Kidney replacement and conservative therapies in rhabdomyolysis: a retrospective analysis.

BACKGROUND: Toxic renal effects of myoglobin following rhabdomyolysis can cause acute kidney injury (AKI) with the necessity of kidney replacement therapy (KRT). Fast elimination of myoglobin seems notable to save kidney function and intensify kidney repair. Clinical data regarding efficacy of KRT in critical care patients with rhabdomyolysis and AKI are limited. This retrospective analysis aimed to identify differences between conservative therapy and different modalities of KRT regarding myoglobin elimination and clinical outcome. METHODS: This systematic, retrospective, single-center study analyzed 328 critical care patients with rhabdomyolysis (myoglobin > 1000 µg/l). Median reduction rate of myoglobin after starting KRT was calculated and compared for different modalities. Multivariate logistic regression models were established to identify potential confounder on hospital mortality. Filter lifetime of the various extracorporeal circuits was analyzed by Kaplan-Meier curves. RESULTS: From 328 included patients 171 required KRT. Health condition at admission of this group was more critical compared to patient with conservative therapy. Myoglobin reduction rate did not differ between the groups (KRT 49% [30.8%; 72.2%] vs. conservative treatment (CT) 61% [38.5%; 73.5%]; p = 0.082). Comparison between various extracorporeal procedures concerning mortality showed no significant differences. Hospital mortality was 55.6% among patients with KRT and 18.5% with CT (p < 0.001). Multivariate logistic regression model identified requirement for KRT (OR: 2.163; CI: 1.061-4.407); p = 0.034) and the SOFA Score (OR: 1.111; CI: 1.004-1.228; p = 0.041) as independent predictive factors for hospital mortality. When comparing specific KRT using multivariate regression, no benefit was demonstrated for any treatment modality. Life span of the extracorporeal circuit was shorter with CVVH compared to that of others (log-Rank p = 0.017). CONCLUSIONS: This study emphasizes that AKI requiring KRT following rhabdomyolysis is accompanied by high mortality rate. Differences in myoglobin reduction rate between various KRTs could not be confirmed, but CVVH was associated with reduced filter lifetime compared to other KRTs, which enable myoglobin elimination, too.

Passive leg raising test versus rapid fluid challenge in critically ill medical patients.

BACKGROUND: The passive leg raising (PLR) test is a simple test to detect preload responsiveness. However, variable fluid doses and infusion times were used in studies evaluating the effect of PLR. Studies showed that the effect of fluid challenge on hemodynamics dissipates in 10 min. This prospective study aimed to compare PLR and a rapid fluid challenge (RFC) with a 300-ml bolus infused within 5 min in adult patients with a hemodynamic compromise. MATERIALS AND METHODS: Critically ill medical patients with signs of systemic hypoperfusion were included if volume expansion was considered. Hemodynamic status was assessed with continuous measurements of cardiac output (CO), when possible, and mean arterial pressure (MAP) at baseline, during PLR, and after RFC. RESULTS: A total of 124 patients with a median age of 65.0 years were included. Their acute physiology and chronic health evaluation (APACHE) II score was 19.7 ± 6.0, with a sequential organ failure assessment (SOFA) score of 9.0 ± 4.4. Sepsis was diagnosed in 73.3%, and 79.8% of the patients were already receiving a norepinephrine infusion. Invasive MAP monitoring was established in all patients, while continuous CO recording was possible in 42 patients (33.9%). Based on CO changes, compared with those with RFC, the false positive and false negative rates with PLR were 21.7 and 36.8%, respectively, with positive and negative predictive values of 70.6 and 72.0%, respectively. Based on MAP changes, compared with those with RFC, the false positive and false negative rates with PLR compared to RFC were 38.2% and 43.3%, respectively, with positive and negative predictive values of 64.4 and 54.0%, respectively. CONCLUSION: This study demonstrated a moderate agreement between PLR and RFC in hemodynamically compromised medical patients, which should be considered when testing preload responsiveness.

Evaluation of POSSUM for patients undergoing pancreatoduodenectomy.

BACKGROUND: The POSSUM score is a predictive scoring system for postoperative morbidity. Although numerous studies have validated its application in major abdominal surgery, few have exclusively considered pancreatic resections, which have unique complications that are costly and problematic. We examined whether POSSUM could accurately reflect the clinical outcomes in pancreatic resection. METHODS: A total of 694 consecutive resections of the pancreatic head were performed between 1993 and 2010 at the Department of General, Thoracic, and Vascular Surgery at the University Hospital Dresden. The POSSUM score calculated for each case was compared with the observed morbidity. Relevance and predictive performance of the score were assessed; in particular, because of the poor calibration of the POSSUM predictions on the Dresden data, a new score was created that was externally validated on patient cohorts from two different centers for pancreatic surgery. RESULTS: The goodness-of-fit analysis revealed that the POSSUM score was not well calibrated because the POSSUM-predicted morbidity rate was 58.9% on average whereas the observed morbidity rate was 43.4%. Discrepancies occurred particularly among the predicted high-risk patients, for whom the score actually overestimated the morbidity risk. Therefore, we adapted the score and complemented it with additional prognostic parameters. The new score was validated in a patient cohort from two other German centers and fitted better to the data. CONCLUSION: The new score, named PS-POSSUM (POSSUM in pancreatic surgery), fits the data better. However, the prediction ability remains rather poor. PS-POSSUM may still be helpful, as it draws attention to additional risk and protective factors in addition to those in the original POSSUM score.