI 1.6–2.9%) developed PE-LDVT and 38 patients (1.8%; 95% CI 1.2–2.4%) developed NLDVT. Renal replacement therapy (OR 3.5 95% CI 1.4–8.6), respiratory failure (OR 2.0; 95% CI 1.1–3.8), and previous VTE (OR 3.6; 95% CI 1.7–7.7) were associated with PE-LDVT. Central venous catheters (OR 5.4; 95% CI 1.7–17.8) and infection (OR 2.2; 95% CI 1.1–4.3) were associated with NLDVT. Occurrence of PE-LDVT but not NLDVT was associated with increased 90-day mortality (HR 2.7; 95% CI 1.6–4.6, respectively, 0.92; 95% CI 0.41–2.1). Conclusion Thrombotic events are common in critically ill patients, both before and after ICU admittance. Development of PE-LDVT but not NLDVT was associated with increased mortality. Prognostic factors for developing PE-LDVT or NLDVT despite prophylaxis can be identified at ICU admission and may be used to select patients at higher risk in future randomized clinical trials. Trial registration NCT03773939.
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Affiliation(s)
- Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Lisa Hulshof
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Critical Care, Treant Zorggroep Emmen, Emmen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Chris H L Thio
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Reinold O B Gans
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Wiersema R, Kaufmann T, van der Veen HN, de Haas RJ, Franssen CF, Koeze J, van der Horst IC, Keus F. Diagnostic accuracy of arterial and venous renal Doppler assessment for acute kidney injury in critically ill patients: A prospective study. J Crit Care 2020; 59:57-62. [DOI: 10.1016/j.jcrc.2020.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/22/2020] [Accepted: 05/23/2020] [Indexed: 12/24/2022]
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Koeze J, van der Horst ICC, Wiersema R, Keus F, Dieperink W, Cox EGM, Zijlstra JG, van Meurs M. Bundled care in acute kidney injury in critically ill patients, a before-after educational intervention study. BMC Nephrol 2020; 21:381. [PMID: 32883219 PMCID: PMC7469422 DOI: 10.1186/s12882-020-02029-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 08/19/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) often occurs in critically ill patients. AKI is associated with mortality and morbidity. Interventions focusing on the reduction of AKI are suggested by the Kidney Disease: Improving Global Outcomes guideline. We hypothesized that these educational interventions would improve outcome in patients admitted to the Intensive Care Unit (ICU). METHODS This was a pragmatic single-centre prospective observational before-after study design in an ICU in a tertiary referral hospital. All consecutive patients admitted to the ICU irrespective their illness were included. A 'Save the Kidney' (STK) bundle was encouraged via an educational intervention targeting health care providers. The educational STK bundle consisted of optimizing the fluid balance (based on urine output, serum lactate levels and/or central venous oxygen saturation), discontinuation of diuretics, maintaining a mean arterial pressure of at least 65 mmHg with the potential use of vasopressors and critical evaluation of the indication and dose of nephrotoxic drugs. The primary outcome was the composite of mortality, renal replacement therapy (RRT), and progression of AKI. Secondary outcomes were the components of the composite outcome the severity of AKI, ICU length of stay and in-hospital mortality. MAIN RESULTS The primary outcome occurred in 451 patients (33%) in the STK group versus 375 patients (29%) in the usual care group, relative risk (RR) 1.16, 95% confidence interval (CI) 1.03-1.3, p < 0.001. Secondary outcomes were, ICU mortality in 6.8% versus 5.6%, (RR 1.22, 95% CI 0.90-1.64, p = 0.068), RRT in 1.6% versus 3.6% (RR 0.46, 95% CI 0.28-0.76, p = 0.002), and AKI progression in 28% versus 24% (RR 1.18, 95% CI 1.04-1.35, p = 0.001). CONCLUSIONS Providing education to uniformly apply an AKI care bundle, without measurement of the implementation in a non-selected ICU population, targeted at prevention of AKI progression was not beneficial.
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Affiliation(s)
- Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands.
