The Relationship Between Heart Rate and Body Temperature in Critically Ill Patients.

OBJECTIVE: The presence of tachycardia in critically ill patients is frequently used as an indication of severity of illness and to guide treatment decisions but can be influenced by body temperature, thus confounding its interpretation. There are few data available on the relationship between body temperature and heart rate in critically ill patients. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Mixed medical-surgical university hospital ICU. PATIENTS: All patients admitted to the ICU between November 2006 and August 2019. MEASUREMENTS AND MAIN RESULTS: Body temperature was recorded in the electronic medical records at least hourly, from invasive measurements (esophageal probe, indwelling urinary catheter, pulse contour cardiac output monitoring system, or pulmonary artery catheter) or manual tympanic recordings. Heart rate was monitored continuously and hourly values were recorded in the electronic medical record. Change in heart rate with change in body temperature was assessed by extracting pairs of simultaneous body temperature and corresponding heart rate measurements from the electronic medical record: 472,941 simultaneous pairs were obtained from the 9,046 patients admitted during the study period. Each 1°C increase in body temperature between 32.0°C and 42.0°C was associated with an 8.35 beats/min increase in heart rate. Crude linear regression showed an r2 of 0.855 between body temperature and heart rate. Heart rate increased more in females than in males (9.46 vs 7.24 beats/min for each 1°C, p < 0.0001); this relationship was not affected by age or adrenergic drugs. The increase in heart rate was related to the severity of organ dysfunction. CONCLUSIONS: Increase in body temperature is associated with a linear increase in heart rate of 9.46 beats/min/°C in female and 7.24 beats/min/°C in male patients. These observations will help to correctly interpret heart rate values at different body temperatures and enable more accurate evaluation of other factors associated with tachycardia.

Nutrients and micronutrients at risk during renal replacement therapy: a scoping review.

PURPOSE OF REVIEW: Malnutrition is frequent in patients with acute kidney injury. Nutrient clearance during renal replacement therapy (RRT) potentially contributes to this complication. Although losses of amino acid, trace elements and vitamins have been described, there is no clear guidance regarding the role of micronutrient supplementation. RECENT FINDINGS: A scoping review was conducted with the aim to review the existing literature on micronutrients status during RRT: 35 publications including data on effluent losses and blood concentrations were considered relevant and analysed. For completeness, we also included data on amino acids. Among trace elements, negative balances have been shown for copper and selenium: low blood levels seem to indicate potential deficiency. Smaller size water soluble vitamins were found in the effluent, but not larger size liposoluble vitamins. Low blood values were frequently reported for thiamine, folate and vitamin C, as well as for carnitine. All amino acids were detectable in effluent fluid. Duration of RRT was associated with decreasing blood values. SUMMARY: Losses of several micronutrients and amino acids associated with low blood levels represent a real risk of deficiency for vitamins B1 and C, copper and selenium: they should be monitored in prolonged RRT. Further Research is urgently required as the data are insufficient to generate strong conclusions and prescription recommendations for clinical practice.

Hypothermia during CRRT, a comparative analysis.

BACKGROUND: One of the most common adverse events during continuous renal replacement therapy (CRRT) is hypothermia, reported to occur in over 4/10 cases. In turn, hypothermia is known to be associated with higher mortality rates among patients treated in intensive care units (ICU). The present study examined if a novel warming device in the current generation of CRRT systems could lower incidence of hypothermia compared to previous generation technology. METHODS: We included ICU patients >18 years, at Skåne University Hospital, Lund from November 2006 to August 2019 and treated with CRRT. Temperature measurements were recorded from the CRRT systems and from the patients hourly. RESULTS: In total, 310 patients treated with the older system vs 32 patients treated using the newer CRRT system were included. We found that historic Prismaflex patients spent 11.43% of their time in hypothermia, as compared to the novel Prismax CRRT system, where 10.06% of patient hours were below 36.0°C (Chi-Square P = .0063). The novel blood warmer is associated with less heat loss compared to the older warmer: mean patient temperature was 37°C vs 36.5°C for these two groups and mean set return temperature was 37.9°C vs 40.9°C (both P < .001). CONCLUSIONS: The current generation CRRT system and blood warmer significantly decreases the risk of hypothermia among critically ill patients treated with continuous renal replacement therapy as compared to historic controls. Achieving target temperature is easier with the new system.

