Epidemiology, microbiology, and diagnosis of infection in diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: A multicenter retrospective observational study.

AIMS: We investigated the characteristics of infection and the utility of inflammatory markers in diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS). METHODS: A multicenter, retrospective observational study in 21 acute-care hospitals was conducted in Japan. This study included adult hospitalized patients with DKA and HHS. We analyzed the diagnostic accuracy of markers including C-reactive protein (CRP) and procalcitonin (PCT) for bacteremia. Multiple regression models were created for estimating bacteremia risk factors. RESULTS: A total of 771 patients, including 545 patients with DKA and 226 patients with HHS, were analyzed. The mean age was 58.2 (SD, 19.3) years. Of these, 70 tested positive for blood culture. The mortality rates of those with and without bacteremia were 14 % and 3.3 % (P-value < 0.001). The area under the curve (AUC) of CRP and PCT for diagnosis of bacteremia was 0.85 (95 %CI, 0.81-0.89) and 0.76 (95 %CI, 0.60-0.92), respectively. Logistic regression models identified older age, altered level of consciousness, hypotension, and higher CRP as risk factors for bacteremia. CONCLUSIONS: The mortality rate was higher in patients with bacteremia than patients without it. CRP, rather than PCT, may be valid for diagnosing bacteremia in hyperglycemic emergencies. TRIAL REGISTRATION: This study is registered in the UMIN clinical trial registration system (UMIN000025393, Registered December 23, 2016).

Characteristics of pulmonary artery catheter use in multicenter ICUs in Japan and the association with mortality: a multicenter cohort study using the Japanese Intensive care PAtient Database.

BACKGROUND: It has been 50 years since the pulmonary artery catheter was introduced, but the actual use of pulmonary artery catheters in recent years is unknown. Some randomized controlled trials have reported no causality with mortality, but some observational studies have been published showing an association with mortality for patients with cardiogenic shock, and the association with a pulmonary artery catheter and mortality is unknown. The aim of this study was to investigate the utilization of pulmonary artery catheters (PACs) in the intensive care unit (ICU) and to examine their association with mortality, taking into account differences between hospitals. METHODS: This is a retrospective analysis using the Japanese Intensive care PAtient Database, a multicenter, prospective, observational registry in Japanese ICUs. We included patients aged 16 years or older who were admitted to the ICU for reasons other than procedures. We excluded patients who were discharged within 24 h or had missing values. We compared the prognosis of patients with and without PAC. The primary outcome was hospital mortality. We performed propensity score analysis to adjust for baseline characteristics and hospital characteristics. RESULTS: Among 184,705 patients in this registry from April 2015 to December 2020, 59,922 patients were included in the analysis. Most patients (94.0%) with a PAC in place had cardiovascular disease. There was a wide variation in the frequency of PAC use between hospitals, from 0 to 60.3% (median 14.4%, interquartile range 2.2-28.6%). Hospital mortality was not significantly different between the PAC use group and the non-PAC use group in patients after adjustment for propensity score analysis (3.9% vs 4.3%; difference, - 0.4%; 95% CI - 1.1 to 0.3; p = 0.32). Among patients with cardiac disease, those with post-open-heart surgery and those in shock, hospital mortality was also not significantly different between the two groups (3.4% vs 3.7%, p = 0.45, 1.7% vs 1.7%, p = 0.93, 4.8% vs 4.9%, p = 0.87). CONCLUSIONS: The frequency of PAC use varied among hospitals. PAC use for ICU patients was not associated with lower hospital mortality after adjusting for differences between hospitals.

Dopamine use and its consequences in the intensive care unit: a cohort study utilizing the Japanese Intensive care PAtient Database.

