Effect of low-dose atrial natriuretic peptide in critically ill patients with acute kidney injury: a retrospective, single-center study with propensity-score matching.

BACKGROUND: Acute kidney injury (AKI) is a major comorbidity in critically ill patients. Low-dose atrial natriuretic peptide (ANP) has been shown to effectively prevent acute kidney injury (AKI), especially in cardiovascular surgery patients. However, its treatment effects for AKI in critically ill patients are unclear. METHODS: This single-center, retrospective, observational study included patients with AKI diagnosed within 7 days after intensive care unit (ICU) admission during the period January 2010 to December 2017. We conducted a propensity-matched analysis to estimate the treatment effect of low-dose carperitide (a recombinant human ANP) on the clinical outcomes. The primary outcome was a composite of death, renal replacement therapy dependence, or no recovery from AKI (defined as an increase of the serum creatinine level to ≥200% of baseline) at hospital discharge. RESULTS: During the study period, 4479 adult patients were admitted to the ICU. We identified 1374 eligible patients with AKI diagnosed within 7 days after ICU admission. Among these patients, 346 (25.2%) were treated with low-dose carperitide, with an average dose of 0.019 µg kg- 1 min- 1. The primary outcome occurred more often in the treatment group than in the control group (29.7% versus 23.4%, respectively; p = 0.022). After propensity score matching, characteristics of 314 patients from each group were well- balanced. Significant difference of the primary outcome, as seen with the full cohort, was no longer obtained; no benefit of carperitide was detected in the matched cohort (29.0% versus 25.2%; p = 0.281). CONCLUSIONS: Low-dose ANP showed no treatment effect in general critically ill patients who developed AKI.

Predictors for sustained new-onset atrial fibrillation in critically ill patients: a retrospective observational study.

PURPOSE: Although new-onset atrial fibrillation (AF) is frequently observed in the intensive care unit (ICU), the incidence and predictors for sustained new-onset AF have not been investigated, except for cardiac surgery patients. We have evaluated potential predictors for sustained new-onset AF in a mixed ICU. METHODS: In this retrospective observational study, we screened non-cardiac surgery patients who were admitted to the ICU between January 2010 and December 2013 and had been hospitalized for > 24 h in the ICU. We collected information about heart rhythm 6 h after the onset of AF. We compared detailed patient characteristics between patients with sinus rhythm (SR) and those with sustained AF at 6 h after the onset of AF. Additionally, we applied variable selection using backward elimination based on Akaike's Information Criterion (AIC). Calibration was performed based on the Hosmer-Lemeshow test. RESULTS: New-onset AF occurred in 151 of 1718 patients and 99 patients converted to SR at 6 h. Backward elimination identified predictors as follows (AIC = 175.3): CHADS2 score, elective surgery, infection on ICU admission, serum potassium > 4.0 mmol/L, male sex, mechanical ventilation, and diagnostic grouping. The model showed good calibration for sustenance of AF at 6 h after the onset using the Hosmer-Lemeshow Chi-square value of 4.36 (degrees of freedom = 4, p = 0.360) indicating a good fit. CONCLUSIONS: These predictors might be useful in future interventional studies to identify patients who are likely to sustain new-onset AF.

Association Between Intraoperative Oliguria and Acute Kidney Injury After Major Noncardiac Surgery.

BACKGROUND: Acute kidney injury (AKI) occurs in 6.1%-22.4% of patients undergoing major noncardiac surgery. Previous studies have shown no association between intraoperative urine output and postoperative acute renal failure. However, these studies used various definitions of acute renal failure. We therefore investigated the association between intraoperative oliguria and postoperative AKI defined by the serum creatinine criteria of the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) classification. METHODS: In this single-center, retrospective, observational study, we screened 26,984 patients undergoing elective or emergency surgery during the period September 1, 2008 to October 31, 2011 at a university hospital. Exclusion criteria were age <18 years; duration of anesthesia <120 minutes; hospital stay <2 nights; local anesthesia only; urologic or cardiac surgery; coexisting end-stage kidney disease; and absence of serum creatinine measurement, intraoperative urine output data, or information regarding intraoperative drug use. Multivariable logistic regression analysis was used as the primary analytic method. RESULTS: A total of 5894 patients were analyzed. The incidence of postoperative AKI was 7.3%. By multivariable analysis, ≥120 minutes of oliguria (odds ratio = 2.104, 95% CI, 1.593-2.778; P < .001) was independently associated with the development of postoperative AKI. After propensity-score matching of patients with ≥120 and <120 minutes of oliguria on baseline characteristics, the incidence of AKI in patients with ≥120 minutes of oliguria (n = 827; 10%) was significantly greater than that in those with <120 minutes of oliguria (n = 827; 4.8%; odds ratio = 2.195, 95% CI, 1.806-2.668; P < .001). CONCLUSIONS: Contrary to previous studies, we found that intraoperative oliguria is associated with the incidence of AKI after major noncardiac surgery.

