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1.
Neurocrit Care ; 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33009658

RESUMO

BACKGROUND/OBJECTIVE: Dysnatremia is common in severe traumatic brain injury (TBI) patients and may contribute to mortality. However, serum sodium variability has not been studied in TBI patients. We hypothesized that such variability would be independently associated with mortality. METHODS: We collected 6-hourly serum sodium levels for the first 7 days of ICU admission from 240 severe TBI patients in 14 neurotrauma ICUs in Europe and Australia. We evaluated the association between daily serum sodium standard deviation (dNaSD), an index of variability, and 28-day mortality. RESULTS: Patients were 46 ± 19 years of age with a median initial GCS of 6 [4-8]. Overall hospital mortality was 28%. Hypernatremia and hyponatremia occurred in 64% and 24% of patients, respectively. Over the first 7 days in ICU, serum sodium standard deviation was 2.8 [2.0-3.9] mmol/L. Maximum daily serum sodium standard deviation (dNaSD) occurred at a median of 2 [1-4] days after admission. There was a significant progressive decrease in dNaSD over the first 7 days (coefficient - 0.15 95% CI [- 0.18 to - 0.12], p < 0.001). After adjusting for baseline TBI severity, diabetes insipidus, the use of osmotherapy, the occurrence of hypernatremia, and hyponatremia and center, dNaSD was significantly independently associated with 28-day mortality (HR 1.27 95% CI (1.01-1.61), p = 0.048). CONCLUSIONS: Our study demonstrates that daily serum sodium variability is an independent predictor of 28-day mortality in severe TBI patients. Further prospective investigations are necessary to confirm the significance of sodium variability in larger cohorts of TBI patients and test whether attenuating such variability confers outcome benefits to such patients.

2.
PLoS One ; 15(10): e0241020, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33085700

RESUMO

BACKGROUND: Postoperative complications after major gastrointestinal surgery are a major contributor to hospital costs. Thus, reducing postoperative complications is a key target for cost-containment strategies. We aimed to evaluate the relationship between postoperative complications and hospital costs following small bowel resection. METHODS: Postoperative complications were recorded for 284 adult patients undergoing major small bowel resection surgery between January 2013 and June 2018. Complications were defined and graded according to the Clavien-Dindo classification system. In-hospital cost of index admission was calculated using an activity-based costing methodology; it was reported in US dollars at 2019 rates. Regression modeling was used to investigate the relationships among a priori selected perioperative variables, complications, and costs. FINDINGS: The overall complication prevalence was 81.6% (95% CI: 85.7-77.5). Most complications (69%) were minor, but 22.9% of patients developed a severe complication (Clavien-Dindo grades III or IV). The unadjusted median total hospital cost for patients with any complication was 70% higher than patients without complications (median [IQR] USD 19,659.64 [13,545.81-35,407.14] vs. 11,551.88 [8,849.46-15,329.87], P < 0.001). The development of 1, 2, 3, and ≥ 4 complications increased hospital costs by 11%, 41%, 50%, and 195%, respectively. Similarly, more severe complications incurred higher hospital costs (P < 0.001). After adjustments were made (for the Charlson Comorbidity Index, anemia, surgical urgency and technique, intraoperative fluid administration, blood transfusion, and hospital readmissions), a greater number and increased severity of complications were associated with a higher adjusted median hospital cost. Patients who experienced complications had an adjusted additional median cost of USD 4,187.10 (95% CI: 1,264.89-7,109.31, P = 0.005) compared to those without complications. CONCLUSIONS: Postoperative complications are a key target for cost-containment strategies. Our findings demonstrate a high prevalence of postoperative complications following small bowel resection surgery and quantify their associated increase in hospital costs. TRIAL REGISTRATION: Australian Clinical Trials Registration number: 12620000322932.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33078888