Catheter-related infections: A Scandinavian observational study on the impact of a simple hygiene insertion bundle.

BACKGROUND: Catheter-related infections (CRIs) and catheter-related bloodstream infections (CRBSIs) are among the most frequent hospital acquired infections. CRI/CRBSI studies in Scandinavian cohorts are scarce. The primary aim of this study was to investigate the CRI/CRBSI incidence and the association between potential risk factors, including the introduction of a simple hygiene insertion bundle and CRIs at a large university hospital in Sweden. METHODS: We retrospectively included all patients aged 12 and above who received a central venous catheter (CVC) or a central dialysis catheter during a 2-year period, 1 year before and 1 year after the implementation of a simple hygiene insertion bundle. Microbiological data, including catheter tip cultures and blood cultures, were merged with CVC insertion data. RESULTS: A total of 1722 catheter insertions in 1428 patients were included. CRI and CRBSI incidence were 1.86/1000 and 0.62/1000 catheter days, respectively. In a multivariable regression model, the implementation of a simple hygiene insertion bundle was the independent factor most strongly associated with significantly lower CRI-incidence (95% confidence interval [CI] of odds ratio [OR] 0.23-0.92, P = .029). Choosing multiple lumen catheters was associated with increasing CRI-incidence (95% CI of OR 1.11-2.39, P = .013). CONCLUSION: The incidence of catheter-related infections and catheter-related bloodstream infections in this Scandinavian cohort was low. The implementation of a simple hygiene insertion bundle seems to be an effective intervention for reducing catheter-related infections. The use of multiple-lumen catheters is associated with increased risk of catheter-related infections.

Mechanical complications of central venous catheter insertions: A retrospective multicenter study of incidence and risks.

BACKGROUND: Incidence and risk factors for complications after insertion of central venous catheters have previously been reported for smaller cohorts. The aim of this observational multicenter study was to study risk factors for mechanical complications in a large, recently collected cohort of patients. METHODS: Records of central venous catheter insertions from 8 hospitals in southern Sweden from 2013 to 2016 were collected from the regional chart system. Data on blood coagulation tests, use of ultrasonography, central venous catheter location, bore size, number of needle passes, arterial puncture, the chronological order of the central venous catheter insertion, and mechanical complications were extracted. Only one insertion/patient was included using worst-case selection criteria. Predefined primary outcome was mechanical complications defined as bleeding, pneumothorax, nerve injury, or malignant arrhythmia. Severe mechanical complications were defined as bleeding requiring intervention or transfusion, pneumothorax, persistent nerve injury, or non-self-limiting arrhythmias. RESULTS: We included 10 949 insertions and identified 118 (1.1%) incidents of mechanical complication, of which 85 (0.8%) were bleedings, 21 (0.2%) were pneumothoraces, 7 (0.06%) were transient nerve injuries, and 5 (0.05%) were self-limiting arrhythmias. Severe mechanical complications occurred in 23 (0.2%) cases. CONCLUSIONS: In this retrospective, multicenter observational study on 10 949 central venous catheter insertions, mechanical complications were rare. Preprocedural coagulopathy, number of needle passes, and arterial puncture were associated with grade 2-4 bleeding. Subclavian vein insertions, arterial puncture, and chronological order of the central venous catheter insertion were associated with pneumothorax.

Analysis of Endotoxin Adsorption in Two Swedish Patients with Septic Shock.

BACKGROUND: Lipopolysaccharide (endotoxin) from the outer Gram-negative bacterial wall can induce a harmful immunologic response, involving hemodynamic deprivation, and is one important motor driving the septic cascade. The positively charged poly-imine ethylene layer on the oXiris membrane is capable of adsorbing negatively charged endotoxin molecules and removing them from the blood compartment. Endotoxin is detrimental and should be removed from blood. SUMMARY: The adsorbable endotoxin fraction in blood arises from a tight balance between seeding from an infectious focus and removal by an overwhelmed immune system. The net sum of remaining endotoxin in blood is available for an adsorption process in the oXiris filter. Endotoxin data from 2 patients with severe Gram-negative septic shock and endotoxemia in this case series, speaks for a considerable share of the adsorption of the oXiris filter in the endotoxin net removal over time. Key Messages: Analysis of combined in vitro and in vivo data speaks for an effect of the oXiris filter in lowering endotoxin.

