Predicting Acute Kidney Injury in Trauma Patients: Biomarkers as Early Indicators.

BACKGROUND Acute kidney injury (AKI) is a common cause of organ failure in patients after major trauma and is associated with increased morbidity and mortality. Early identification of patients at risk enables the implementation of a bundle of supportive care, which reduces the incidence of AKI. The primary objective of our study was to investigate whether the levels of biomarkers on admission predicted the onset of early AKI in patients with serious injuries. MATERIAL AND METHODS This prospective observational study included 98 adult patients of both sexes with a serious injury (injury severity score >16). At admission, blood samples were taken, and creatinine, neutrophil gelatinase-associated lipocalin (NGAL), high mobility group box 1 (HMGB-1), and markers of rhabdomyolysis (creatine kinase, myoglobin) were evaluated. The patients were provided with standard resuscitation care, and the occurrence of AKI was monitored during the first 7 days after admission to the Intensive Care Unit, according to the Kidney Disease Improving Global Outcomes diagnostic criteria. RESULTS AKI occurred in 25 (25.5%) patients, in whom the admission levels of HMGB-1, NGAL, creatinine, and myoglobin were significantly higher than in non-AKI patients (48.3±98.4 vs 113.0±209.4 µg/L, P=0.006; 150.2±349.9 vs 181.4±152.2 µg/L, P=0.004; 83.1±20.8 vs 118.8±32.2 µmol/L, P<0.005; 2734.4±2214.5 vs 4182.3±2477.1 µg/L, P=0.008, respectively). Creatine kinase was 14.5±9.2 µkat/L in non-AKI patients and 13.7±7.9 µkat/L in AKI patients (P=0.916). CONCLUSIONS Admission levels of HMGB-1, NGAL, creatinine, and myoglobin predicted the risk of AKI in severely injured patients.

Effect of BIS-guided anesthesia on emergence delirium following general anesthesia in children: A prospective randomized controlled trial.

OBJECTIVE: Emergence delirium (ED) is a postoperative complication in pediatric anesthesia characterized by a perception and psychomotor disorder, with a negative impact on postoperative recovery. As the use of inhalation anesthesia is associated with a higher incidence of ED, we investigated whether titrating the depth of general anesthesia with BIS monitor can reduce the incidence of ED. DESIGN: Randomized, prospective, and double-blind. SETTING: Patients undergoing endoscopic adenoidectomy under general anesthesia according to a uniform protocol. PATIENTS: A total of 163 patients of both sexes aged 3-8 years were enrolled over 18 months. INTERVENTIONS: Immediately after the induction of general anesthesia, a bispectral index (BIS) electrode was placed on the patient's forehead. In the study group, the depth of general anesthesia was monitored with the aim of achieving BIS values of 40-60. In the control group, the dose of sevoflurane was determined by the anaesthesiologist based on MAC (minimum alveolar concentration) and the end-tidal concentration. MEASUREMENTS: The primary objective was to compare the occurrence of ED during the PACU (post-anesthesia care unit) stay in both arms of the study. The secondary objective was to determine the PAED score at 10 and 30 min in the PACU and the need for rescue treatment of ED. MAIN RESULTS: 86 children were randomized in the intervention group and 77 children in the control group. During the entire PACU stay, 23.3% (38/163) of patients developed ED with PAED score >10: 35.1% (27/77) in the control group and 12.8% (11/86) in the intervention group (p = 0.001). Lower PAED scores were also found in the intervention group at 10 (p < 0.001) and 30 (p < 0.001) minutes compared to the control group. The need for rescue treatment did not differ between groups (p = 0.067). CONCLUSION: Individualization of the depth of general anesthesia with BIS monitoring is an effective method of preventing ED in children. CLINICAL TRIAL REGISTRATION: NCT04466579.

The Impact of Mechanical Energy Assessment on Mechanical Ventilation: A Comprehensive Review and Practical Application.