RESUMO

AIM: We aimed to test the performance of the quick Sequential Organ Failure Assessment score (qSOFA) in predicting the outcomes of oncology patients admitted to the emergency department (ED) with suspected infection. METHODS: Retrospective cohort analysis of all oncology patients presenting to the ED of a tertiary hospital with suspected infection from 1 December 2014 to 1 June 2017. Patients were identified by cross-linkage of ED and Oncology electronic health records. The primary outcome was in-hospital mortality and/or ICU stay ≥ 3 days. RESULTS: A total of 1655 patients were included in this study--1267 (76.6%) with solid tumor and 388 (23.4%) with hematological malignancies. At presentation, 495 patients had chemotherapy, and 140 had radiotherapy within the preceding 6 months. Four hundred patients received chemotherapy and/or radiotherapy in the previous 4 weeks. Overall, 371 (22.4%) patients had qSOFA ≥ 2. Such patients had a higher likelihood of respiratory infections compared to patients with a qSOFA < 2 (43.9% vs 29%) and were more likely to be admitted to ICU or require mechanical ventilation. In-hospital mortality or in-hospital mortality and/or ICU stay ≥ 3 days were 17.3% and 21%, for qSOFA ≥ 2 patients versus 4.7% and 6.9% for qSOFA < 2 patients (P < .001). qSOFA ≥ 2 had a negative predictive value of 95% for in-hospital mortality and 93% for in-hospital mortality or ICU stay ≥ 3 days. CONCLUSION: Among oncology patients presenting to the ED with suspected infection, a qSOFA ≥ 2 is associated with a threefold risk of hospital mortality/prolonged ICU stay. Its absence helps identify low-risk patients.

4.
Intensive Care Med ; 2020 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-33052418

RESUMO

The article Is the literature inconclusive about the harm from HES? No.

5.
Artigo em Inglês | MEDLINE | ID: mdl-33079893

RESUMO

OBJECTIVES: To describe the hemodynamic response to fluid boluses for hypotension in children in a cardiac ICU. DESIGN: A prospective, observational study. SETTING: Single-centered cardiac ICU. PATIENTS: Children in a cardiac ICU with hypotension. INTERVENTIONS: Clinician prescribed fluid bolus. MEASUREMENTS AND MAIN RESULTS: Sixty-four fluid boluses were administered to 52 children. Fluid composition was 4% albumin in 36/64 (56%), 0.9% saline in 18/64 (28%), and cardiopulmonary bypass pump blood in 10/64 (16%). The median volume and duration were 5.0 mL/kg (interquartile range, 4.8-5.4) and 8 minutes (interquartile range, 4-19), respectively. Hypovolemia/low filling pressures was the most common additional indication (25/102 [25%]). Mean arterial pressure response, defined as a 10% increase from baseline, occurred in 42/64 (66%) of all fluid boluses at a median time of 6 minutes (interquartile range, 4-11). Mean arterial pressure responders had a median peak increase in the mean arterial pressure of 15 mm Hg (43 mm Hg [interquartile range, 29-50 mm Hg] to 58 mm Hg [interquartile range, 49-65 mm Hg]) at 17 minutes (interquartile range, 14-24 min) compared with 4 mm Hg (48 mm Hg [interquartile range, 40-51 mm Hg] to 52 mm Hg [interquartile range, 45-56 mm Hg]) at 10 minutes (interquartile range, 3-18 min) in nonresponders. Dissipation of mean arterial pressure response, when defined as a subsequent decrement in mean arterial pressure below 10%, 5%, and 2% increases from baseline, occurred in 28/42 (67%), 18/42 (43%), and 13/42 (31%) of mean arterial pressure responders, respectively. Cardiopulmonary bypass pump blood was strongly associated with peak change in mean arterial pressure from baseline (coefficient 11.0 [95% CI, 4.3-17.7]; p = 0.02). Fifty out of 64 (78%) were receiving a vasoactive agent. However, change in vasoactive inotrope score was not associated with change in mean arterial pressure (coefficient 2.3 [95% CI, -2.5 to -7.2]; p = 0.35). Timing from admission, nor fluid bolus duration, influenced mean arterial pressure response. CONCLUSIONS: In children with hypotension in a cardiac ICU, the median dose and duration of fluid boluses were 5 mL/kg and 8 minutes. Peak response occurred shortly following administration and commonly returned to baseline.