Comparison of the Accuracy of the Novel PrisMax Continuous Renal Replacement Therapy System to the Classic Prismaflex System.

BACKGROUND/AIMS: We assessed how the novel PrisMax continuous renal replacement therapy (CRRT) system performed in an international multicentre setting. The system has multiple novel tools aiming to increase accuracy and dose delivery. METHODS: Data was prospectively collected from 7 intensive care units in 6 countries. The PrisMax device data logs constituted the raw material and last generation Prismaflex data was used as comparison. Clinical parameters like treatment time, filter life span, downtime as well as prescribed and delivered dose were recorded. RESULTS: PrisMax delivered/prescribed effluent ratios (mean ± SD) 0.92 ± 0.15 vs. Prismaflex ratios 0.85 ± 0.21, p < 0.001; delivered effluent dose (mL/kg/h) was 18.16 ± 12.93 vs. 10.95 ± 10.96, p < 0.0001; and (Kt/V) 0.76 ± 0.52 vs. 0.44 ± 0.44, p < 0.0001. Moreover, downtime was 27 minutes less for the newer device. CONCLUSION: The PrisMax CRRT device outperforms its predecessor with regard to dose delivery and accuracy.

Sepsis Management with a Blood Purification Membrane: European Experience.

BACKGROUND: Septic shock is a leading cause of acute kidney injury (AKI). Endotoxins and cytokine levels are associated with the occurrence and severity of AKI, and different blood purification devices are available to remove them from circulation. One such device, oXiris, is a hollow-fibre purification filter that clears both endotoxins and cytokines. Due to limited evidence, clinical use of this device is not currently advocated in guidelines. However, clinics do regularly use this device, and there is a critical need for guidance on the application of it in sepsis with and without AKI. METHOD: A modified Delphi-based method was used to collate -European experts' views on the indication(s), initiation and discontinuation criteria and success measures for oXiris. RESULTS: A panel of 14 participants was selected based on known clinical expertise in the areas of critical care and sepsis management, as well as their experience of using the oXiris blood purification device. The participants used different criteria to initiate treatment with oXiris in sepsis patients with and without AKI. Septic shock with AKI was the priority patient population, with oXiris used to rapidly improve haemodynamic parameters. Achieving haemodynamic stability within 72 h was a key factor for determining treatment success. CONCLUSION: In the absence of established guidelines, users of hollow-fibre purification devices such as oXiris may benefit from standardised approaches to selecting patients and initiating and terminating treatment, as well as measuring success. Further evidence in the form of randomised clinical trials is urgently required.

The Novel PrisMax Continuous Renal Replacement Therapy System in a Multinational, Multicentre Pilot Setting.

BACKGROUND/AIMS: We assessed how the novel PrisMax continuous renal replacement therapy (CRRT) system performed in a prospective international multicentre setting. We compared this device to its predecessor, the Prismaflex, with regards to multiple treatment parameters. Additionally, we performed a survey, aiming to measure user satisfaction. METHODS: Data was prospectively collected from 7 intensive care units (ICU) in 6 countries. The PrisMax device data logs constituted the raw material. Clinical parameters like treatment time, filter life span, downtime, delivered dose and number and type of alarms were recorded. A user questionnaire was sent out to 3 of the participating ICUs. RESULTS: Filter life, downtime, blood pump stops, bag changing time and number of malfunction alarms showed significantly improved values compared to the historic Prismaflex data. The survey showed high scores with regards to user friendliness. CONCLUSION: The PrisMax CRRT device is safe and outperformed its' previous generation counterpart in virtually all aspects. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=489213.

Analysis of Hypo- and Hyperphosphatemia in an Intensive Care Unit Cohort.

