Optimal Arterial Blood Oxygen Tension in the Early Postresuscitation Phase of Extracorporeal Cardiopulmonary Resuscitation: A 15-Year Retrospective Observational Study.

OBJECTIVES: Hyperoxia could lead to a worse outcome after cardiac arrest. Few studies have investigated the impact of oxygenation status on patient outcomes following extracorporeal cardiopulmonary resuscitation. We sought to delineate the association between oxygenation status and neurologic outcomes in patients receiving extracorporeal cardiopulmonary resuscitation. DESIGN: Retrospective analysis of a prospective extracorporeal cardiopulmonary resuscitation registry database. SETTING: An academic tertiary care hospital. PATIENTS: Patients receiving extracorporeal cardiopulmonary resuscitation between 2000 and 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 291 patients were included, and 80.1% were male. Their mean age was 56.0 years. The arterial blood gas data employed in the primary analysis were recorded from the first sample over the first 24 hours in the ICUs after return of spontaneous circulation. The mean PaO2 after initiation of venoarterial extracorporeal membrane oxygenation was 178.0 mm Hg, and the mean PaO2/FIO2 ratio was 322.0. Only 88 patients (30.2%) demonstrated favorable neurologic status at hospital discharge. Multivariate logistic regression analysis indicated that PaO2 between 77 and 220 mm Hg (odds ratio, 2.29; 95% CI, 1.01-5.22; p = 0.05) and PaO2/FIO2 ratio between 314 and 788 (odds ratio, 5.09; 95% CI, 2.13-12.14; p < 0.001) were both positively associated with favorable neurologic outcomes. CONCLUSIONS: Oxygenation status during extracorporeal membrane oxygenation affects neurologic outcomes in patients receiving extracorporeal cardiopulmonary resuscitation. The PaO2 range of 77 to 220 mm Hg, which is slightly narrower than previously defined, seems optimal. The PaO2/FIO2 ratio was also associated with outcomes in our analysis, indicating that both PaO2 and the PaO2/FIO2 ratio should be closely monitored during the early postcardiac arrest phase for postextracorporeal cardiopulmonary resuscitation patients.

Peroxiredoxin 1 induces inflammatory cytokine response and predicts outcome of cardiogenic shock patients necessitating extracorporeal membrane oxygenation: an observational cohort study and translational approach.

BACKGROUND: Extracellular peroxiredoxin 1 (Prdx1) has been implicated to play a pivotal role in regulating inflammation; however, its function in tissue hypoxia-induced inflammation, such as severe cardiogenic shock patients, has not yet been defined. Thus, the objective of this study was to test the hypothesis that Prdx1 possesses prognostic value and instigates systemic inflammatory response syndrome in cardiogenic shock patients undergoing extracorporeal membrane oxygenation (ECMO) support. METHODS: We documented the early time course evolution of circulatory Prdx1, hypoxic marker carbonic anhydrase IX, inflammatory cytokines including IL-6, IL-8, IL-10, MCP-1, TNF-α, IL-1ß, and danger signaling receptors (TLR4 and CD14) in a cohort of cardiogenic shock patients within 1 day after ECMO support. In vitro investigations employing cultured murine macrophage cell lines and human monocytes were applied to clarify the relationship between Prdx1 and inflammatory response. RESULTS: Prdx1 not only peaked earlier than all the other cytokines we studied during the initial course, but also predicted a worse outcome in patients who had higher initial Prdx1 plasma levels. The Prdx1 levels in patients positively correlated with hypoxic markers carbonic anhydrase IX and lactate, and inflammatory cytokines. In vitro study demonstrated that hypoxia/reoxygenation induced Prdx1 release from human monocytes and enhanced the responsiveness of the monocytes in Prdx1-induced cytokine secretions. Furthermore, functional inhibition by Prdx1 antibody implicated a crucial role of Prdx1 in hypoxia/reoxygenation-induced IL-6 secretion. CONCLUSIONS: Prdx1 release during the early phase of ECMO support in cardiogenic shock patients is associated with the development of systemic inflammatory response syndrome and poor clinical outcomes. Thus, circulating Prdx1 provides not only prognostic information but may be a promising target against ischemia/reperfusion injury.

Long-term risk of coronary events after AKI.