6.
Resuscitation ; 2020 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-33058991

RESUMO

AIM: The effect of conservative versus liberal oxygen therapy on mortality rates in post cardiac arrest patients is uncertain. METHODS: We undertook an individual patient data meta-analysis of patients randomised in clinical trials to conservative or liberal oxygen therapy after a cardiac arrest. The primary end point was mortality at last follow-up. RESULTS: Individual level patient data were obtained from seven randomised clinical trials with a total of 429 trial participants included. Four trials enrolled patients in the pre-hospital period. Of these, two provided protocol-directed oxygen therapy for 60 minutes, one provided it until the patient was handed over to the emergency department staff, and one provided it for a total of 72 hours or until the patient was extubated. Three trials enrolled patients after intensive care unit (ICU) admission and generally continued protocolised oxygen therapy for a longer period, often until ICU discharge. A total of 90 of 221 patients (40.7%) assigned to conservative oxygen therapy and 103 of 206 patients (50%) assigned to liberal oxygen therapy had died by this last point of follow-up; absolute difference; odds ratio (OR) adjusted for study only; 0.67; 95% CI 0.45 to 0.99; P = 0.045; adjusted OR, 0.58; 95% CI 0.35 to 0.96; P = 0.04. CONCLUSION: Conservative oxygen therapy was associated with a statistically significant reduction in mortality at last follow-up compared to liberal oxygen therapy but the certainty of available evidence was low or very low due to bias, imprecision, and indirectness. (PROSPERO registration number: CRD42019138931).

7.
Ann Thorac Surg ; 2020 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-33069678

RESUMO

BACKGROUND: Total arterial coronary revascularization for three vessel disease can be achieved with a second arterial conduit joined to the left internal mammary artery as a Y graft, using either a radial artery (RAY) or second mammary artery (BIMAY). METHODS: Patients receiving total arterial revascularization for three coronary territory disease were identified from two cardiac surgical databases (Sydney and Melbourne) using Society of Thoracic Surgeons-based definitions. BIMAY patients underwent surgery between 1994 and 2009, mostly using an age-limited protocol, while RAY patients underwent surgery between 1996 and 2003 without age limits. All-cause mortality was acquired from the national death registry and survival estimated by the Kaplan-Meier method. Propensity score matching was performed using 13 variables. Due to the age imbalance between groups, the primary comparison was performed for age ≤66 years. RESULTS: Overall, 1,896 patients received RAY and 720 patients received BIMAY. Older age at surgery was the strongest independent predictor for mortality with a hazard ratio of HR 2.06, 95%CI 1.93, 2.22, P<0.001. After propensity score matching, we identified 299 pairs of patients ≤66 years with no preoperative or operative differences and similar age at surgery, RAY 56.4±7.0 vs. BIMAY 56.4±6.8 years, P=0.96. The RAY group had 4.0±0.9 grafts and the BIMAY group had 3.9±0.9, P=0.814. All-cause mortality was not different, with the proportion surviving at 15 years at 74.9% for RAY vs. 76.2% for BIMAY (P=0.211). CONCLUSIONS: Survival was not different between RAY and BIMAY for total arterial revascularization of three coronary territory bypass grafting.

8.
Artigo em Inglês | MEDLINE | ID: mdl-33074016

RESUMO

Glomerular filtration rate (GFR) is acutely increased following a high protein meal or systemic infusion of amino acids. The mechanisms underlying this renal functional response remain to be fully elucidated. Nevertheless, they appear to culminate in pre-glomerular vasodilation. Inhibition of the tubuloglomerular feedback signal appears critical. However, nitric oxide, vasodilator prostaglandins, and glucagon also appear important. The increase in GFR during amino acid infusion reveals a 'renal reserve' which can be utilized when the physiological demand for single nephron GFR increases. This has led to the concept that in sub-clinical renal disease, before basal GFR begins to reduce, renal functional reserve can be recruited in a manner that preserves renal function. The extension of this concept is that, once a decline in basal GFR can be detected, renal disease is already well-progressed. This concept likely applies both in the contexts of chronic kidney disease and acute kidney injury. Critically, its corollary is that deficits in renal functional reserve have the potential to provide early detection of renal dysfunction, before basal GFR is reduced. There is growing evidence that the renal response to infusion of amino acids can be used to identify patients at risk of developing either chronic kidney disease or acute kidney injury and as a treatment target for acute kidney injury. However, large multicenter clinical trials are required to test these propositions. A renewed effort to understand the renal physiology underlying the response to amino acid infusion is also warranted.