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Willem Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Eline G M Cox
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Postbus 30.001, 9700, RB, Groningen, The Netherlands
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9
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Wiersema R, Jukarainen S, Eck RJ, Kaufmann T, Koeze J, Keus F, Pettilä V, van der Horst ICC, Vaara ST. Different applications of the KDIGO criteria for AKI lead to different incidences in critically ill patients: a post hoc analysis from the prospective observational SICS-II study. Crit Care 2020; 24:164. [PMID: 32316994 PMCID: PMC7175574 DOI: 10.1186/s13054-020-02886-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 04/13/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent and clinically relevant problem in critically ill patients. Various randomized controlled trials (RCT) have attempted to assess potentially beneficial treatments for AKI. Different approaches to applying the Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI make a comparison of studies difficult. The objective of this study was to assess how different approaches may impact estimates of AKI incidence and whether the association between AKI and 90-day mortality varied by the approach used. METHODS Consecutive acutely admitted adult intensive care patients were included in a prospective observational study. AKI was determined following the KDIGO criteria during the first 7 days of ICU admission. In this post hoc analysis, we assessed whether AKI incidence differed when applying the KDIGO criteria in 30 different possible methods, varying in (A) serum creatinine (sCr), (B) urine output (UO), and (C) the method of combining these two into an outcome, e.g., severe AKI. We assessed point estimates and 95% confidence intervals for each incidence. Univariable regression was used to assess the associations between AKI and 90-day mortality. RESULTS A total of 1010 patients were included. Baseline creatinine was available in 449 (44%) patients. The incidence of any AKI ranged from 28% (95%CI 25-31%) to 75% (95%CI 72-77%) depending on the approach used. Methods to estimate missing baseline sCr caused a variation in AKI incidence up to 15%. Different methods of handling UO caused a variation of up to 35%. At 90 days, 263 patients (26%) had died, and all 30 variations were associated with 90-day mortality. CONCLUSIONS In this cohort of critically ill patients, AKI incidence varied from 28 to 75%, depending on the method used of applying the KDIGO criteria. A tighter adherence to KDIGO definitions is warranted to decrease the heterogeneity of AKI and increase the comparability of future studies.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Sakari Jukarainen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas Kaufmann
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
| | - Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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10
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Wiersema R, Jukarainen S, Vaara ST, Poukkanen M, Lakkisto P, Wong H, Linder A, van der Horst ICC, Pettilä V. Two subphenotypes of septic acute kidney injury are associated with different 90-day mortality and renal recovery. Crit Care 2020; 24:150. [PMID: 32295614 PMCID: PMC7161019 DOI: 10.1186/s13054-020-02866-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/31/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The pathophysiology of septic acute kidney injury is inadequately understood. Recently, subphenotypes for sepsis and AKI have been derived. The objective of this study was to assess whether a combination of comorbidities, baseline clinical data, and biomarkers could classify meaningful subphenotypes in septic AKI with different outcomes. METHODS We performed a post hoc analysis of the prospective Finnish Acute Kidney Injury (FINNAKI) study cohort. We included patients admitted with sepsis and acute kidney injury during the first 48 h from admission to intensive care (according to Kidney Disease Improving Global Outcome criteria). Primary outcomes were 90-day mortality and renal recovery on day 5. We performed latent class analysis using 30 variables obtained on admission to classify subphenotypes. Second, we used logistic regression to assess the association of derived subphenotypes with 90-day mortality and renal recovery on day 5. RESULTS In total, 301 patients with septic acute kidney injury were included. Based on the latent class analysis, a two-class model was chosen. Subphenotype 1 was assigned to 133 patients (44%) and subphenotype 2 to 168 patients (56%). Increased levels of inflammatory and endothelial injury markers characterized subphenotype 2. At 90 days, 29% of patients in subphenotype 1 and 41% of patients in subphenotype 2 had died. Subphenotype 2 was associated with a lower probability of short-term renal recovery and increased 90-day mortality. CONCLUSIONS In this post hoc analysis, we identified two subphenotypes of septic acute kidney injury with different clinical outcomes. Future studies are warranted to validate the suggested subphenotypes of septic acute kidney injury.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sakari Jukarainen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Meri Poukkanen