Mechanical ventilation (MV) provides basic organ support for patients who have acute hypoxemic respiratory failure, with acute respiratory distress syndrome as the most severe form. The use of excessive ventilation forces can exacerbate the lung condition and lead to ventilator-induced lung injury (VILI); mechanical energy (ME) or power can characterize such forces applied during MV. The ME metric combines all MV parameters affecting the respiratory system (ie, lungs, chest, and airways) into a single value. Besides evaluating the overall ME, this parameter can be also related to patient-specific characteristics, such as lung compliance or patient weight, which can further improve the value of ME for characterizing the aggressiveness of lung ventilation. High ME is associated with poor outcomes and could be used as a prognostic parameter and indicator of the risk of VILI. ME is rarely determined in everyday practice because the calculations are complicated and based on multiple equations. Although low ME does not conclusively prevent the possibility of VILI (eg, due to the lung inhomogeneity and preexisting damage), individualization of MV settings considering ME appears to improve outcomes. This article aims to review the roles of bedside assessment of mechanical power, its relevance in mechanical ventilation, and its associations with treatment outcomes. In addition, we discuss methods for ME determination, aiming to propose the most suitable method for bedside application of the ME concept in everyday practice.

Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure.

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.

Postdischarge nausea and vomiting (PDNV) in children: A review and observational study.

Postdischarge nausea and vomiting (PDNV) cause substantial pediatric morbidity with potentially serious postoperative complications. However, few studies have addressed PDNV prevention and treatment in pediatric patients. Here we searched the literature and processed it in a narrative review describing PDNV incidence, risk factors, and management in pediatric patients.. A successful strategy for reducing PDNV considers both the pharmacokinetics of the antiemetic agents and the principle of multimodal prophylaxis, utilizing agents of different pharmacologic classes. Since many highly effective antiemetic agents have relatively short half-lives, a different approach must be used to prevent PDNV. A combination of oral and intravenous medications with longer half-lives, such as palonosetron or aprepitant, can be used. In addition, we designed a prospective observational study with the primary objective of determining PDNV incidence. In our study group of 205 children, the overall PDNV incidence was 14.6% (30 of 205), including 21 children suffering from nausea and 9 suffering from vomiting.

Patient Self-Inflicted Lung Injury-A Narrative Review of Pathophysiology, Early Recognition, and Management Options.

Patient self-inflicted lung injury (P-SILI) is a life-threatening condition arising from excessive respiratory effort and work of breathing in patients with lung injury. The pathophysiology of P-SILI involves factors related to the underlying lung pathology and vigorous respiratory effort. P-SILI might develop both during spontaneous breathing and mechanical ventilation with preserved spontaneous respiratory activity. In spontaneously breathing patients, clinical signs of increased work of breathing and scales developed for early detection of potentially harmful effort might help clinicians prevent unnecessary intubation, while, on the contrary, identifying patients who would benefit from early intubation. In mechanically ventilated patients, several simple non-invasive methods for assessing the inspiratory effort exerted by the respiratory muscles were correlated with respiratory muscle pressure. In patients with signs of injurious respiratory effort, therapy aimed to minimize this problem has been demonstrated to prevent aggravation of lung injury and, therefore, improve the outcome of such patients. In this narrative review, we accumulated the current information on pathophysiology and early detection of vigorous respiratory effort. In addition, we proposed a simple algorithm for prevention and treatment of P-SILI that is easily applicable in clinical practice.

Anticoagulation Management during Extracorporeal Membrane Oxygenation-A Mini-Review.

Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.

Extracorporeal membrane oxygenation survival: External validation of current predictive scoring systems focusing on influenza A etiology.