9.
Blood Purif ; : 1-11, 2020 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-33027799

RESUMO

INTRODUCTION: In continuous renal replacement therapy (CRRT)-treated patients, a net ultrafiltration (NUF) rate >1.75 mL/kg/h has been associated with increased mortality. However, there may be heterogeneity of effect of NUF rate on mortality, according to patient characteristics. METHODS: To investigate the presence and impact of heterogeneity of effect, we performed a secondary analysis of the "Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy" (RENAL) trial. Exposure was NUF rate (weight-adjusted fluid volume removed per hour) stratified into tertiles (<1.01 mL/kg/h; 1.01-1.75 mL/kg/h; or >1.75 mL/kg/h). Primary outcome was 90-day mortality. Patients were clustered according to baseline characteristics. Heterogeneity of effect was assessed according to clusters and baseline edema and related to the additional impact of baseline cardiovascular Sequential Organ Failure Assessment (SOFA) score. We excluded patients with missing values for baseline weight and/or treatment duration. RESULTS: We identified 2 clusters. The largest (cluster 1; n = 941) included more severely ill patients, with more sepsis, more edema, and more vasopressor therapy (all p < 0.001). Compared to the middle tertile, the probability of harm was greater with the high tertile of NUF rate in patients in cluster 1 and in patients with baseline edema (probability of harm, cluster 1: 99.9%; edema: 99.1%). Moreover, higher baseline cardiovascular SOFA score also increased mortality risk with both high and low compared to middle NUF rates in cluster 1 patients and in patients with edema. CONCLUSIONS: In CRRT patients, both high and low NUF rates may be harmful, especially in those with edema, sepsis, and greater illness severity. Cardiovascular SOFA scores modulate this association. Additional studies are needed to test these hypotheses, and targeted trials of NUF rates based on risk stratification appear justified. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00221013.

10.
Crit Care Med ; 48(10): e934-e942, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32885938

RESUMO

OBJECTIVES: During continuous renal replacement therapy, a high net ultrafiltration rate has been associated with increased mortality. However, it is unknown what might mediate its putative effect on mortality. In this study, we investigated whether the relationship between early (first 48 hr) net ultrafiltration and mortality is mediated by fluid balance, hemodynamic instability, or low potassium or phosphate blood levels using mediation analysis and the primary outcome was hospital mortality. DESIGN: Retrospective, observational study. SETTING: Mixed medical and surgical ICUs at Austin hospital, Melbourne, Australia. PATIENTS: Critically ill patients treated with continuous renal replacement therapy within 14 days of ICU admission who survived greater than 48 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We studied 347 patients (median [interquartile range] age: 64 yr [53-71 yr] and Acute Physiology and Chronic Health Evaluation III score: 73 (54-90)]. After adjustment for confounders, compared with a net ultrafiltration less than 1.01 mL/kg/hr, a net ultrafiltration rate greater than 1.75 mL/kg/hr was associated with significantly greater mortality (adjusted odds ratio, 1.15; 95% CI, 1.03-1.29; p = 0.011). Adjusted univariable mediation analysis found no suggestion of a causal mediation pathway for this effect by blood pressure, vasopressor therapy, or potassium levels, but identified a possible mediation effect for fluid balance (average causal mediation effect, 0.95; 95% CI, 0.89-1.00; p = 0.060) and percentage of phosphate measurements with hypophosphatemia (average causal mediation effect, 0.96; 95% CI, 0.92-1.00; p = 0.055). However, on multiple mediator analyses, these two variables showed no significant effect. In contrast, a high net ultrafiltration rate had an average direct effect of 1.24 (95% CI, 1.11-1.40; p < 0.001). CONCLUSIONS: An early net ultrafiltration greater than 1.75 mL/kg/hr was independently associated with increased hospital mortality. Its putative effect on mortality was direct and not mediated by a causal pathway that included fluid balance, low blood pressure, vasopressor use, hypokalemia, or hypophosphatemia.

11.
Crit Care Resusc ; 22(3): 221-226, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900328

RESUMO

BACKGROUND: Regularly informing families of the condition of their relative can be difficult. Text messaging via mobile telephones may achieve such communication effectively. OBJECTIVE: To test the hypotheses that we could efficiently deliver real-time short message service (SMS) updates to families and that these SMS updates would be accepted and welcomed. DESIGN: Prospective observational study. PARTICIPANTS: Cohort of 91 cardiac surgery patients and 156 family participants. INTERVENTION: At five distinct landmark events, we sent pre-written SMS updates to designated mobile numbers. We used the sendQuick (TalariaX) mobile messaging platform via the internet in our hospital. To alleviate privacy concerns, all patients were referred to as "your loved one". The message confirmed the passing of each landmark and directed the families towards the next one. After the patient's discharge, families were followed up with a telephone call and a five-point Likert scale questionnaire. RESULTS: We successfully sent all five SMS messages for 72 patients to 114 participants (73%). Among 114 participants, all agreed the SMS service was reassuring and that the SMS messages were easy to follow and kept participants informed. Almost all felt the SMS service did not increase anxiety and all disagreed with the SMS service being intrusive. All surveyed participants stated that they would recommend the service to other families. CONCLUSION: We successfully instituted real-time SMS updates. All surveyed participants agreed that these messages were reassuring, informative and easy to follow and that they would recommend the SMS service to other families.


