Acute Kidney Injury After Cardiac Surgery by Complete KDIGO Criteria Predicts Increased Mortality.

OBJECTIVES: Acute kidney injury (AKI) occurs frequently after cardiac surgery and is associated with increased mortality. The Kidney Disease: Improving Global Outcomes (KDIGO) criteria for diagnosing AKI include creatinine and urine output values. However, the value of the latter is debated. The authors aimed to evaluate the incidence of AKI after cardiac surgery and the independent association of KDIGO criteria, especially the urine output criterion, and 2.5-year mortality. DESIGN: Prospective, observational, cohort study. SETTING: Single-center study in a university hospital. PARTICIPANTS: The study comprised 638 cardiac surgical patients from September 1, 2011, to June 20, 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Hourly urine output, daily plasma creatinine, risk factors for AKI, and variables for EuroSCORE II were recorded. AKI occurred in 183 (28.7%) patients. Patients with AKI diagnosed using only urine output had higher 2.5-year mortality than did patients without AKI (9/53 [17.0%] v 23/455 [5.1%], p = 0.001). AKI was associated with mortality (hazard ratios [95% confidence intervals]: 3.3 [1.8-6.1] for KDIGO 1; 5.8 [2.7-12.1] for KDIGO 2; and 7.9 [3.5-17.6]) for KDIGO 3. KDIGO stages and AKI diagnosed using urine output were associated with mortality even after adjusting for mortality risk assessed using EuroSCORE II and risk factors for AKI. CONCLUSIONS: AKI diagnosed using only the urine output criterion without fulfilling the creatinine criterion and all stages of AKI were associated with long-term mortality. Preoperatively assessed mortality risk using EuroSCORE II did not predict this AKI-associated mortality.

Determination of saturation, heart rate, and respiratory rate at forearm using a Nellcor™ forehead SpO2-saturation sensor.

Alterations in arterial blood oxygen saturation, heart rate (HR), and respiratory rate (RR) are strongly associated with intra-hospital cardiac arrests and resuscitations. A wireless, easy-to-use, and comfortable method for monitoring these important clinical signs would be highly useful. We investigated whether the Nellcor™ OxiMask MAX-FAST forehead sensor could provide data for vital sign measurements when located at the distal forearm instead of its intended location at the forehead to provide improved comfortability and easy placement. In a prospective setting, we recruited 30 patients undergoing surgery requiring postoperative care. At the postoperative care unit, patients were monitored for two hours using a standard patient monitor and with a study device equipped with a Nellcor™ Forehead SpO2 sensor. The readings were electronically recorded and compared in post hoc analysis using Bland-Altman plots, Spearman's correlation, and root-mean-square error (RMSE). Bland-Altman plot showed that saturation (SpO2) differed by a mean of -0.2 % points (SD, 4.6), with a patient-weighted Spearman's correlation (r) of 0.142, and an RMSE of 4.2 points. For HR measurements, the mean difference was 0.6 bpm (SD, 2.5), r = 0.997, and RMSE = 1.8. For RR, the mean difference was -0.5 1/min (4.1), r = 0.586, and RMSE = 4.0. The SpO2 readings showed a low mean difference, but also a low correlation and high RMSE, indicating that the Nellcor™ saturation sensor cannot reliably assess oxygen saturation at the forearm when compared to finger PPG measurements.

Indirect measurement of the vascular endothelial glycocalyx layer thickness in human submucosal capillaries with a plug-in for ImageJ.

BACKGROUND: The thickness of vascular endothelial glycocalyx layer can be measured indirectly during a spontaneous leukocyte passage from oral submucosal capillaries in humans. The subsequent differences in red blood cell (RBC) column widths, before a spontaneous white blood cell passage (pre-WBC) and after a spontaneous WBC passage (post-WBC) can be used in off-line analysis to measure glycocalyx thickness: [pre-WBC width-post-WBC width]/2. We created and validated a semi-automatic plug-in for ImageJ to measure the endothelial glycocalyx layer thickness. METHODS: Video clips presenting human sublingual microvasculature were created with a side-stream dark field imaging device. Spontaneous leukocyte passages in capillaries were analyzed from video clips with ImageJ. The capillary glycocalyx layer thickness was measured by the indirect approach with two manual and two semi-automatic methods. RESULTS: There were no statistically significant differences between glycocalyx layer thicknesses measured with different methods, even though small inter-method differences in RBC column thicknesses could be detected. Inter-rater differences were systematically smaller with both semi-automatic methods. Intra-rater coefficient of variation [CV] (95% CI) was largest when measurements were made completely manually [9.2% (8.4-10.0)], but improved significantly with automatic image enhancement prior to manual measurement [7.2% (6.4-8.0)]. CV could be improved further when using semi-automatic analysis with an in-frame median filter radius of 1 pixel [5.8% (5.0-6.6)], or a median filter radius of 2 pixels [4.3% (3.5-5.1)]. CONCLUSIONS: Semi-automatic analysis of glycocalyx decreased the intra-rater CV and the inter-rater differences compared to the manual method. On average, each of the four methods yielded equal results for the glycocalyx thickness. Being the only feasible bed side method in most clinical scenarios, indirect measurement of glycocalyx thickness with orthogonal polarization spectral imaging or side-stream dark field imaging device and our plug-in can advance the study of glycocalyx layer pathology in man.