- Department of Anesthesiology and Intensive Care, Lapland Central Hospital, Rovaniemi, Finland
| | - Päivi Lakkisto
- Department of Clinical Chemistry and Hematology, University of Helsinki and Helsinki University Hospital and Minerva Foundation Institute for Medical Research, Helsinki, Finland
| | - Hector Wong
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Adam Linder
- Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Intensive Care, Maastricht University Medical Centre+, University Maastricht, Maastricht, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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11
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Keuning BE, Kaufmann T, Wiersema R, Granholm A, Pettilä V, Møller MH, Christiansen CF, Castela Forte J, Snieder H, Keus F, Pleijhuis RG, Horst ICC. Mortality prediction models in the adult critically ill: A scoping review. Acta Anaesthesiol Scand 2020; 64:424-442. [PMID: 31828760 DOI: 10.1111/aas.13527] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 05/13/2019] [Revised: 10/07/2019] [Accepted: 12/04/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Mortality prediction models are applied in the intensive care unit (ICU) to stratify patients into different risk categories and to facilitate benchmarking. To ensure that the correct prediction models are applied for these purposes, the best performing models must be identified. As a first step, we aimed to establish a systematic review of mortality prediction models in critically ill patients. METHODS Mortality prediction models were searched in four databases using the following criteria: developed for use in adult ICU patients in high-income countries, with mortality as primary or secondary outcome. Characteristics and performance measures of the models were summarized. Performance was presented in terms of discrimination, calibration and overall performance measures presented in the original publication. RESULTS In total, 43 mortality prediction models were included in the final analysis. In all, 15 models were only internally validated (35%), 13 externally (30%) and 10 (23%) were both internally and externally validated by the original researchers. Discrimination was assessed in 42 models (98%). Commonly used calibration measures were the Hosmer-Lemeshow test (60%) and the calibration plot (28%). Calibration was not assessed in 11 models (26%). Overall performance was assessed in the Brier score (19%) and the Nagelkerke's R2 (4.7%). CONCLUSIONS Mortality prediction models have varying methodology, and validation and performance of individual models differ. External validation by the original researchers is often lacking and head-to-head comparisons are urgently needed to identify the best performing mortality prediction models for guiding clinical care and research in different settings and populations.
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Affiliation(s)
- Britt E. Keuning
- Department of Critical Care University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Thomas Kaufmann
- Department of Anesthesiology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Renske Wiersema
- Department of Critical Care University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | - Ville Pettilä
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
- Centre for Research in Intensive Care Copenhagen University Hospital Rigshospitalet, Copenhagen Denmark
| | | | - José Castela Forte
- Department of Critical Care University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
- Bernoulli Institute for MathematicsComputer Science and Artificial IntelligenceUniversity of Groningen Groningen The Netherlands
| | - Harold Snieder
- Department of Epidemiology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Frederik Keus
- Department of Critical Care University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Rick G. Pleijhuis
- Department of Internal Medicine University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Iwan C. C. Horst
- Department of Critical Care University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