Assuntos
Telefone Celular , Comunicação , Cuidados Críticos/métodos , Família/psicologia , Envio de Mensagens de Texto , Humanos , Estudos Prospectivos
12.
Crit Care Resusc ; 22(3): 227-236, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900329

RESUMO

OBJECTIVE: The systemic inflammatory response syndrome (SIRS) is a dysregulated response that contributes to critical illness. Adjunctive acetylsalicylic acid (ASA) treatment may offer beneficial effects by increasing the synthesis of specialised proresolving mediators (a subset of polyunsaturated fatty acid-derived lipid mediators). DESIGN: Pilot, feasibility, multicentre, double-blind, randomised, placebo-controlled trial. SETTING: Four interdisciplinary intensive care units (ICUs) in Australia. PARTICIPANTS: Critically ill patients with SIRS. INTERVENTIONS: ASA 100 mg 12-hourly or placebo, administered within 24 hours of ICU admission and continued until ICU day 7, discharge or death, whichever came first. MAIN OUTCOME MEASURES: Interleukin-6 (IL-6) serum concentration at 48 hours after randomisation and, in a prespecified subgroup of patients, serum lipid mediator concentrations measured by mass spectrometry. RESULTS: The trial was discontinued in December 2017 due to slow recruitment and after the inclusion of 48 patients. Compared with placebo, ASA did not decrease IL-6 serum concentration at 48 hours. In the 32 patients with analysis of lipid mediators, low-dose ASA increased the concentration of 15-hydroxyeicosatetraenoic acid, a proresolving precursor of lipoxin A4, and reduced the concentration of the proinflammatory cytochrome P-dependent mediators 17-HETE (hydroxyeicosatetraenoic acid), 18-HETE and 20-HETE. In the eicosapentaenoic acid pathway, ASA significantly increased the concentration of the anti-inflammatory mediators 17,18-DiHETE (dihydroxyeicosatetraenoic acid) and 14,15-DiHETE. CONCLUSIONS: In ICU patients with SIRS, low-dose ASA did not significantly alter serum IL-6 concentrations, but it did affect plasma concentrations of certain lipid mediators. The ability to measure lipid mediators in clinical samples and to monitor the effect of ASA on their levels unlocks a potential area of biological investigation in critical care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN 12614001165673).


Assuntos
Aspirina/administração & dosagem , Estado Terminal , Citocinas/efeitos dos fármacos , Metaboloma/efeitos dos fármacos , Síndrome de Resposta Inflamatória Sistêmica/tratamento farmacológico , Austrália , Método Duplo-Cego , Estudos de Viabilidade , Humanos , Interleucina-6/sangue , Lipídeos , Resultado do Tratamento
13.
Crit Care Resusc ; 22(3): 245-252, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900331

RESUMO

OBJECTIVE: The degree of sedation or agitation in critically ill patients is typically assessed with the Richmond Agitation and Sedation Scale (RASS). However, this approach is intermittent and subject to unrecognised variation between assessments. High frequency accelerometry may assist in achieving a quantitative and continuous assessment of sedation while heralding imminent agitation. DESIGN: We undertook a prospective, observational pilot study. SETTING: An adult tertiary intensive care unit in Melbourne, Australia. PARTICIPANTS: 20 patients with an admission diagnosis of trauma. MAIN OUTCOME MEASURES: Accelerometers were applied to patients' wrists and used to continuously record patient movement. Video data of patient behaviour were simultaneously collected, and observers blinded to accelerometry data were adjudicated the RASS score every 30 seconds. Exploratory analyses were undertaken. RESULTS: Patients were enrolled for a median duration of 9.7 hours (interquartile range [IQR], 0-22.8) and a total of 160 hours. These patients had a median RASS score of 0 (IQR, -4 to 0). A 2-minute moving window of amplitude variance was seen to reflect contemporaneous fluctuations in motor activity and was proportional to the RASS score. Furthermore, the moving window of amplitude variance was observed to spike immediately before ≥ 2 point increases in the RASS score. CONCLUSIONS: We describe a novel approach to the analysis of wrist accelerometry data in critically ill patients. This technique not only appears to provide novel and continuous information about the depth of sedation or degree of agitation, it is also notable in its aptitude to anticipate impending transitions to higher RASS values.