The incidence and outcome of hyperlactatemia in patients admitted to the intensive care unit after elective surgery.

BACKGROUND: Although hyperlactatemia is often developed in critically ill patients, it is unclear whether hyperlactatemia is associated with poor prognosis for surgical ICU (SICU) patients. METHODS: We performed a retrospective analysis in an academic hospital in Tokyo. The maximum lactate was defined as the highest value within the SICU stay. The primary outcome was the composite outcome of in-hospital mortality, re-admission to the SICU or admission to the general ICU and emergency reoperation. RESULTS: There were 3421 patients with normal lactate (<2 mmoL/L), 1642 with moderate hyperlactatemia (2-3.9 mmoL/L) and 299 with severe hyperlactatemia (≥4 mmoL/L). The composite outcome occurred in 6.2%. In multivariable logistic regression analysis, the odds ratio for the composite outcome was 1.49 for moderate hyperlactatemia and 1.42 for severe hyperlactatemia. CONCLUSIONS: The odds ratio was similar between moderate and severe hyperlactatemia, so the cause and meaning of hyperlactatemia might be different among patients with elective surgery.

The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study.

PURPOSE: The purpose of the study is to evaluate the impact of sustained new-onset AF on mortality and the incidence of stroke in critically ill non-cardiac surgery patients. MATERIAL AND METHODS: This was a retrospective cohort study of non-cardiac surgery patients with new-onset AF conducted in a general intensive care unit. We compared patients remaining in AF with those restored to sinus rhythm (SR) at 6h after the onset of AF and conducted multivariable logistic regression analysis for in-hospital mortality. We also examined the impact of the cumulative time of AF duration in the first 48h on hospital outcomes. RESULTS: New-onset AF occurred in 151 of 1718 patients (9%). Patients with sustained AF after 6h (34% of 151 patients included) experienced greater in-hospital mortality than patients with SR at 6h (37% vs. 20%, p=0.033). Multivariable logistic regression analysis confirmed the association between AF at 6h and in-hospital mortality (adjusted odds ratio, 3.14; 95% confidence intervals, 1.28-7.69; p=0.012). Patients with longer AF duration had greater in-hospital mortality (p=0.043) and in-hospital ischemic stroke incidence (p=0.041). CONCLUSION: Sustained new-onset AF is associated with poor outcomes.

Intraoperative hydroxyethyl starch 70/0.5 administration may increase postoperative bleeding: a retrospective cohort study.

PURPOSE: Studies evaluating the safety of hydroxyethyl starch with a molecular weight of 70 kDa and a molar substitution ratio of 0.5 (HES 70/0.5) are scarce in the literature. In this study, we investigated the relationship between intraoperative HES 70/0.5 administration and postoperative bleeding. METHODS: This is a single-center, retrospective cohort study. Subjects were postoperative adult patients who stayed in the intensive care unit (ICU) for more than 24 h during the period from January 1, 2010 to December 31, 2012. We compared postoperative adult patients with and without intraoperative HES 70/0.5 administration. The primary outcome was the drainage volume from surgical sites during the first 24 h after ICU admission. We conducted propensity score matching between the control group and the HES group. RESULTS: We analyzed data for 769 patients who met our inclusion criteria. Using propensity score matching, we successfully created 119 matched pairs from the HES group and control group, with no significant differences in patient characteristics. The drainage volume during the first 24 h after ICU admission was greater in the HES group than in the control group (400 ± 479 vs. 260 ± 357 mL, p < 0.003). CONCLUSION: Our retrospective cohort study suggests that intraoperative HES 70/0.5 administration is associated with increased postoperative bleeding.

Postoperative blood pressure deficit and acute kidney injury progression in vasopressor-dependent cardiovascular surgery patients.

BACKGROUND: In vasopressor-dependent patients who had undergone cardiovascular surgery, we examined whether those with progression of acute kidney injury (AKI) had a greater difference (deficit) between premorbid and within-ICU hemodynamic pressure-related parameters compared to those without AKI progression. METHODS: We assessed consecutive adults who underwent cardiovascular surgery and who stayed in our ICU for at least 48 hours and received vasopressor support for more than 4 hours. We obtained premorbid and vasopressor-associated, time-weighted average values for hemodynamic pressure-related parameters (systolic [SAP], diastolic [DAP], and mean arterial pressure [MAP]; central venous pressure [CVP], mean perfusion pressure [MPP], and diastolic perfusion pressure [DPP]) and calculated deficits in those values. We defined AKI progression as an increase of at least one Kidney Disease: Improving Global Outcomes stage. RESULTS: We screened 159 patients who satisfied the inclusion criteria and identified 76 eligible patients. Thirty-six patients (47%) had AKI progression. All achieved pressure-related values were similar between patients with or without AKI progression. However, deficits in DAP (P = 0.027), MPP (P = 0.023), and DPP (P = 0.002) were significantly greater in patients with AKI progression. CONCLUSIONS: Patients with AKI progression had greater DAP, MPP, and DPP deficits compared to patients without AKI progression. Such deficits might be modifiable risk factors for the prevention of AKI progression.