- Department of Intensive Care Maastricht University Medical Center+Maastricht University Maastricht The Netherlands
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12
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Kaufmann T, Cox EGM, Wiersema R, Hiemstra B, Eck RJ, Koster G, Scheeren TWL, Keus F, Saugel B, van der Horst ICC. Non-invasive oscillometric versus invasive arterial blood pressure measurements in critically ill patients: A post hoc analysis of a prospective observational study. J Crit Care 2020; 57:118-123. [PMID: 32109843 DOI: 10.1016/j.jcrc.2020.02.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 12/21/2019] [Revised: 02/16/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim was to compare non-invasive blood pressure measurements with invasive blood pressure measurements in critically ill patients. METHODS Non-invasive blood pressure was measured via automated brachial cuff oscillometry, and simultaneously the radial arterial catheter-derived measurement was recorded as part of a prospective observational study. Measurements of systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and mean arterial pressure (MAP) were compared using Bland-Altman and error grid analyses. RESULTS Paired measurements of blood pressure were available for 736 patients. Observed mean difference (±SD, 95% limits of agreement) between oscillometrically and invasively measured blood pressure was 0.8 mmHg (±15.7 mmHg, -30.2 to 31.7 mmHg) for SAP, -2.9 mmHg (±11.0 mmHg, -24.5 to 18.6 mmHg) for DAP, and -1.0 mmHg (±10.2 mmHg, -21.0 to 18.9 mmHg) for MAP. Error grid analysis showed that the proportions of measurements in risk zones A to E were 78.3%, 20.7%, 1.0%, 0%, and 0.1% for MAP. CONCLUSION Non-invasive blood pressure measurements using brachial cuff oscillometry showed large limits of agreement compared to invasive measurements in critically ill patients. Error grid analysis showed that measurement differences between oscillometry and the arterial catheter would potentially have triggered at least low-risk treatment decisions in one in five patients.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Geert Koster
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, the Netherlands
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13
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Koeze J, van der Horst ICC, Keus F, Wiersema R, Dieperink W, Kootstra-Ros JE, Zijlstra JG, van Meurs M. Plasma neutrophil gelatinase-associated lipocalin at intensive care unit admission as a predictor of acute kidney injury progression. Clin Kidney J 2020; 13:994-1002. [PMID: 33391742 PMCID: PMC7769547 DOI: 10.1093/ckj/sfaa002] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common complication in patients during intensive care unit (ICU) admission. AKI is defined as an increase in serum creatinine (SCr) and/or a reduction in urine output. SCr is a marker of renal function with several limitations, which led to the search for biomarkers for earlier AKI detection. Our aim was to study the predictive value of plasma neutrophil gelatinase-associated lipocalin (NGAL) at admission as a biomarker for AKI progression during the first 48 h of ICU admission in an unselected, heterogeneous ICU patient population. Methods We conducted a prospective observational study in an academic tertiary referral ICU population. We recorded AKI progression in all ICU patients during the first 48 h of ICU admission in a 6-week period. Plasma NGAL was measured at admission but levels were not reported to the attending clinicians. As possible predictors of AKI progression, pre-existing AKI risk factors were recorded. We examined the association of clinical parameters and plasma NGAL levels at ICU admission with the incidence and progression of AKI within the first 48 h of the ICU stay. Results A total of 361 patients were included. Patients without AKI progression during the first 48 h of ICU admission had median NGAL levels at admission of 115 ng/mL [interquartile range (IQR) 81–201]. Patients with AKI progression during the first 48 h of ICU admission had median NGAL levels at admission of 156 ng/mL (IQR 97–267). To predict AKI progression, a multivariant model with age, sex, diabetes mellitus, body mass index, admission type, Acute Physiology and Chronic Health Evaluation score and SCr at admission had an area under the receiver operating characteristics (ROC) curve of 0.765. Adding NGAL to this model showed a small increase in the area under the ROC curve to 0.783 (95% confidence interval 0.714–0.853). Conclusions NGAL levels at admission were higher in patients with progression of AKI during the first 48 h of ICU admission, but adding NGAL levels at admission to a model predicting this AKI progression showed no significant additive value.