Despite increasing clinical experience with extracorporeal membrane oxygenation (ECMO), its optimal indications remain unclear. Here, we externally evaluated all currently available ECMO survival-predicting scoring systems and the APACHE II score in subjects undergoing veno-venous ECMO (VV ECMO) support due to acute respiratory distress syndrome (ARDS) with influenza (IVA) and non-influenza (n-IVA) etiologies. Our aim was to find the best scoring system for influenza A ARDS ECMO success prediction. Retrospective data were analyzed to assess the abilities of the PRESERVE, RESP, PRESET, ECMOnet, Roch, and APACHE II scores to predict patient outcome. Patients treated with veno-venous ECMO support for ARDS were divided into two groups: IVA and n-IVA etiologies. Parameters collected within 24 hours before ECMO initiation were used to calculate PRESERVE, RESP, PRESET, ECMOnet, Roch, and APACHE II scores. Compared to the IVA group, the n-IVA group exhibited significantly higher ICU, 28-day, and 6-month mortality (P = .043, .034, and .047, respectively). Regarding ECMO support success predictions, the area under the receiver operating characteristic curve (AUC) was 0.62 for PRESERVE, 0.44 for RESP, 0.57 for PRESET, and 0.67 for ECMOnet, and 0.62 for Roch calculated for all subjects according to the original papers. In the IVA group, APACHE II had the best predictive value for ICU, hospital, 28-day, and 6-month mortality (AUC values of 0.73, 0.73, 0.70, and 0.73, respectively). In the n-IVA group, APACHE II was the best predictor of survival in the ICU and hospital (AUC 0.54 and 0.57, respectively). From all possible ECMO survival scoring systems, the APACHE II score had the best predictive value for VV ECMO subjects with ARDS caused by influenza A-related pneumonia with a cut-off value of about 32 points.

Alarmins as biomarkers of gastrointestinal surgical injury - a pilot study.

The dysregulation of inflammatory response to surgical injury affects outcomes. Alarmins, the earliest bioactive substances from damaged cells, play a crucial role in initiating the inflammation. We analyzed serum levels of alarmins (S100A8, S100A12, high mobility group box, and heat shock protein 70) after major abdominal surgery (MAS) in surgical (S) (n = 82) and nonsurgical (NS) groups (n = 35). The main objective was determining a role of selected alarmins in host response to MAS. The secondary objectives were (i) evaluation of the relationship among alarmins and selected biomarkers (C-reactive protein, interleukin-6), (ii) influence of the place of gastrointestinal resection, and (iii) role of alarmins in MAS for cancer. Except for HMGB1, the levels of all alarmins were higher in the S group compared with the NS group. In the S group, positive correlations were found between S100A8 and both IL-6 and CRP. Additionally, the S100A8 level was higher (p < 0.01) in patients who underwent upper gastrointestinal tract (GIT) surgery compared to middle and lower GIT resections. Alarmins levels did not differ between cancer and noncancer patients. MAS is able to elicit increase in alarmin levels. S100A8 can be considered a potential biomarker of surgical injury, especially in the upper part of the GIT.

Exogenous surfactant as a bridge to prolonged "total lung rest" in severely injured patient during extracorporeal membrane oxygenation.

We report a case of a 20-year-old male patient suffering from motorcycle accident complicated by rapid development of severe refractory hypoxemia and hypercapnia due to serious bilateral lung contusions and lacerations. Positive pressure mechanical ventilation induced pressure-dependent massive air leak from disrupted pulmonary tissue. Simultaneous implementation of veno-venous extracorporeal membrane oxygenation together with surfactant application allowed prolonged disconnection of patient from mechanical ventilation ("total lung rest" mode). Despite considerable areas of nonaerated tissue on computed tomography prior to the disconnection from mechanical ventilation, almost total functional recovery of lungs was eventually achieved.

Past and Present ARDS Mortality Rates: A Systematic Review.