Intraoperative hydroxyethyl starch 70/0.5 is not related to acute kidney injury in surgical patients: retrospective cohort study.

BACKGROUND: Although high-molecular-weight hydroxyethyl starch (HES) has been reported to cause acute kidney injury (AKI), it is not clear whether low-molecular-weight HES (6% HES 70/0.5) can be a risk for AKI or not. We hypothesized that intraoperative 6% HES 70/0.5 administration is not related to postoperative AKI. METHODS: A retrospective chart review was conducted to identify adult surgical patients with intraoperative blood loss of ≥1000 mL at a university hospital. AKI was defined as >50% increase in serum creatinine from the preoperative value within 7 days after the operation according to the RIFLE (Risk, Injury, Failure, Loss, or End-stage kidney disease) criteria. We compared the incidence of AKI between patients with and without intraoperative HES administration. Multivariate logistic regression analysis and propensity score matching were also conducted to elucidate the impact of HES on postoperative AKI. RESULTS: Among 14,332 surgical cases, 846 patients met the inclusion criteria. In patients given HES (a median dose of 1000 mL, n = 635), 12.9% developed AKI, compared with 16.6% (-3.7%, -1.7% to 9.1%) in patients without HES (n = 211). Multivariate logistic regression analysis showed that HES was not an independent risk factor for postoperative AKI (odds ratio: 0.76, 0.48-1.21). Using the propensity score, 179 pairs were matched. In patients with HES, 12.3% developed AKI, compared with 14.5% in patients without HES (-2.2%, -4.9% to 9.3%). CONCLUSION: In this uncontrolled retrospective chart review, intraoperative 6% HES 70/0.5 in a low dose was not related to postoperative AKI in patients with major intraoperative blood loss. Randomized controlled trials are warranted to further evaluate the safety and efficacy of low-molecular-weight HES.

Prospective external validation of the new scoring system for disseminated intravascular coagulation by Japanese Association for Acute Medicine (JAAM).

INTRODUCTION: A new disseminated intravascular coagulation (DIC) scoring system was recently announced by Japanese Association for Acute Medicine (JAAM). We have conducted a prospective external validation study to assess the accuracy of this scoring system. MATERIALS AND METHODS: All patients admitted to the ICU in a tertiary academic hospital in 2007 were prospectively observed. All patients younger than 15 years of age, those who stayed in the ICU for less than 24 hours, had cardiac surgery, hematological diseases, recent chemotherapy or radiotherapy or liver cirrhosis were excluded. The remaining patients were then screened using the JAAM DIC scoring system. RESULTS: DIC was diagnosed by the JAAM DIC scoring system in 45 of the 242 patients screened (18.6%). The DIC patients were older, had a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and stayed in the ICU longer in comparison to the non-DIC patients. However, hospital mortality was similar between the two groups (p=0.98). There was no difference in the JAAM DIC score between the surviving and non-surviving DIC patients (p=0.40). A multivariate logistic regression analysis revealed the DIC diagnosed by JAAM to have a non-significant low odds ratio for hospital mortality (OR 0.29, 95%CI 0.08-1.08, p=0.066). CONCLUSION: We have reported an external validation study of the JAAM DIC scoring system, which was conducted outside of the centers where data for developing the score were collected. DIC diagnosed by this scoring system was not related to hospital mortality.

[One-lung anesthesia was successfully maintained by means of Fogarty Catheter in infants].

We experienced one-lung anesthesia using Fogarty catheter as a selective bronchial blocker in two infants. First case was a one-year and ten month-old female who underwent partial resection of the right middle lobe for her giant lung cyst under general anesthesia. Second case was an eight-month-old male who underwent thoracoscopic resection of his left mediastinal tumor under general anesthesia. One-lung anesthesia was successfully established with Fogarty catheters for both cases. Size of the catheter and its balloon was decided beforehand by measuring the diameter and length of the trachea and both bronchi based on the image obtained from computerized tomography (CT) in both cases. Therefore, surgical field was well visible during operation. There was no accidental episode in perioperative period. Bronchoscopy with ultra-thin fiberscope and X-ray fluoroscopy is useful to decide the position of Fogarty catheter and its balloon. Our means is recommendable for maintenance of one-lung anesthesia in infant.