BACKGROUND: Dopamine is used to treat patients with shock in intensive care units (ICU) throughout the world, despite recent evidence against its use. The aim of this study was to identify the latest practice of dopamine use in Japan and also to explore the consequences of dopamine use in a large Asian population. METHODS: The Japanese Intensive Care PAtient Database (JIPAD), the largest intensive care database in Japan, was utilized. Inclusion criteria included: 1) age 18 years or older, 2) admitted to the ICU for reasons other than procedures, 3) ICU length of stay of 24 h or more, and 4) treatment with either dopamine or noradrenaline within 24 h of admission. The primary outcome was in-hospital mortality. Multivariable regression analysis was performed, followed by a propensity score-matched analysis. RESULTS: Of the 132,354 case records, 14,594 records from 56 facilities were included in this analysis. Dopamine was administered to 4,653 patients and noradrenaline to 11,844. There was no statistically significant difference in facility characteristics between frequent dopamine users (N = 28) and infrequent users (N = 28). Patients receiving dopamine had more cardiovascular diagnosis codes (70% vs. 42%; p < 0.01), more post-elective surgery status (60% vs. 31%), and lower APACHE III scores compared to patients given noradrenaline alone (70.7 vs. 83.0; p < 0.01). Multivariable analysis showed an odds ratio for in-hospital mortality of 0.86 [95% CI: 0.71-1.04] in the dopamine ≤ 5 µg/kg/min group, 1.46 [95% CI: 1.18-1.82] in the 5-15 µg/kg/min group, and 3.30 [95% CI: 1.19-9.19] in the > 15 µg/kg/min group. In a 1:1 propensity score matching for dopamine use as a vasopressor (570 pairs), both in-hospital mortality and ICU mortality were significantly higher in the dopamine group compared to no dopamine group (22.5% vs. 17.4%, p = 0.038; 13.3% vs. 8.8%, p = 0.018), as well as ICU length of stay (mean 9.3 days vs. 7.4 days, p = 0.004). CONCLUSION: Dopamine is still widely used in Japan. The results of this study suggest detrimental effects of dopamine use specifically at a high dose. Trial registration Retrospectively registered upon approval of the Institutional Review Board and the administration office of JIPAD.

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.

The Japanese Intensive care PAtient Database (JIPAD): A national intensive care unit registry in Japan.

PURPOSE: The Japanese Intensive care PAtient Database (JIPAD) was established to construct a high-quality Japanese intensive care unit (ICU) database. MATERIALS AND METHODS: A data collection structure for consecutive ICU admissions in adults (≥16 years) and children (≤15 years) has been established in Japan since 2014. We herein report a current summary of the data in JIPAD for admissions between April 2015 and March 2017. RESULTS: There were 21,617 ICU admissions from 21 ICUs (217 beds) including 8416 (38.9%) for postoperative or procedural monitoring, defined as adult admissions following elective surgery or for procedures and discharged alive within 24 h, 11,755 (54.4%) critically ill adults other than monitoring, and 1446 (6.7%) children. The standardized mortality ratios (SMRs) based on the Acute Physiology and Chronic Health Evaluation (APACHE) III-j, APACHE II, and Simplified Acute Physiology Score II scores in adults ranged from 0.387 to 0.534, whereas the SMR based on the Paediatric Index of Mortality 2 in children was 0.867. CONCLUSION: The data revealed that the SMRs based on general severity scores in adults were low because of high proportions of elective and monitoring admission. The development of a new mortality prediction model for Japanese ICU patients is needed.

Human atrial natriuretic peptide for acute kidney injury in adult critically ill patients: A multicenter prospective observational study.

PURPOSE: Acute kidney injury (AKI) is common in the intensive care unit (ICU). Selected clinical studies have implied human atrial natriuretic peptide (hANP) improves renal function; however, the treatment effects for AKI are unclear. METHODS: A multicenter prospective observational study in 13 Japanese ICUs. The effects of hANP were estimated by the standardized mortality ratio weighted analyses of generalized linear models using propensity scores. The primary outcome was renal replacement therapy (RRT) or death in the ICU. RESULTS: Of 904 patients with AKI, 63 received hANP as a treatment for AKI. The primary outcome occurred in 20.5% (185/904). HANP did not reduce the risk of RRT or death in the ICU (risk ratio 1.12, 95% confidence interval [CI] 0.74 to 1.69) and was associated with a lower mean arterial pressure (ß -3.8 mmHg, 95%CI -7.6 to -0.1), a longer hospital length of stay (ß 12.0 days, 95%CI 1.2 to 22.8) and a lower eGFR at hospital discharge (ß -10.4 mL/min/m2, 95%CI -19.1 to -1.7). No beneficial effect was observed in subgroups of cardiovascular surgery, sepsis, nor chronic kidney disease. CONCLUSIONS: In critically ill patients with AKI, the treatment effect of hANP was not evident on dialysis-free survival in the ICU.

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.

Creatinine.