ARDS is severe form of respiratory failure with significant impact on the morbidity and mortality of critical care patients. Epidemiological data are crucial for evaluating the efficacy of therapeutic interventions, designing studies, and optimizing resource distribution. The goal of this review is to present general aspects of mortality data published over the past decades. A systematic search of the MEDLINE/PubMed was performed. The articles were divided according to their methodology, type of reported mortality, and time. The main outcome was mortality. Extracted data included study duration, number of patients, and number of centers. The mortality trends and current mortality were calculated for subgroups consisting of in-hospital, ICU, 28/30-d, and 60-d mortality over 3 time periods (A, before 1995; B, 1995-2000; C, after 2000). The retrospectivity and prospectivity were also taken into account. Moreover, we present the most recent mortality rates since 2010. One hundred seventy-seven articles were included in the final analysis. General mortality rates ranged from 11 to 87% in studies including subjects with ARDS of all etiologies (mixed group). Linear regression revealed that the study design (28/30-d or 60-d) significantly influenced the mortality rate. Reported mortality rates were higher in prospective studies, such as randomized controlled trials and prospective observational studies compared with retrospective observational studies. Mortality rates exhibited a linear decrease in relation to time period (P < .001). The number of centers showed a significant negative correlation with mortality rates. The prospective observational studies did not have consistently higher mortality rates compared with randomized controlled trials. The mortality trends over 3 time periods (before 1995, 1995-2000, and after 2000) yielded variable results in general ARDS populations. However, a mortality decrease was present mostly in prospective studies. Since 2010, the overall rates of in-hospital, ICU, and 28/30-d and 60-d mortality were 45, 38, 30, and 32%, respectively.

Alarmins and Clinical Outcomes After Major Abdominal Surgery-A Prospective Study.

PURPOSE: Tissue injury causing immune response is an integral part of surgical procedure. Evaluation of the degree of surgical trauma could help to improve postoperative management and determine the clinical outcomes. MATERIALS AND METHODS: We analyzed serum levels of alarmins, including S100A5, S100A6, S100A8, S100A9, S100A11, and S100A12; high-mobility group box 1; and heat-shock protein 70, after elective major abdominal surgery (n = 82). Blood samples were collected for three consecutive days after surgery. The goals were to evaluate the relationships among the serum levels of alarmins and selected surgical characteristics and to test potential of alarmins to predict the clinical outcomes. RESULTS: Significant, positive correlations were found for high-mobility group box 1 with the length of surgery, blood loss, and intraoperative fluid intake for all three days of blood sampling. The protein S100A8 serum levels showed positive correlations with intensive care unit length of stay, 28-day and in-hospital mortality. The protein S100A12 serum levels had significant, positive correlations with intensive care unit length of stay, 28-day mortality, and in-hospital mortality. We did not find significant differences in alarmin levels between cancer and noncancer subjects. CONCLUSION: The high-mobility group box 1 serum levels reflect the degree of surgical injury, whereas proteins S100A8 and S100A12 might be considered good predictors of major abdominal surgery morbidity and mortality.

Anaerobic metabolism associated with traumatic hemorrhagic shock monitored by microdialysis of muscle tissue is dependent on the levels of hemoglobin and central venous oxygen saturation: a prospective, observational study.

BACKGROUND: Traumatic hemorrhagic shock resulting in tissue hypoxia is a significant cause of morbidity and mortality in polytraumatized patients. Early identification of tissue hypoxia is possible with microdialysis. The aim of this study was to determine the correlation between a marker of tissue hypoxia (L/P; lactate to pyruvate ratio) and selected parameters of systemic oxygen delivery (Hb; hemoglobin) and oxygen extraction (ScvO2; central venous oxygen saturation). We also investigated the severity of tissue hypoxia over the course of care. METHODS: Adult patients with traumatic hemorrhagic shock were enrolled in this prospective, observational study. Microdialysis of the peripheral muscle tissue was performed. Demographic data and timeline of care were collected. Tissue lactate, pyruvate, glycerol, glucose levels, hemoglobin, serum lactate and oxygen saturation of the central venous blood (ScvO2) levels were also measured. RESULTS: The L/P ratio trend may react to changes in systemic hemoglobin levels with a delay of 7 to 10 hours, particularly when systemic hemoglobin levels are increased by transfusion. Decrease in tissue L/P ratio may react to increase in ScvO2 with a delay of up to 10 hours, and such a decrease may signify elimination of tissue hypoxia after transfusion. We also observed changes in the L/P trend in the 13 hours preceding a change in the hemoglobin level. Fluid administration, which is routinely used as a first-line treatment of hypovolemic shock, can cause hemodilution and decreased hemoglobin. When ScvO2 decreases, increase in L/P ratio may precede the ScvO2 trend by 10 or 11 hours. An increase in the L/P ratio is an early warning sign of insufficient tissue oxygenation and should lead to intensive observation of hemoglobin levels, ScvO2 and other hemodynamic parameters. Patients who were treated more rapidly had lower maximal L/P values and a lower degree of tissue ischemia. CONCLUSION: The L/P ratio is useful to identify tissue ischemia and can estimate the effectiveness of fluid resuscitation. An increase in the L/P ratio is an early warning sign of inadequate tissue oxygenation and should lead to more detailed hemodynamic and laboratory monitoring. This information cannot usually be obtained from global markers.