The effect of levosimendan on bupivacaine-induced severe myocardial depression in anesthetized pigs.

BACKGROUND AND OBJECTIVES: Levosimendan, an inodilator without proarrhythmogenic properties, has been shown to reverse ropivacaine-induced negative inotropy in isolated heart preparations. In this randomized and blinded study, we investigated whether levosimendan is able to reverse rapidly bupivacaine-induced myocardial depression in pigs. METHODS: Twenty invasively monitored pigs anesthetized with isoflurane 1% received bupivacaine 2 mg/kg per minute into a central vein until mean arterial pressure decreased to 55% of baseline. Thereafter, levosimendan 80 microg/kg for 10 mins, followed by 0.7 microg/kg per minute during the next 50 mins (L-SIM) or corresponding amounts of placebo were administered intravenously. Simultaneously, Ringer's acetate was infused intravenously, 20 mL/kg for 10 mins, followed by 20 mL/kg for 50 mins. RESULTS: Two pigs in each group developed cardiac arrest immediately after bupivacaine and could not be resuscitated. Bupivacaine induced widening of the QRS complex in the electrocardiogram and bradycardia.In the remaining 16 pigs, 3 (2 in L-SIM group and 1 in placebo group) needed short-lasting manual cardiac compression and 1 dose of epinephrine. Cardiac output, ejection fraction, and stroke power/end-diastolic volume recovered initially very rapidly in the L-SIM group.However, there was no time x group effect difference in the overall recovery in the various parameters between the 2 groups, except in heart rate which was higher (P G 0.05) when levosimendan was administered.During the 50-min levosimendan infusion, mean arterial pressure and systemic vascular resistance stayed slightly lower in comparison with placebo infusion, but the difference was not statistically significant. CONCLUSIONS: Levosimendan together with the infusion of Ringer's solution rapidly reversed the cardiac depression, but there was no difference in overall cardiovascular recovery in comparison to treatment with Ringer's solution alone. Levosimendan-induced increase in heart rate possibly facilitated the recovery from bupivacaine intoxication.

Enhanced extrastriate activation during observation of distorted finger postures.

Hand and finger postures of other people are important body language cues that strongly contribute to the observer's decision about the person's intentions, thoughts, and attentional state. We compared neuromagnetic cortical activation elicited by color images of natural and distorted finger postures. The distorted postures contained computer-deformed joint angles and thereby easily caught the observer's attention. From about 260 msec onwards, extrastriate occipital areas of both hemispheres were activated more strongly by distorted than natural finger postures. We interpret this result as an early top-down effect of emotional valence on the processing of unusual hand shapes in the extrastriate visual cortex.

Impaired mirror-image imitation in Asperger and high-functioning autistic subjects.

Imitation is crucial for proper development of social and communicative skills. Here, we argue that, based on an error analysis of a behavioral imitation task, adult Asperger and high-functioning autistic subjects suffer from an intriguing deficit of imitation: they lack the natural preference for imitation in a mirror-image fashion. The imitation task consisted of a simple movement sequence of putting a pen with the left or right hand into a green or a blue cup using one of two possible grips. The subjects were asked to imitate the experimenter's hand movements either using the crossed hand (e.g., the subject's right hand corresponding to the experimenter's right hand) for imitation or to imitate as if looking in a mirror (e.g., the subject's left hand corresponding to the experimenter's right hand). When people normally view other persons face-to-face, they prefer to imitate as in a mirror, and observation of mirror-image-like movements speeds up performance in nonimitative tasks. However, our autistic subjects, defective in social cognition, did not profit from mirror-image movements of others. These results provide a new insight into the difficulties that autistic subjects face in viewing and understanding actions of others.