PURPOSE OF REVIEW: To summarize the history and current findings for creatinine as a renal biomarker and try to predict its future, looking at new biomarkers for kidneys (neutrophil gelatinase-associated lipocalin and cystatin C) and comparing current development to other diseases (troponins and procalcitonin). RECENT FINDINGS: In general, biomarkers are used for diagnosis, severity classification, outcome prediction, and most importantly, outcome modification. Creatinine can be used for the first three (except for outcome modification). Multiple clinical studies have shown that new renal biomarkers, especially neutrophil gelatinase-associated lipocalin and cystatin C, can diagnose acute kidney injury more rapidly and accurately, have a better relationship with disease severity, and predict outcome of patients with acute kidney injury more accurately, than creatinine. However, to prove the true superiority of the new renal biomarkers to creatinine, more clinical studies will be required. Such studies include interventional ones that can improve outcome (especially mortality) of patients with acute kidney injury and ones showing relationship of the markers with beneficial effects of specific interventions. SUMMARY: Unless enough evidence accumulates, considering the history, familiarity, and recent findings related to outcome, creatinine will continue to be used and dominate in clinical practice.

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.

Diuretics and mortality in acute renal failure.

OBJECTIVE: According to recent research, diuretics may increase mortality in acute renal failure patients. The administration of diuretics in such patients has been discouraged. Our objective was to determine the impact of diuretics on the mortality rate of critically ill patients with acute renal failure. DESIGN: Prospective, multiple-center, multinational epidemiologic study. SETTING: Intensive care units from 54 centers and 23 countries. PATIENTS: Patients were 1,743 consecutive patients who either were treated with renal replacement therapy or fulfilled predefined criteria for acute renal failure. INTERVENTIONS: Three distinct multivariate models were developed to assess the relationship between diuretic use and subsequent mortality: a) a propensity score adjusted multivariate model containing terms previously identified to be important predictors of outcome; b) a new propensity score adjusted multivariate model; and c) a multivariate model developed using standard methods, compensating for collinearity. MEASUREMENTS AND MAIN RESULTS: Approximately 70% of patients were treated with diuretics at study inclusion. Mean age was 68 and mean Simplified Acute Physiology Score II was 47. Severe sepsis/septic shock (43.8%), major surgery (39.1), low cardiac output (29.7), and hypovolemia (28.2%) were the most common conditions associated with the development of acute renal failure. Furosemide was the most common diuretic used (98.3%). Combination therapy was used in 98 patients only. In all three models, diuretic use was not associated with a significantly increased risk of mortality. CONCLUSIONS: Diuretics are commonly prescribed in critically ill patients with acute renal failure, and their use is not associated with higher mortality. There is full equipoise for a randomized controlled trial of diuretics in critically ill patients with renal dysfunction.

Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates.

OBJECTIVE: To determine whether the introduction of an intensive care unit-based medical emergency team, responding to hospital-wide preset criteria of physiologic instability, would decrease the rate of predefined adverse outcomes in patients having major surgery. DESIGN: Prospective, controlled before-and-after trial. SETTING: University-affiliated hospital. PATIENTS: Consecutive patients admitted to hospital for major surgery during a 4-month control phase and during a 4-month intervention phase. INTERVENTIONS: Introduction of a hospital-wide intensive care unit-based medical emergency team to evaluate and treat in-patients deemed at risk of developing an adverse outcome by nursing, paramedical, and/or medical staff. MEASUREMENTS AND MAIN RESULTS: We measured incidence of serious adverse events, mortality after major surgery, and mean duration of hospital stay. There were 1,369 operations in 1,116 patients during the control period and 1,313 in 1,067 patients during the medical emergency team intervention period. In the control period, there were 336 adverse outcomes in 190 patients (301 outcomes/1,000 surgical admissions), which decreased to 136 in 105 patients (127 outcomes/1,000 surgical admissions) during the intervention period (relative risk reduction, 57.8%; p <.0001). These changes were due to significant decreases in the number of cases of respiratory failure (relative risk reduction, 79.1%; p <.0001), stroke (relative risk reduction, 78.2%; p =.0026), severe sepsis (relative risk reduction, 74.3%; p =.0044), and acute renal failure requiring renal replacement therapy (relative risk reduction, 88.5%; p <.0001). Emergency intensive care unit admissions were also reduced (relative risk reduction, 44.4%; p =.001). The introduction of the medical emergency team was also associated with a significant decrease in the number of postoperative deaths (relative risk reduction, 36.6%; p =.0178). Duration of hospital stay after major surgery decreased from a mean of 23.8 days to 19.8 days (p =.0092). CONCLUSIONS: The introduction of an intensive care unit-based medical emergency team in a teaching hospital was associated with a reduced incidence of postoperative adverse outcomes, postoperative mortality rate, and mean duration of hospital stay.

Norepinephrine for hypotensive vasodilatation after cardiac surgery: impact on renal function.