Tissue ischemia microdialysis assessments following severe traumatic haemorrhagic shock: lactate/pyruvate ratio as a new resuscitation end point?

BACKGROUND: Intensive care of severe trauma patients focuses on the treatment of haemorrhagic shock. Tissues should be perfused sufficiently with blood and with sufficient oxygen content to ensure adequate tissue oxygen delivery. Tissue metabolism can be monitored by microdialysis, and the lactate/pyruvate ratio (LPR) may be used as a tissue ischemia marker. The aim of this study was to determine the adequate cardiac output and haemoglobin levels that avoid tissue ischemia. METHODS: Adult patients with serious traumatic haemorrhagic shock were enrolled in this prospective observational study. The primary observed parameters included haemoglobin, cardiac output, central venous saturation, arterial lactate and the tissue lactate/pyruvate ratio. RESULTS: Forty-eight patients were analysed. The average age of the patients was 39.8 ± 16.7, and the average ISS was 43.4 ± 12.2. Hb < 70 g/l was associated with pathologic arterial lactate, ScvO2 and LPR. Tissue ischemia (i.e., LPR over 25) developed when CI ≤ 3.2 l/min/m(2) and Hb between 70 and 90 g/l were observed. Severe tissue ischemia events were recorded when the Hb dropped below 70 g/l and CI was 3.2-4.8 l/min/m(2). CI ≥ 4.8 l/min/m(2) was not found to be connected with tissue ischemia, even when Hb ≤ 70 g/l. CONCLUSION: LPR could be a useful marker to manage traumatic haemorrhagic shock therapies. In initial traumatic haemorrhagic shock treatments, it may be better to maintain CI ≥ 3.2 l/min/m(2) and Hb ≥ 70 g/l to avoid tissue ischemia. LPR could also be a useful transfusion trigger when it may demonstrate ischemia onset due to low local DO2 and early reveal low/no tissue perfusion.

[Problems with placement and using of automated external defibrillators in Czech Republic]. / Problematika rozmísteni a pouzití automatizovaných externích defibrilátoru v Ceské republice.

The use of automated external defibrillators improves the survival of adults who suffer from cardiopulmonary arrest. Automated external defibrillators detect ventricular fibrillation with almost perfect sensitivity and specificity. Authors describe the use of automated external defibrillator during cardiopulmonary resuscitation in a patient with sudden cardiac arrest during ice-hockey match. The article reports also the use of automated external defibrillators in children.

[Metabolism monitoring with microdialysis in the intensive care]. / Sledování metabolismu v intenzivní péci pomocí mikrodialýzy.

Therapy of haemorrhagic shock presents a huge challenge nowadays. Changes in circulation and metabolism are preceded with changes in cells, vessels and extracellular fluid. The main disorder takes place in microcirculation. Monitoring of extracellular fluid is possible with microdialysis. This method was verified on animal models and a became base of many clinical examinations in the world. First of all it is monitoring of lactate, pyruvate, glucose and glycerole as main markers of cell metabolism. Tissue condition can be described not only with absolute values but also as relations between individual parameters e.g. lactate/pyruvate and lactate/glucose. These values do not only inform us about forthcoming change from aerobic to anaerobic metabolism but also about the degree of reperfusion. Precious information about mitochondrial dysfunction which is the essence of multiorgan dysfunction in intensive care is collected as well. Based on changes we can asses the quality of resuscitation care together with speed of shock elimination, increasing oxygen delivery and mitochondrial dysfunction treatment.