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Affiliation(s)
- Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wim Dieperink
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jenny E Kootstra-Ros
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan G Zijlstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Medical Biology Section, Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Medical Biology Section, Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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14
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Cox EGM, Koster G, Baron A, Kaufmann T, Eck RJ, Veenstra TC, Hiemstra B, Wong A, Kwee TC, Tulleken JE, Keus F, Wiersema R, van der Horst ICC. Should the ultrasound probe replace your stethoscope? A SICS-I sub-study comparing lung ultrasound and pulmonary auscultation in the critically ill. Crit Care 2020; 24:14. [PMID: 31931844 PMCID: PMC6958607 DOI: 10.1186/s13054-019-2719-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background In critically ill patients, auscultation might be challenging as dorsal lung fields are difficult to reach in supine-positioned patients, and the environment is often noisy. In recent years, clinicians have started to consider lung ultrasound as a useful diagnostic tool for a variety of pulmonary pathologies, including pulmonary edema. The aim of this study was to compare lung ultrasound and pulmonary auscultation for detecting pulmonary edema in critically ill patients. Methods This study was a planned sub-study of the Simple Intensive Care Studies-I, a single-center, prospective observational study. All acutely admitted patients who were 18 years and older with an expected ICU stay of at least 24 h were eligible for inclusion. All patients underwent clinical examination combined with lung ultrasound, conducted by researchers not involved in patient care. Clinical examination included auscultation of the bilateral regions for crepitations and rhonchi. Lung ultrasound was conducted according to the Bedside Lung Ultrasound in Emergency protocol. Pulmonary edema was defined as three or more B lines in at least two (bilateral) scan sites. An agreement was described by using the Cohen κ coefficient, sensitivity, specificity, negative predictive value, positive predictive value, and overall accuracy. Subgroup analysis were performed in patients who were not mechanically ventilated. Results The Simple Intensive Care Studies-I cohort included 1075 patients, of whom 926 (86%) were eligible for inclusion in this analysis. Three hundred seven of the 926 patients (33%) fulfilled the criteria for pulmonary edema on lung ultrasound. In 156 (51%) of these patients, auscultation was normal. A total of 302 patients (32%) had audible crepitations or rhonchi upon auscultation. From 130 patients with crepitations, 86 patients (66%) had pulmonary edema on lung ultrasound, and from 209 patients with rhonchi, 96 patients (46%) had pulmonary edema on lung ultrasound. The agreement between auscultation findings and lung ultrasound diagnosis was poor (κ statistic 0.25). Subgroup analysis showed that the diagnostic accuracy of auscultation was better in non-ventilated than in ventilated patients. Conclusion The agreement between lung ultrasound and auscultation is poor. Trial registration NCT02912624. Registered on September 23, 2016.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Geert Koster
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Aidan Baron
- Emergency, Cardiovascular, and Critical Care Research Group, Centre for Health and Social Care Research, Kingston University and St George's University, London, UK
| | - Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - T Corien Veenstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adrian Wong
- Department of Anaesthesiology and Intensive Care, Royal Surrey County Hospital, Guildford, UK
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
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15
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Koster G, Kaufmann T, Hiemstra B, Wiersema R, Vos ME, Dijkhuizen D, Wong A, Scheeren TWL, Hummel YM, Keus F, van der Horst ICC. Feasibility of cardiac output measurements in critically ill patients by medical students. Ultrasound J 2020; 12:1. [PMID: 31912438 PMCID: PMC6946766 DOI: 10.1186/s13089-020-0152-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 08/10/2019] [Accepted: 01/01/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Critical care ultrasonography (CCUS) is increasingly applied also in the intensive care unit (ICU) and performed by non-experts, including even medical students. There is limited data on the training efforts necessary for novices to attain images of sufficient quality. There is no data on medical students performing CCUS for the measurement of cardiac output (CO), a hemodynamic variable of importance for daily critical care. OBJECTIVE The aim of this study was to explore the agreement of cardiac output measurements as well as the quality of images obtained by medical students in critically ill patients compared to the measurements obtained by experts in these images. METHODS In a prospective observational cohort study, all acutely admitted adults with an expected ICU stay over 24 h were included. CCUS was performed by students within 24 h of admission. CCUS included the images required to measure the CO, i.e., the left ventricular outflow tract (LVOT) diameter and the velocity time integral (VTI) in the LVOT. Echocardiography experts were involved in the evaluation of the quality of images obtained and the quality of the CO measurements. RESULTS There was an opportunity for a CCUS attempt in 1155 of the 1212 eligible patients (95%) and in 1075 of the 1212 patients (89%) CCUS examination was performed by medical students. In 871 out of 1075 patients (81%) medical students measured CO. Experts measured CO in 783 patients (73%). In 760 patients (71%) CO was measured by both which allowed for comparison; bias of CO was 0.0 L min-1 with limits of agreement of - 2.6 L min-1 to 2.7 L min-1. The percentage error was 50%, reflecting poor agreement of the CO measurement by students compared with the experts CO measurement. CONCLUSIONS Medical students seem capable of obtaining sufficient quality CCUS images for CO measurement in the majority of critically ill patients. Measurements of CO by medical students, however, had poor agreement with expert measurements. Experts remain indispensable for reliable CO measurements. Trial registration Clinicaltrials.gov; http://www.clinicaltrials.gov; registration number NCT02912624.
