Obesity, acute kidney injury and mortality in patients with sepsis: a cohort analysis.

Although the prognostic effect of obesity has been studied in critically ill patients its impact on outcomes of septic patients and its role as a risk factor for acute kidney injury (AKI) is not consensual. We aimed to analyze the impact of obesity on the occurrence of AKI and on in-hospital mortality in a cohort of critically ill septic patients. This study is retrospective including 456 adult patients with sepsis admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Obesity was defined as a body mass index of 30 kg/m2 or higher. The Kidney Disease Improving Global Outcomes classification was used to diagnose and classify patients developing AKI. AKI occurred in 87.5% of patients (19.5% with stage 1, 22.6% with stage 2 and 45.4% with stage 3). Obese patients developed AKI more frequently than non-obese patients (92.8% versus 85.5%, p = .035; unadjusted OR 2.2 (95% CI: 1.04-4.6), p = .039; adjusted OR 2.31 (95% CI: 1.07-5.02), p = .034). The percentage of obese patients, however, did not differ between AKI stages (stage 1, 25.1%; stage 2, 28.6%; stage 3, 15.4%; p = .145). There was no association between obesity and mortality (p = .739). Of note, when comparing AKI patients with or without obesity in terms of in-hospital mortality there were also no significant differences between those groups (38.4% versus 38.4%, p = .998). Obesity was associated with the occurrence of AKI in critically ill patients with sepsis; however, it was not associated with in-hospital mortality.

Consensus Protocol for the Treatment of Super-Refractory Status Epilepticus.

INTRODUCTION: Super-refractory status epilepticus is defined as status epilepticus that persists or recurs 24 hours after anaesthetic therapy onset or after its withdrawal. It is mostly found in intensive care units and carries high mortality but good long-term prognosis for those who survive. In contrast with the initial phases of status epilepticus, treatment lacks strong scientific evidence and is mostly derived from case reports or small case series. OBJECTIVE: To propose a protocol for the treatment of super-refractory status epilepticus in level III intensive care units, focusing on the treatment strategies to control clinical and/or electroencephalographic epileptic activity. MATERIAL AND METHODS: Narrative review of the literature by PubMed search. Available evidence was discussed in consensus meetings by intensive care and neurology experts' from a level III intensive care unit and one of the Portuguese reference centres for the treatment of refractory epilepsy, respectively. RESULTS: Anaesthetics with the highest level of evidence are propofol, midazolam, thiopental and ketamine. These represent the basis of the treatment of super-refractory status epilepticus and should be used in combination with antiepileptic drugs. The level of evidence for the latter is lower, however, levetiracetam, topiramate, pregabalin, lacosamide, valproic acid, phenytoin and perampanel may be recommended. Alternative therapeutic strategies with very low level of evidence are recommended in cases of total absence of clinical response, such as magnesium sulphate, pyridoxine, ketogenic diet, therapeutic hypothermia and immunosupression. CONCLUSION: We propose a treatment protocol based on a sequential combination of anaesthetics, anti-epileptic drugs and alternative therapies. Strategies to evaluate treatment response and to wean drugs based on clinical results are also proposed.

Introdução: O estado de mal epiléptico super-refractário define-se como um estado de mal epiléptico que persiste ou recorre 24 horas após o início da terapêutica anestésica ou após a sua suspensão. Encontra-se fundamentalmente em unidades de cuidados intensivos e está associado a uma elevada mortalidade apesar de ter um bom prognóstico a longo prazo nos doentes que sobrevivem. Ao contrário das fases iniciais do estado de mal epiléptico, o tratamento não é baseado numa forte evidência científica e deriva principalmente de relatos ou pequenas séries de casos. Objectivo: Propor um protocolo de tratamento do estado de mal epiléptico super-refractário em unidades de cuidados intensivos de nível III, focando-se nas estratégias de tratamento para controlar a actividade epiléptica clínica e/ou electroencefalográfica. Material e Métodos: Revisão narrativa da literatura no PubMed, seguida de discussão em reuniões de consenso de peritos de medicina intensiva e neurologia de uma unidade de cuidados intensivos de nível III e de um dos centros de referência para o tratamento da epilepsia refractária em Portugal, respectivamente. Resultados: Os fármacos anestésicos com maior nível de evidência são o propofol, midazolam, tiopental e ketamina. Estes representam a base do tratamento do estado de mal super-refractário e devem ser utilizados em combinação com fármacos antiepilépticos. O nível de evidência para estes últimos é menor, contudo, podem ser recomendados o levetiracetam, topiramato, pregabalina, lacosamida, perampanel, ácido valpróico, fenitoína e perampanel. São recomendadas estratégias terapêuticas alternativas com muito baixo nível de evidência, em casos de ausência total de resposta clínica, tais como o sulfato de magnésio, piridoxina, dieta cetogénica, hipotermia terapêutica e imunossupressão. Conclusão: Propomos um protocolo de tratamento baseado numa combinação sequencial de fármacos anestésicos, antiepilépticos e terapêuticas alternativas. São também propostas estratégias de avaliação da eficácia da terapêutica e de desmame farmacológico progressivo de acordo com a resposta clínica obtida.