OBJECTIVES: Norepinephrine use in patients after cardiac surgery is controversial because of the fear that norepinephrine might decrease kidney function through regional vasoconstriction. Accordingly, we studied the renal effects of norepinephrine use for hypotensive vasodilatation after cardiac surgery. DESIGN AND SETTING: Retrospective controlled study in the cardiothoracic ICU of tertiary hospital. PATIENTS. 100 cardiac surgery patients with post-operative hypotensive vasodilatation and 100 control cardiac surgery patients. INTERVENTION: Treatment of hypotension (MAP<70 mmHg) with continuous norepinephrine infusion. MEASUREMENTS AND RESULTS: We collected data on demographic and surgical characteristics, haemodynamics, serum creatinine and mortality. Just after surgery the norepinephrine group had a significantly higher mean central venous pressure, lower mean arterial pressure, and lower systemic vascular resistance index with a similarly elevated mean cardiac index. Despite norepinephrine administration at a mean peak dose of 7.3+/-6.4 micro g/min the mean post-operative change in creatinine was not different between two groups on days 0, 2 or 4 after surgery. CONCLUSIONS: Norepinephrine does not increase post-operative serum creatinine concentrations in patients with hypotensive vasodilatation after cardiac surgery. Concerns related to its potential adverse effects on the kidney function in this setting appear unjustified.

On-pump coronary artery surgery versus off-pump exclusive arterial coronary grafting: a matched cohort comparison.

BACKGROUND: It is unknown whether coronary artery bypass grafting without cardiopulmonary bypass and with exclusive use of arterial grafts (arterial off-pump CABG) offers any significant short-term advantages over standard CABG with cardiopulmonary bypass. Accordingly, we performed a comparison of the short-term outcomes of arterial off-pump and standard CABG patients matched for preoperative risk and number of grafts. METHODS: We studied 90 consecutive arterial off-pump CABG patients during a 2-year period, obtained demographic and clinical features and surgical characteristics, and calculated their predicted surgical risk (EuroSCORE). Using a database of 750 contemporaneous patients treated with standard CABG, we created a matched cohort of 90 patients using an iterative process prioritizing number of grafts, target vessels, EuroSCORE, age, and sex. We compared the two groups for baseline features and short-term clinical outcomes. RESULTS: There were no differences in age (65.9 versus 64.7 years), sex, EuroSCORE (3.3 versus 3. 6), number of grafts (2.1 versus 2.1), and preoperative left ventricular function. Arterial off-pump CABG, however, was associated with decreased duration of operation (213 versus 252 minutes; p < 0.0013), decreased peak postoperative troponin I levels (mean, 10.8 versus 29.1 ng/mL; p < 0.0001), decreased peak norepinephrine dose (2.3 versus 4.1 microg/ min; p < 0.0082), and decreased likelihood of receiving red blood cell transfusion (17.8% versus 40%; p = 0.0016). There were no differences in duration of intensive care unit or hospital stay, incidence of atrial fibrillation, or other clinical complications. There was one death in each group. CONCLUSIONS: After matching for number of grafts and other important preoperative risk markers, arterial off-pump CABG still decreases the need for red blood cell transfusion and offers other moderate clinical advantages compared with standard on-pump CABG.

Cytokine dialysis: an ex vivo study.

To test the hypothesis that dialysis using a new large pore membrane would achieve effective cytokine removal, blood from six volunteers was incubated with endotoxin (1 mg) and then circulated through a closed circuit with a polyamide membrane (nominal cut-off: 100 kDa). Hemodialysis was conducted at 1 or 9 L/hr of dialysate flow at the start of circulation and after 2 and 4 hours. The peak dialysate/plasma concentration ratios were 0.92 for interleukin (IL)-1beta, 0.67 for IL-6, 0.94 for IL-8, 0.33 for tumor necrosis factor (TNF)-a, and 0.11 for albumin. The dialysate/plasma ratios for all cytokines and albumin were decreased with increased dialysate flow from 1 to 9 L/hr (p < 0.05). Clearances for IL-1beta, IL-6, and IL-8, however, were significantly improved with increased dialysate flow (p < 0.01). There was no increase in TNF-a clearance (not significant) and a decrease in albumin clearance (p < 0.01). The peak clearance at 9 L/hr was 33 ml/min for IL-1beta, 19 for IL-6, 51 for IL-8, 11 for TNF-alpha, and 1.2 for albumin. No adsorption of cytokines was observed. We conclude that cytokine dialysis is achievable through a membrane with a high cut-off point with negligible albumin loss. These findings support the technical feasibility of this new approach to blood purification in sepsis.