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Affiliation(s)
- Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Thomas Kaufmann
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Madelon E. Vos
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Devon Dijkhuizen
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Adrian Wong
- Department of Anaesthesia and Intensive Care, Royal Surrey Hospital, Guildford, UK
| | - Thomas W. L. Scheeren
- Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yoran M. Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
- Department of Intensive Care, Maastricht University Medical Center+, University Maastricht, Maastricht, The Netherlands
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16
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Wiersema R, Koeze J, Eck RJ, Kaufmann T, Hiemstra B, Koster G, Franssen CFM, Vaara ST, Keus F, Van der Horst ICC. Clinical examination findings as predictors of acute kidney injury in critically ill patients. Acta Anaesthesiol Scand 2020; 64:69-74. [PMID: 31465554 PMCID: PMC6916375 DOI: 10.1111/aas.13465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute Kidney Injury (AKI) in critically ill patients is associated with a markedly increased morbidity and mortality. The aim of this study was to establish the predictive value of clinical examination for AKI in critically ill patients. METHODS This was a sub-study of the SICS-I, a prospective observational cohort study of critically ill patients acutely admitted to the Intensive Care Unit (ICU). Clinical examination was performed within 24 hours of ICU admission. The occurrence of AKI was determined at day two and three after admission according to the KDIGO definition including serum creatinine and urine output. Multivariable regression modeling was used to assess the value of clinical examination for predicting AKI, adjusted for age, comorbidities and the use of vasopressors. RESULTS A total of 1003 of 1075 SICS-I patients (93%) were included in this sub-study. 414 of 1003 patients (41%) fulfilled the criteria for AKI. Increased heart rate (OR 1.12 per 10 beats per minute increase, 98.5% CI 1.04-1.22), subjectively cold extremities (OR 1.52, 98.5% CI 1.07-2.16) and a prolonged capillary refill time on the sternum (OR 1.89, 98.5% CI 1.01-3.55) were associated with AKI. This multivariable analysis yielded an area under the receiver-operating curve (AUROC) of 0.70 (98.5% CI 0.66-0.74). The model performed better when lactate was included (AUROC of 0.72, 95%CI 0.69-0.75), P = .04. CONCLUSION Clinical examination findings were able to predict AKI with moderate accuracy in a large cohort of critically ill patients. Findings of clinical examination on ICU admission may trigger further efforts to help predict developing AKI.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Ruben J. Eck
- Department of Internal Medicine University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Thomas Kaufmann
- Department of Anesthesiology University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Geert Koster
- Department of Internal Medicine University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Casper F. M. Franssen
- Department of Internal Medicine University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Suvi T. Vaara
- Division of Intensive Care Medicine Department of Anesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Frederik Keus
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
| | - Iwan C. C. Van der Horst
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
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17
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Wiersema R, Eck RJ, Haapio M, Koeze J, Poukkanen M, Keus F, van der Horst ICC, Pettilä V, Vaara ST. Burden of acute kidney injury and 90-day mortality in critically ill patients. BMC Nephrol 2019; 21:1. [PMID: 31892313 PMCID: PMC6938017 DOI: 10.1186/s12882-019-1645-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 11/28/2019] [Indexed: 12/20/2022] Open
Abstract
Background Mortality rates associated with acute kidney injury (AKI) vary among critically ill patients. Outcomes are often not corrected for severity or duration of AKI. Our objective was to analyse whether a new variable, AKI burden, would outperform 1) presence of AKI, 2) highest AKI stage, or 3) AKI duration in predicting 90-day mortality. Methods Kidney Diseases: Improving Global Outcomes (KDIGO) criteria using creatinine, urine output and renal replacement therapy were used to diagnose AKI. AKI burden was defined as AKI stage multiplied with the number of days that each stage was present (maximum five), divided by the maximum possible score yielding a proportion. The AKI burden as a predictor of 90-day mortality was assessed in two independent cohorts (Finnish Acute Kidney