Assuntos
Acelerometria/estatística & dados numéricos , Estado de Consciência , Estado Terminal , Agitação Psicomotora , Adulto , Austrália , Cuidados Críticos , Humanos , Projetos Piloto , Estudos Prospectivos
14.
Crit Care Resusc ; 22(3): 257-265, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900333

RESUMO

Albumin is the most abundant and perhaps most important protein in human blood. Research has identified many of albumin's possible roles in modulating acid-base balance, modifying inflammation, maintaining vascular endothelial integrity, and binding endogenous and exogenous compounds. Albumin plays a key role in the homeostasis of vascular endothelium, offering protection from inflammation and damage to the glycocalyx. Albumin binds a diverse range of compounds. It transports, delivers and clears drugs, plus it helps with uptake, storage and disposal of potentially harmful biological products. The biological effects of albumin in critical illness are incompletely understood, but may enhance its clinical role beyond use as an intravenous fluid. In this article, we summarise the evidence surrounding albumin's biological and physiological effects beyond its use for plasma volume expansion, and explore potential mechanistic effects of albumin as a disease modifier in patients with critical illness.


Assuntos
Albuminas/farmacologia , Endotélio Vascular/efeitos dos fármacos , Glicocálix , Células Endoteliais/metabolismo , Homeostase , Humanos
15.
Crit Care Resusc ; 22(3): 275-280, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900336

RESUMO

OBJECTIVE: To help shape the design of a future double blind placebo-controlled randomised clinical trial of bicarbonate therapy for metabolic acidosis, based on opinions of intensive care clinicians in Australia and New Zealand. DESIGN: An online survey was designed, piloted and distributed electronically to members of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) mailing list. The survey sought to collect information about choice of placebo, method of bicarbonate administration, and acid-base monitoring. MAIN OUTCOME MEASURES: Responses to six questions in the following domains were sought: 1) solution to be used as placebo; 2) method of administration; 3) target of the intervention; 4) timing of arterial blood gases to monitor the intervention; 5) duration of therapy; and 6) rate of bolus therapy (if selected as the best option). RESULTS: One in every eight ANZICS CTG members completed the survey (118/880, 13.4%). Compound sodium lactate was the preferred solution for placebo (54/118, 45.8%), and continuous infusion of bicarbonate (80/118, 67.8%) was the most frequently selected method of administration. A pH > 7.30 was the preferred target (50/118, 42.4%), while monitoring with arterial blood gas analysis every 2 hours until the target is reached and then every 4 hours was the most favoured option (40/118, 33.9%). The preferred duration of therapy was until the target is achieved (53/118, 44.9%). CONCLUSIONS: This survey offers important insights into the preferences of Australian and New Zealand clinicians in regards to any future randomised controlled trial of bicarbonate therapy for metabolic acidosis in the critically ill.


Assuntos
Acidose/tratamento farmacológico , Bicarbonato de Sódio/uso terapêutico , Acidose/sangue , Austrália , Cálcio/sangue , Cuidados Críticos , Estado Terminal , Método Duplo-Cego , Humanos , Nova Zelândia , Bicarbonato de Sódio/efeitos adversos , Inquéritos e Questionários , Resultado do Tratamento
16.
Crit Care Med ; 48(10): e951-e958, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32931198