BACKGROUND: Blood phosphate levels are vulnerable to fluctuations and changes in phosphate levels are often neglected. The aim of this study was to evaluate whether deviations in phosphate levels correlate to higher 180-day overall mortality or morbidity. METHODS: Four thousand six hundred fifty-six patients with 19,467 phosphate values treated at the adult intensive care unit at Skåne University Hospital, Lund, Sweden during 2006-2014 were retrospectively divided into a control group and 3 study groups: hypophosphatemia, hyperphosphatemia, and a mixed group showing both hypo/hyperphosphatemia. Sex, age, disease severity represented by maximal organ system Sequential Organ Failure Assessment score, renal Sequential Organ Failure Assessment score, lowest ionized calcium value, and diagnoses classes were included in a Cox hazard model to adjust for confounding factors, with time to death in the first 180 days from the intensive care unit (ICU) admission as outcome. RESULTS: When compared to normophosphatemic controls, the hyperphosphatemic study group was associated with higher risk of death with a hazard ratio of 1.2 (98.3% confidence interval 1.0-1.5, P = .0089). Mortality in the hypophosphatemic or mixed study group did not differ from controls. The mixed group showed markedly longer ventilator times and ICU stays compared to all other groups. CONCLUSIONS: Phosphate alterations in ICU patients are common and associated with worse morbidity and mortality. Many underlying pathophysiologic mechanisms may play a role. A rapidly changing phosphate level or isolated hypo or hyperphosphatemia should be urgently corrected.

Cost-effectiveness of the TherMax blood warmer during continuous renal replacement therapy.

Hypothermia is a common adverse event during continuous renal replacement therapy (CRRT), affecting multiple organ systems and increasing risk of poor health outcomes among patients with acute kidney injury (AKI) undergoing CRRT. TheraMax blood warmers are the next generation of extracorporeal blood warmers which reduce risk of hypothermia during CRRT. The purpose of this study is to elucidate the potential health economic impacts of avoiding CRRT-induced hypothermia by using the novel TherMax blood warming device. This study compares health care costs associated with use of the new TherMax blood warmer unit integrated with the PrisMax system compared to CRRT with a standalone blood warming device to avoid hypothermia in continuous renal replacement therapy (CRRT). An economic model was developed in which relevant health states for each intervention were normothermia, hypothermia, discharge, and death. Clinical inputs and costs were obtained from a combination of retrospective chart review and publicly available summary estimates. The proportion of AKI patients treated with CRRT who became hypothermic (<36°C) during CRRT treatment was 34.5% in the TherMax group compared to 71.9% in the 'standalone warmer' group. Given the 78.7-year average life expectancy in the US and the assumed average patient age at discharge/death of 65.4 years, the total life-years gained by avoiding mortality related to hypothermia was 9.0 in the TherMax group compared to 8.0 in the 'standalone warmer' group. Cost per life-year gained was $8,615 in the TherMax group versus $10,115 in the 'standalone warmer' group for a difference of -$1,501 favoring TherMax. The incremental cost-effectiveness ratio was negative, indicating superior cost-effectiveness for TherMax versus 'standalone warmer'. The TherMax blood warming device used with the PrisMax system is associated with lower risk of hypothermia, which our model indicates leads to lower costs, lower risk of mortality due to hypothermia, and superior cost-effectiveness.

Analysis of acid-base disorders in an ICU cohort using a computer script.

BACKGROUND/AIMS: Acid-base status is important for understanding pathophysiology, making a diagnosis, planning effective treatment and monitoring progress of critically ill patients. Manual calculations are cumbersome, easily result in wrong conclusions. We wanted to develop an automated assessment of acid-base status. METHODS: A simplified adaptive MATLAB script processing all available theory to date was created, evaluated and used on blood gas analyses drawn immediately after admission to ICU. The script was compared to golden standard, calculating manually by two experienced ICU physicians. RESULTS: Results from the script correlated completely with detailed manual calculations of randomly chosen 100 blood gas results and it was able to deliver complex data on cohort level with advanced graphics. The initial blood gas analyses from 8875 admissions constituted the cohort, of which 4111 (46.3%) were normal. Respiratory acidosis was the primary disturbance in 2753 (31.0%) and metabolic acidosis in 464 (5.2%). Respiratory alkalosis was the primary disturbance in 1501 (17.0%) and metabolic alkalosis in 46 (0.5%). Of the disturbances 74.7% were mixed with two and 2.1% with three simultaneous disturbances. Acidoses were less compensated compared to alkaloses. CONCLUSIONS: Acid-base theories are developed on ideal models and not on critical care patients, they require inputs that might not be available, and therefore, estimations are needed. In our cohort, it was difficult to develop a working script based on Stewart, whereas Boston/Copenhagen worked better. Acidoses were more common and more deviated compared to alkaloses.