Injury, FINNAKI and Simple Intensive Care Studies I, SICS-I) by comparing four multivariate logistic regression models that respectively incorporated either the presence of AKI, the highest AKI stage, the duration of AKI, or the AKI burden. Results In the FINNAKI cohort 1096 of 2809 patients (39%) had AKI and 90-day mortality of the cohort was 23%. Median AKI burden was 0.17 (IQR 0.07–0.50), 1.0 being the maximum. The model including AKI burden (area under the receiver operator curve (AUROC) 0.78, 0.76–0.80) outperformed the models using AKI presence (AUROC 0.77, 0.75–0.79, p = 0.026) or AKI severity (AUROC 0.77, 0.75–0.79, p = 0.012), but not AKI duration (AUROC 0.77, 0.75–0.79, p = 0.06). In the SICS-I, 603 of 1075 patients (56%) had AKI and 90-day mortality was 28%. Median AKI burden was 0.19 (IQR 0.08–0.46). The model using AKI burden performed better (AUROC 0.77, 0.74–0.80) than the models using AKI presence (AUROC 0.75, 0.71–0.78, p = 0.001), AKI severity (AUROC 0.76, 0.72–0.79. p = 0.008) or AKI duration (AUROC 0.76, 0.73–0.79, p = 0.009). Conclusion AKI burden, which appreciates both severity and duration of AKI, was superior to using only presence or the highest stage of AKI in predicting 90-day mortality. Using AKI burden or other more granular methods may be helpful in future epidemiological studies of AKI.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Ruben J Eck
- Department of Internal medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mikko Haapio
- Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meri Poukkanen
- Department of Anaesthesia and Intensive Care, Lapland Central Hospital, Rovaniemi, Finland
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Suvi T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Wiersema R, Koeze J, Hiemstra B, Pettilä V, Perner A, Keus F, van der Horst ICC. Associations between tricuspid annular plane systolic excursion to reflect right ventricular function and acute kidney injury in critically ill patients: a SICS-I sub-study. Ann Intensive Care 2019; 9:38. [PMID: 30868290 PMCID: PMC6419793 DOI: 10.1186/s13613-019-0513-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/05/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) occurs in up to 50% of all critically ill patients and hemodynamic abnormalities are assumed to contribute, but their nature and share is still unclear. We explored the associations between hemodynamic variables, including cardiac index and right ventricular function, and the occurrence of AKI in critically ill patients. METHODS In this prospective cohort study, we included all patients acutely admitted to an intensive care unit (ICU). Within 24 h after ICU admission clinical and hemodynamic variables were registered including ultrasonographic measurements of cardiac index and right ventricular function, assessed using tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic excursion (RV S'). Maximum AKI stage was assessed according to the KDIGO criteria during the first 72 h after admission. Multivariable logistic regression modeling was used including both known predictors and univariable significant predictors of AKI. Secondary outcomes were days alive outside ICU and 90-day mortality. RESULTS A total of 622 patients were included, of which 338 patients (54%) had at least AKI stage 1 within 72 h after ICU admission. In the final multivariate model higher age (OR 1.01, 95% CI 1.00-1.03, for each year), higher weight (OR 1.03 CI 1.02-1.04, for each kg), higher APACHE IV score (OR 1.02, CI 1.01-1.03, per point), lower mean arterial pressure (OR 1.02, CI 1.01-1.03, for each mmHg decrease) and lower TAPSE (OR 1.05, CI 1.02-1.09 per millimeter decrease) were all independent predictors for AKI in the final multivariate logistic regression model. Sepsis, cardiac index, RV S' and use of vasopressors were not significantly associated with AKI in our data. AKI patients had fewer days alive outside of ICU, and their mortality rate was significantly higher than those without AKI. CONCLUSIONS In our cohort of acutely admitted ICU patients, the incidence of AKI was 54%. Hemodynamic variables were significantly different between patients with and without AKI. A worse right ventricle function was associated with AKI in the final model, whereas cardiac index was not.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Perner
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - SICS Study Group