RESUMO

OBJECTIVES: To compare the effects of restoring mean arterial pressure with vasopressin or norepinephrine on systemic hemodynamics, renal blood flow, intrarenal perfusion and oxygenation, and renal function in ovine septic acute kidney injury. DESIGN: Interventional Study. SETTING: Research Institute. SUBJECTS: Adult Merino ewes. INTERVENTIONS: Flow probes were implanted on the pulmonary and renal arteries (and the mesenteric artery in sheep that received vasopressin). Fiber-optic probes were implanted in the renal cortex and medulla to measure tissue perfusion and oxygen tension (PO2). Conscious sheep were administered Escherichia coli to induce septic acute kidney injury. Vasopressin (0.03 IU/min [0.03-0.05 IU/min]; n = 7) or norepinephrine (0.60 µg/kg/min [0.30-0.70 µg/kg/min]; n = 7) was infused IV and titrated to restore baseline mean arterial pressure during 24-30 hours of sepsis. MEASUREMENTS AND MAIN RESULTS: Ovine septic acute kidney injury was characterized by reduced mean arterial pressure (-16% ± 2%) and creatinine clearance (-65% ± 9%) and increased renal blood flow (+34% ± 7%) but reduced renal medullary perfusion (-44% ± 7%) and PO2 (-47% ± 10%). Vasopressin infusion did not significantly affect renal medullary perfusion or PO2 and induced a sustained (6 hr) ~2.5-fold increase in creatinine clearance. Vasopressin reduced sepsis-induced mesenteric hyperemia (+61 ± 13 to +9% ± 6%). Norepinephrine transiently (2 hr) improved creatinine clearance (by ~3.5-fold) but worsened renal medullary ischemia (to -64% ± 7%) and hypoxia (to -71% ± 6%). CONCLUSIONS: In ovine septic acute kidney injury, restoration of mean arterial pressure with vasopressin induced a more sustained improvement in renal function than norepinephrine, without exacerbating renal medullary ischemia and hypoxia or reducing mesenteric blood flow below baseline values.

17.
Kidney Int ; 2020 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-32882263

RESUMO

In sepsis-induced acute kidney injury, kidney blood flow may increase despite decreased glomerular filtration. Normally, angiotensin-II reduces kidney blood flow to maintain filtration. We hypothesized that sepsis reduces angiotensin type-1 receptor (AT1R) expression to account for this observation and tested this hypothesis in a patient case-control study and studies in mice. Seventy-three mice underwent cecal ligation and puncture (a sepsis model) or sham operation. Additionally, 94 septic mice received losartan (selective AT1R antagonist), angiotensin II without or with losartan, or vehicle. Cumulative urine output, kidney blood flow, blood urea nitrogen, and creatinine were measured. AT1R expression was assessed using ELISA, qPCR, and immunofluorescence. A blinded pathologist evaluated tissue for ischemic injury. AT1R expression was compared in autopsy tissue from seven patients with sepsis to that of the non-involved portion of kidney from ten individuals with kidney cancer and three non-infected but critically ill patients. By six hours post ligation/puncture, kidney blood flow doubled, blood urea nitrogen rose, and urine output fell. Concurrently, AT1R expression significantly fell 2-fold in arterioles and the macula densa. Creatinine significantly rose by 24 hours and sham operation did not alter measurements. Losartan significantly exacerbated ligation/puncture-induced changes in kidney blood flow, blood urea nitrogen, creatinine, and urine output. There was no histologic evidence of cortical ischemia. Significantly, angiotensin II prevented changes in kidney blood flow, creatinine, and urine output compared to vehicle. Co-administering losartan with angiotensin-II reversed this protection. Relative to both controls, patients with sepsis had low AT1R expression in arterioles and macula densa. Thus, murine cecal ligation/puncture and clinical sepsis decrease renal AT1R expression. Angiotensin II prevents functional changes while AT1R-blockade exacerbates them independent of ischemia in mice.

18.
Br J Anaesth ; 125(5): 730-738, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32891413

RESUMO

BACKGROUND: A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU. METHODS: We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1-4) frail (CFS 5-8), mild/moderately frail (CFS 5-6),and severe/very severely frail (CFS 7-8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories. RESULTS: 1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3-7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6-20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7-3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7-3.9]). CONCLUSIONS: Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ≥5 to guide ICU admission for pneumonia.