Screening of the ryanodine 1 gene for malignant hyperthermia causative mutations by high resolution melt curve analysis.

BACKGROUND: A diagnosis of malignant hyperthermia (MH) can be determined by performing an in vitro (muscle) contracture test (IVCT) or by identifying a known MH causative mutation in the ryanodine receptor 1 gene (RYR1). Genetic diagnosis has an advantage over IVCT because it is less invasive. Direct sequencing of the very large RYR1 coding region (15.117 bases) is a laborious and expensive task. In this study, we applied the High Resolution Melting (HRM) curve analysis as a tool to screen the entire coding region of the gene. METHODS: Genomic DNA was extracted from peripheral blood samples in a cohort of 16 MH-susceptible patients diagnosed by the IVCT. The total coding region of RYR1 was divided and amplified by polymerase chain reaction in 131 DNA fragments and the melting profiles were compared with those of control samples. HRM curves were evaluated by Rotor-Gene Q software and visual inspection. Fragments showing aberrant melting profiles were sequenced to identify the underlying sequence variation. RESULTS: A subset of 520 of 2520 DNA fragments (21%) showed significantly aberrant melting profiles. Upon sequencing, 131 known polymorphisms and 17 known or suspected mutations were found in 13 of 16 MH-susceptible patients (81%). Thus, the workload of sequencing was reduced by 79%. CONCLUSION: HRM curve analysis is a sensitive and cost-effective tool for the identification of nucleotide sequence variants in complex genes such as the RYR1 gene.

Mathematical modelling of post-filter ionized calcium during citrate anticoagulated continuous renal replacement therapy.

BACKGROUND/AIMS: Post-filter ionized calcium (iCa) measured on a blood gas analyzer (BGA) during regional citrate anticoagulated continuous renal replacement therapy (CRRT) are needed to control the regime. This increases the workload and requires attention including interpretation of blood analyses. Two algorithms were developed to calculate the post-filter iCa instead. The first algorithm used measured systemic total calcium and the second used a selected set of values from an initial blood gas sample as input. METHODS: Calculated post-filter iCa values were compared to real blood gas analyses. 57 patients treated at the intensive care unit at Skåne University Hospital in Lund during 2010-2017 were included after applying inclusion and exclusion criteria. Clinical and machine parameters were collected from the electronic medical records. Non-quality checked data contained 1240 measurements and quality checked data contained 1034 measurements. RESULTS: The first algorithm using measured systemic total calcium resulted in slightly better precision and trueness with an average difference between the predicted and measured post-filter iCa concentration of 0.0185±0.0453 mmol/L for quality checked data, p<0.001. Neither algorithm could detect all instances requiring intervention. CONCLUSION: The algorithms were able to estimate in range postfilter iCa values with great trueness and precision. However, they had some difficulties to estimate out-of-range postfilter iCa values. More work is needed to improve the algorithms especially in their citrate-modelling.

Functional properties of RYR1 mutations identified in Swedish patients with malignant hyperthermia and central core disease.

