Severe Acute Kidney Injury Postheart Transplantation: Analysis of Risk Factors.

Background: Acute kidney injury (AKI) is a common complication postheart transplantation and is associated with significant morbidity and increased mortality. Methods: We conducted a single-center, retrospective, observational cohort study of 109 consecutive patients undergoing heart transplantation between September 2019 and September 2021 to determine major risk factors for, and the incidence of, severe postoperative AKI as defined by Kidney Disease Improving Global Outcomes criteria in the first 48-h posttransplantation and the impact that this has on mortality and dialysis dependence. Results: One hundred nine patients were included in our study, 83 of 109 (78%) patients developed AKI, 42 (39%) developed severe AKI, and 37 (35%) required renal replacement therapy in the first-week posttransplantation. We found preoperative estimated glomerular filtration rate (eGFR), postoperative noradrenaline dose, and the need for postoperative mechanical circulatory support to be independent risk factors for the development of severe AKI. Patients who developed severe AKI had a 19% 12-mo mortality compared with 1% for those without. Of those who survived to hospital discharge, 20% of patients in the severe AKI group required dialysis at time of hospital discharge compared with 3% in those without severe AKI. Conclusion: Severe AKI is common after heart transplantation. Preoperative kidney function, postoperative vasoplegia with high requirements for vasoactive drugs, and graft dysfunction with the need for mechanical circulatory supports were independently associated with the development of severe AKI in the first-week following heart transplantation. Severe AKI is associated with a significantly increased mortality and dialysis dependence at time of hospital discharge.

Severe disseminated primary varicella in a patient on long term inhaled corticosteroids.

Disseminated primary varicella infection can carry risks of significant morbidity and mortality particularly in immunocompromised populations. Routine, funded childhood vaccination against varicella has significantly reduced associated hospitalization and deaths, however, uptake and efficacy among adults is unknown. We present a case of disseminated primary varicella infection (including rash, pneumonitis, hepatitis and thrombocytopenia) in an immunocompetent patient on long term inhaled corticosteroids for asthma. This case highlights potential risk factors for severe varicella which require further study in adults and raises the need to discuss vaccination in at risk groups including appropriate counselling in those who may be at higher risk.

Nosocomial infections acquired by patients treated with extracorporeal membrane oxygenation.

BACKGROUND: Infectious complications in patients treated with extracorporeal membrane oxygenation (ECMO) are a frequent contributor to morbidity and mortality in this group. Defining the characteristics of ECMO-related infections may inform treatment decisions, including antimicrobial therapy. METHODS: A retrospective observational study in an Australian intensive care unit, including adult patients treated with ECMO for at least 48 hours, over a 3-year period. Medical records were analysed for evidence of bloodstream infections (BSIs) and wound infections (WIs) at the ECMO cannulation site or the sternum. Demographic, ECMO-related and clinical data were collected, including inpatient antibiotic usage. RESULTS: We included 98 patients in the study. The median age was 50 years (IQR, 39-57 years). The median duration of ECMO treatment was 6.6 days (IQR, 4.0-12.8 days). Twenty-four infections were diagnosed in 21 patients; eight patients were diagnosed with BSIs on ECMO, 14 developed cannulation-site WIs, and two patients developed sternal wound infections. On multivariate analysis, we found that factors that increased infection risk included immunosuppression (OR, 2.9; P = 0.04) and treatment with venoarterial (VA) ECMO (OR, 14.7; P = 0.01). Infected patients had a significantly longer duration of hospital admission than patients without BSI or WI (55 days v 30 days; P = 0.03). Prior antibiotic use did not appear to be protective against subsequent infection. CONCLUSIONS: Infectious complications are common in ECMO patients and are associated with longer durations of hospital admission. Isolated pathogens were predominantly hospital-acquired Gram-negative bacteria and yeasts. Immunosuppression and treatment with VA ECMO were found to be specific risk factors for infection.

A case of bilateral adrenal haemorrhage following traumatic brain injury.

We report the case of a 57-year-old man who sustained an isolated severe traumatic brain injury (TBI). During his admission to the intensive care unit (ICU), he developed marked arterial hypotension of unclear cause. Eventually, the presence of renal angle tenderness on clinical examination and a low random-cortisol level lead to the suspicion of primary adrenal insufficiency. A computed tomography scan of his abdomen demonstrated new bilateral adrenal haemorrhages. This diagnosis is not unlikely to be missed, as symptoms and laboratory tests are often nonspecific.

Lack of association between body weight and mortality in patients on veno-venous extracorporeal membrane oxygenation.

PURPOSE: To analyse the association of body weight with hospital mortality of adult patients supported with veno-venous extracorporeal membrane oxygenation (VV ECMO). METHODS: Retrospective analysis of the international Extracorporeal Life Support Organization (ELSO) registry. Univariate and multivariable logistic regression analyses were used to estimate the odds ratio (OR) of hospital death for each body weight quartile. Adjustment was made for demographic, physiologic and ECMO-related characteristics. We undertook a similar analysis for the subgroup of patients with confirmed H1N1 infection on VV ECMO. RESULTS: The study group consisted of 1,334 adult patients supported with VV ECMO between 2005 and 2011 with a median (Q1, Q3) body weight of 80 kg (69, 101 kg). Univariate analysis identified increased body weight to be associated with a reduced risk of death. In multivariable analysis, only age greater than 53 years, primary diagnosis other than pneumonia and intubation time longer than 3 days prior to initiation of ECMO were independent risk factors for mortality, whereas the association between high body weight and adjusted risk of death (OR 0.73, 95% CI 0.52-1.04, P = 0.08) was no longer statistically significant. The body weight of the 196 patients with confirmed H1N1 infection was significantly higher than that of the remaining study group. Body weight was not significantly associated with risk of death for these patients either (univariate OR for Q4 vs. Q1: 0.75, 95% CI 0.33-1.72, P = 0.49). CONCLUSIONS: Increased body weight was not a risk factor for hospital mortality in adult patients who required support with VV ECMO. High body weight should therefore not be regarded as a contraindication to initiation of VV ECMO in adult patients. Data collection and reporting that include patient height in addition to body weight would facilitate future research into the association of obesity with outcome of ECMO patients.

Sedation practice in veno-venous extracorporeal membrane oxygenation: an international survey.

Sedation practice in extracorporeal membrane oxygenation (ECMO) is challenging, and some studies suggest that pharmacokinetics of sedative drugs are altered by the circuitry components. We conducted an international survey of sedation practice in centers offering veno-venous ECMO for adult patients in collaboration with the Extracorporeal Life Support Organization. A total 102 respondents participated representing various experienced centers from around the world. Fifty-eight percent responded that patients on ECMO have a higher or much higher sedation requirement than other critically ill patients, whilst 51% achieved a responsive or cooperative level of sedation. Midazolam (79%), morphine (43%) and fentanyl (45%) were most frequently used. Alpha-2 agonists were prescribed in 66% while propofol was used infrequently (36%). Thirty-five percent did not use continuous muscle relaxants. Responses from experienced users differed to those who reported less experience. Sedation practice in ECMO varies widely. Cooperative or responsive levels of sedation can frequently be achieved, and the drugs used differ from those used in non-ECMO patients.