19.
Crit Care Resusc ; 22(3): 200-211, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32900326

RESUMO

OBJECTIVE: Describe characteristics, daily care and outcomes of patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS). DESIGN: Case series of 73 patients. SETTING: Large tertiary hospital in Milan. PARTICIPANTS: Mechanically ventilated patients with confirmed COVID-19 admitted to the intensive care unit (ICU) between 20 February and 2 April 2020. MAIN OUTCOME MEASURES: Demographic and daily clinical data were collected to identify predictors of early mortality. RESULTS: Of the 73 patients included in the study, most were male (83.6%), the median age was 61 years (interquartile range [IQR], 54-69 years), and hypertension affected 52.9% of patients. Lymphocytopenia (median, 0.77 x 103 per mm3; IQR, 0.58-1.00 x 103 per mm3), hyperinflammation with C-reactive protein (median, 184.5 mg/dL; IQR, 108.2-269.1 mg/dL) and pro-coagulant status with D-dimer (median, 10.1 µg/m; IQR, 5.0-23.8 µg/m) were present. Median tidal volume was 6.7 mL/kg (IQR, 6.0-7.5 mL/kg), and median positive end-expiratory pressure was 12 cmH2O (IQR, 10-14 cmH2O). In the first 3 days, prone positioning (12-16 h) was used in 63.8% of patients and extracorporeal membrane oxygenation in five patients (6.8%). After a median follow-up of 19.0 days (IQR, 15.0-27.0 days), 17 patients (23.3%) had died, 23 (31.5%) had been discharged from the ICU, and 33 (45.2%) were receiving invasive mechanical ventilation in the ICU. Older age (odds ratio [OR], 1.12; 95% CI, 1.04-1.22; P = 0.004) and hypertension (OR, 6.15; 95% CI, 1.75-29.11; P = 0.009) were associated with mortality, while early improvement in arterial partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) ratio was associated with being discharged alive from the ICU (P = 0.002 for interaction). CONCLUSIONS: Despite multiple advanced critical care interventions, COVID-19 ARDS was associated with prolonged ventilation and high short term mortality. Older age and pre-admission hypertension were key mortality risk factors. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04318366.


Assuntos
Infecções por Coronavirus/mortalidade , Pneumonia Viral/mortalidade , Respiração Artificial , Síndrome do Desconforto Respiratório do Adulto/mortalidade , Fatores Etários , Idoso , Betacoronavirus , Causas de Morte , Infecções por Coronavirus/terapia , Feminino , Humanos , Hipertensão/complicações , Itália , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/terapia , Síndrome do Desconforto Respiratório do Adulto/terapia , Síndrome do Desconforto Respiratório do Adulto/virologia , Fatores de Risco
20.
JAMA ; 324(9): 848-858, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32870298

RESUMO

Importance: In patients who undergo mechanical ventilation during surgery, the ideal tidal volume is unclear. Objective: To determine whether low-tidal-volume ventilation compared with conventional ventilation during major surgery decreases postoperative pulmonary complications. Design, Setting, and Participants: Single-center, assessor-blinded, randomized clinical trial of 1236 patients older than 40 years undergoing major noncardiothoracic, nonintracranial surgery under general anesthesia lasting more than 2 hours in a tertiary hospital in Melbourne, Australia, from February 2015 to February 2019. The last date of follow-up was February 17, 2019. Interventions: Patients were randomized to receive a tidal volume of 6 mL/kg predicted body weight (n = 614; low tidal volume group) or a tidal volume of 10 mL/kg predicted body weight (n = 592; conventional tidal volume group). All patients received positive end-expiratory pressure (PEEP) at 5 cm H2O. Main Outcomes and Measures: The primary outcome was a composite of postoperative pulmonary complications within the first 7 postoperative days, including pneumonia, bronchospasm, atelectasis, pulmonary congestion, respiratory failure, pleural effusion, pneumothorax, or unplanned requirement for postoperative invasive or noninvasive ventilation. Secondary outcomes were postoperative pulmonary complications including development of pulmonary embolism, acute respiratory distress syndrome, systemic inflammatory response syndrome, sepsis, acute kidney injury, wound infection (superficial and deep), rate of intraoperative need for vasopressor, incidence of unplanned intensive care unit admission, rate of need for rapid response team call, intensive care unit length of stay, hospital length of stay, and in-hospital mortality. Results: Among 1236 patients who were randomized, 1206 (98.9%) completed the trial (mean age, 63.5 years; 494 [40.9%] women; 681 [56.4%] undergoing abdominal surgery). The primary outcome occurred in 231 of 608 patients (38%) in the low tidal volume group compared with 232 of 590 patients (39%) in the conventional tidal volume group (difference, -1.3% [95% CI, -6.8% to 4.2%]; risk ratio, 0.97 [95% CI, 0.84-1.11]; P = .64). There were no significant differences in any of the secondary outcomes. Conclusions and Relevance: Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume compared with conventional tidal volume, with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days. Trial Registration: ANZCTR Identifier: ACTRN12614000790640.


Assuntos
Pneumopatias/prevenção & controle , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios , Volume de Ventilação Pulmonar , Adulto , Feminino , Humanos , Incidência , Cuidados Intraoperatórios , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Método Simples-Cego , Procedimentos Cirúrgicos Operatórios/efeitos adversos
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