BACKGROUND: A diagnosis of malignant hyperthermia susceptibility by in vitro contraction testing can often only be performed at specialized laboratories far away from where patients live. Therefore, we have designed a protocol for genetic screening of the RYR1-cDNA and for functional testing of newly identified ryanodine receptor 1 (RYR1) gene variants in B lymphocytes isolated from peripheral blood samples drawn at local primary care centers. METHODS: B lymphocytes were isolated for the extraction of RYR1-mRNA and genomic DNA and for establishment of lymphoblastoid B cell lines in 5 patients carrying yet unclassified mutations in the RYR1. The B lymphoblastoid cell lines were used to study resting cytoplasmic calcium concentration, the peak calcium transient induced by the sarco(endo)plasmic reticulum Ca-ATPase inhibitor thapsigargin, and the dose-dependent calcium release induced by the ryanodine receptor agonist 4-chloro-m-cresol. RESULTS: It was possible to extract mRNA for cDNA synthesis and to create B lymphocyte clones from all samples. All B lymphoblastoid cell lines carrying RYR1 candidate mutations showed significantly increased resting cytoplasmic calcium levels as well as a shift to lower concentrations of 4-chloro-m-cresol inducing calcium release compared with controls. CONCLUSIONS: Peripheral blood samples are stable regarding RNA and DNA extraction and establishment of lymphoblastoid B cell lines after transportation at ambient temperature over large distances by ordinary mail. Functional tests on B cells harboring the newly identified amino acid substitutions indicate that they alter intracellular Ca2+ homeostasis and are most likely causative of malignant hyperthermia.

Monitoring of low molecular weight heparin anticoagulation during haemodialysis with a Sonoclot Analyzer.

OBJECTIVES: Sonoclot was used in this study to monitor low molecular weight heparin (LMWH) during haemodialysis. MATERIAL AND METHODS: Two different intravenous doses (standard / half-dose) of dalteparin were studied in eight patients. Blood was sampled for coagulation analyses with Sonoclot, thrombin-antithrombin (TAT) and anti-Xa. A visual fibrin deposition score (VFS) in the venous drip chamber was also evaluated. RESULTS: All patients completed their dialysis. There was a progressive increase in TAT levels, which correlated to the dalteparin dose. Significant differences (p<0.05) were found for TAT, VFS and Sonoclot celite-activated clotting time (SonACT) between the different LMWH dosages. TAT and Sonoclot correlated to each other, but not to the VFS. SonACT was significantly increased at two hours, with the high dalteparin dose compared to the lower dose. CONCLUSION: Both Sonoclot and TAT failed to predict the VFS. No patient had any clinical clotting events and all dialyses were completed successfully.

Endotoxin and cytokine reducing properties of the oXiris membrane in patients with septic shock: A randomized crossover double-blind study.

BACKGROUND: Endotoxin induces an inflammatory response, with secondary release of cytokines, which can progress to shock and multiple organ failure. We explored whether continuous renal replacement therapy (CRRT) using a modified membrane (oXiris) capable of adsorption could reduce endotoxin and cytokine levels in septic patients. METHODS: Sixteen patients requiring CRRT for septic shock-associated acute renal failure and who had endotoxin levels >0.03 EU/ml were prospectively randomized in a crossover double-blind design to receive CRRT with an oXiris filter or with a standard filter. Endotoxin and cytokine levels were measured at baseline and 1, 3, 8, 16 and 24 hours after the start of CRRT. Norepinephrine infusion rate and blood lactate levels were monitored. RESULTS: During the first filter treatment period, endotoxin levels decreased in 7 of 9 (77.8%) oXiris filter patients, but in only 1 of 6 (16.7%) standard filter patients (P = 0.02). Levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-8 and interferon (IFN)γ decreased more with the oXiris filter than with the standard filter. Lactate concentration decreased with oXiris (-1.3[-2.2 to -1.1] mmol/l, P = 0.02), but not with the standard filter (+0.15[-0.95 to 0.6]). The norepinephrine infusion rate was reduced during oXiris CRRT, but not during standard filter CRRT. In the second filter treatment period, there was no significant reduction in endotoxin or cytokine levels in either group. CONCLUSIONS: CRRT with the oXiris filter seemed to allow effective removal of endotoxin and TNF-α, IL-6, IL-8 and IFNγ in patients with septic shock-associated acute renal failure. This may be associated with beneficial hemodynamic effects.

Effect of dextran-70 on outcome in severe sepsis; a propensity-score matching study.