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Wiersema R, Castela Forte JN, Kaufmann T, de Haas RJ, Koster G, Hummel YM, Koeze J, Franssen CFM, Vos ME, Hiemstra B, Keus F, van der Horst ICC. Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies. J Vis Exp 2019. [PMID: 30735183 DOI: 10.3791/58802] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) may detect adverse events of interventions such as fluid overload at an early stage. The Simple Intensive Care Studies (SICS) is a research line that focuses on the prognostic and diagnostic value of combinations of clinical variables. The SICS-I specifically focused on the use of clinical variables obtained within 24 h of acute admission for prediction of cardiac output (CO) and mortality. Its sequel, SICS-II, focuses on repeated evaluations during ICU admission. The first clinical examination by trained researchers is performed within 3 h after admission consisting of physical examination and educated guessing. The second clinical examination is performed within 24 h after admission and includes physical examination and educated guessing, biochemical analysis and CCUS assessments of heart, lungs, inferior vena cava (IVC) and kidney. This evaluation is repeated at days 3 and 5 after admission. CCUS images are validated by an independent expert, and all data is registered in an online secured database. Follow-up at 90 days includes registration of complications and survival status according to patient's medical charts and the municipal person registry. The primary focus of SICS-II is the association between venous congestion and organ dysfunction. The purpose of publishing this protocol is to provide details on the structure and methods of this on-going prospective observational cohort study allowing answering multiple research questions. The design of the data collection of combined clinical examination and CCUS assessments in critically ill patients are explicated. The SICS-II is open for other centers to participate and is open for other research questions that can be answered with our data.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen;
| | - Jose N Castela Forte
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Thomas Kaufmann
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen
| | - Robbert J de Haas
- Department of Radiology, University of Groningen, University Medical Center Groningen
| | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen
| | - Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Casper F M Franssen
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen
| | - Madelon E Vos
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen
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20
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Hiemstra B, Eck RJ, Koster G, Wetterslev J, Perner A, Pettilä V, Snieder H, Hummel YM, Wiersema R, de Smet AMGA, Keus F, van der Horst ICC. Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I. BMJ Open 2017; 7:e017170. [PMID: 28963297 PMCID: PMC5623575 DOI: 10.1136/bmjopen-2017-017170] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE In the Simple Intensive Care Studies-I (SICS-I), we aim to unravel the value of clinical and haemodynamic variables obtained by physical examination and critical care ultrasound (CCUS) that currently guide daily practice in critically ill patients. We intend to (1) measure all available clinical and haemodynamic variables, (2) train novices in obtaining values for advanced variables based on CCUS in the intensive care unit (ICU) and (3) create an infrastructure for a registry with the flexibility of temporarily incorporating specific (haemodynamic) research questions and variables. The overall purpose is to investigate the diagnostic and prognostic value of clinical and haemodynamic variables. PARTICIPANTS The SICS-I includes all patients acutely admitted to the ICU of a tertiary teaching hospital in the Netherlands with an ICU stay expected to last beyond 24 hours. Inclusion started on 27 March 2015. FINDINGS TO DATE On 31 December 2016, 791 eligible patients fulfilled our inclusion criteria of whom 704 were included. So far 11 substudies with additional variables have been designed, of which six were feasible to implement in the basic study, and two are planned and awaiting initiation. All researchers received focused training for obtaining specific CCUS images. An independent Core laboratory judged that 632 patients had CCUS images of sufficient quality. FUTURE PLANS We intend to optimise the set of variables for assessment of the haemodynamic status of the critically ill patient used for guiding diagnostics, prognosis and interventions. Repeated evaluations of these sets of variables are needed for continuous improvement of the diagnostic and prognostic models. Future plans include: (1) more advanced imaging; (2) repeated clinical and haemodynamic measurements; (3) expansion of the registry to other departments or centres; and (4) exploring possibilities of integration of a randomised clinical trial superimposed on the registry. STUDY REGISTRATION NUMBER NCT02912624; Pre-results.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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