BACKGROUND: Albumin may be beneficial in patients with septic shock but availability is limited and cost is high. The objective of the present study was to investigate if the use of dextran-70 in addition to albumin and crystalloids influences organ failure or mortality in patients with severe sepsis or septic shock. METHODS: Patients with severe sepsis or septic shock (n = 778) admitted to a university hospital intensive care unit (ICU) between 2007 and 2015 that received dextran-70 during resuscitation were propensity score matched to controls at a 1 to 1 ratio. Outcomes were highest acute kidney injury network (AKIN) score the first 10 days in the ICU, use of renal replacement therapy, days alive and free of organ support the first 28 days after admission to ICU, mortality and events of severe bleeding. Outcomes were assessed using paired hypothesis testing. RESULTS: Propensity score matching resulted in two groups of patients with 245 patients in each group. The dextran group received a median volume of 1483 ml (interquartile range, 1000-2000 ml) of dextran-70 during the ICU stay. Highest AKIN score did not differ between the control- and dextran groups (1 (0-3) versus 2 (0-3), p = 0.06). Incidence of renal replacement therapy in the control- and dextran groups was similar (19% versus 22%, p = 0.42, absolute risk reduction -2.9% [95% CI: -9.9 to 4.2]). Days alive and free of renal replacement, vasopressors and mechanical ventilation did not differ between the control- and dextran groups. The 180-day mortality was 50.2% in the control group and 41.6% in the dextran group (p = 0.046, absolute risk reduction 8.6% [-0.2 to 17.4]). Fraction of patients experiencing a severe bleeding in the first 10 days in the ICU did not differ between the control and dextran groups (14% versus 18%, p = 0.21). DISCUSSION: There is a paucity of high quality data regarding effects of dextran solutions on outcome in sepsis. In the present study, propensity score matching was used in attempt to reduce bias. CONCLUSION: No evidence to support a detrimental effect of dextran-70 on mortality or on organ failures in patients with severe sepsis or septic shock could be detected.

Phoxilium(®) reduces hypophosphataemia and magnesium supplementation during continuous renal replacement therapy.

BACKGROUND: Although associated with severe clinical complications, phosphate remains a neglected ion. Additionally, phosphate balance during continuous renal replacement therapy (CRRT) is complex and multifunctional. The present retrospective study investigated the effects of phosphate-containing CRRT fluid on phosphate homeostasis. METHODS: We retrospectively analysed 112 patients treated with CRRT at Skåne University Hospital, Sweden. The control group was treated with Hemosol(®) B0 (no phosphate; n = 36) as dialysis and replacement fluid, while the study group received Phoxilium(®) (phosphate; n = 76) as dialysis fluid and Hemosol(®) B0 as replacement fluid. RESULTS: Hypophosphataemia (<0.7 mM) occurred in 15% of the treatment days in the control group compared with 7% in the study group (P = 0.027). Magnesium substitution was reduced by 40% in the study group (P < 0.001). No differences in acid-base parameters were detected between the groups. CONCLUSIONS: In this larger cohort, we could confirm that Phoxilium(®) reduced the episodes of hypophosphataemia during CRRT. A beneficial effect on magnesium balance could also be observed.

Simplified Citrate Anticoagulation for CRRT Without Calcium Replacement.

Since 2012, citrate anticoagulation is the recommended anticoagulation strategy for continuous renal replacement therapy (CRRT). The main drawback using citrate as anticoagulant compared with heparin is the need for calcium replacement and the rigorous control of calcium levels. This study investigated the possibility to achieve anticoagulation while eliminating the need for calcium replacement. This was successfully achieved by including citrate and calcium in all CRRT solutions. Thereby the total calcium concentration was kept constant throughout the extracorporeal circuit, whereas the ionized calcium was kept at low levels enough to avoid clotting. Being a completely new concept, only five patients with acute renal failure were included in a short, prospective, intensely supervised nonrandomized pilot study. Systemic electrolyte levels and acid-base parameters were stable and remained within physiologic levels. Ionized calcium levels declined slightly initially but stabilized at 1.1 mmol/L. Plasma citrate concentrations stabilized at approximately 0.6 mmol/L. All postfilter ionized calcium levels were <0.5 mmol/L, that is, an anticoagulation effect was reached. All filter pressures were normal indicating no clotting problems, and no visible clotting was observed. No calcium replacement was needed. This pilot study suggests that it is possible to perform regional citrate anticoagulation without the need for separate calcium infusion during CRRT.