The incidence rate of AKI in hospitalized patients is increasing. However, relatively little attention has been paid to the association of AKI with long-term risk of adverse coronary events. Our study investigated hospitalized patients who recovered from de novo dialysis-requiring AKI between 1999 and 2008 using patient data collected from inpatient claims from Taiwan National Health Insurance. We used Cox regression with time-varying covariates to adjust for subsequent CKD and ESRD after discharge. Results were further validated by analysis of a prospectively constructed database. Among 17,106 acute dialysis patients who were discharged, 4869 patients recovered from dialysis-requiring AKI (AKI recovery group) and were matched with 4869 patients without AKI (non-AKI group). The incidence rates of coronary events were 19.8 and 10.3 per 1000 person-years in the AKI recovery and non-AKI groups, respectively. AKI recovery associated with higher risk of coronary events (hazard ratio [HR], 1.67; 95% confidence interval [95% CI], 1.36 to 2.04) and all-cause mortality (HR, 1.67; 95% CI, 1.57 to 1.79) independent of the effects of subsequent progression to CKD and ESRD. The risk levels of de novo coronary events after hospital discharge were similar in patients with diabetes alone and patients with AKI alone (P=0.23). Our results reveal that AKI with recovery associated with higher long-term risks of coronary events and death in this cohort, suggesting that AKI may identify patients with high risk of future coronary events. Enhanced postdischarge follow-up of renal function of patients who have recovered from temporary dialysis may be warranted.

Multi-scale symbolic entropy analysis provides prognostic prediction in patients receiving extracorporeal life support.

INTRODUCTION: Extracorporeal life support (ECLS) can temporarily support cardiopulmonary function, and is occasionally used in resuscitation. Multi-scale entropy (MSE) derived from heart rate variability (HRV) is a powerful tool in outcome prediction of patients with cardiovascular diseases. Multi-scale symbolic entropy analysis (MSsE), a new method derived from MSE, mitigates the effect of arrhythmia on analysis. The objective is to evaluate the prognostic value of MSsE in patients receiving ECLS. The primary outcome is death or urgent transplantation during the index admission. METHODS: Fifty-seven patients receiving ECLS less than 24 hours and 23 control subjects were enrolled. Digital 24-hour Holter electrocardiograms were recorded and three MSsE parameters (slope 5, Area 6-20, Area 6-40) associated with the multiscale correlation and complexity of heart beat fluctuation were calculated. RESULTS: Patients receiving ECLS had significantly lower value of slope 5, area 6 to 20, and area 6 to 40 than control subjects. During the follow-up period, 29 patients met primary outcome. Age, slope 5, Area 6 to 20, Area 6 to 40, acute physiology and chronic health evaluation II score, multiple organ dysfunction score (MODS), logistic organ dysfunction score (LODS), and myocardial infarction history were significantly associated with primary outcome. Slope 5 showed the greatest discriminatory power. In a net reclassification improvement model, slope 5 significantly improved the predictive power of LODS; Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in MODS. In an integrated discrimination improvement model, slope 5 added significantly to the prediction power of each clinical parameter. Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in sequential organ failure assessment. CONCLUSIONS: MSsE provides additional prognostic information in patients receiving ECLS.

To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization.

BACKGROUND: The growing prevalence of health care ethics consultation (HCEC) services in the U.S. has been accompanied by an increase in calls for accountability and quality assurance, and for the debates surrounding why and how HCEC is evaluated. The objective of this study was to evaluate the effectiveness of HCEC as indicated by several novel outcome measurements in East Asian medical encounters. METHODS: Patients with medical uncertainty or conflict regarding value-laden issues, and requests made by the attending physicians or nurses for HCEC from December 1, 2009 to April 30, 2012 were randomly assigned to the usual care group (UC group) and the intervention group (HCEC group). The patients in the HCEC group received HCEC conducted by an individual ethics consultant. Data analysis was based on the intention-to-treat principle. Mann-Whitney test and Chi-squared test were used depending on the scale of measurement. RESULTS: Thirty-three patients (53.23%) were randomly assigned to the HCEC group and 29 patients were randomly assigned to the UC group. Among the 33 patients in the HCEC group, two (6.06%) of them ultimately did not receive a HCEC service. Among the 29 patients in the UC group, four (13.79%) of them received a HCEC service. The survival rate at hospital discharge did not differ between the two groups. Patients in the HCEC group showed significant reductions in the entire ICU stay and entire hospital stay. HCEC significantly facilitated achieving the goal of medical care (p < .01). Furthermore, patients in the HCEC group had a shorter ICU stay and shorter hospital stay after the occurrence of medical uncertainty or conflict regarding value-laden issues than those in the UC group. CONCLUSIONS: Our findings demonstrated that HCEC were associated with reduced consumption of medical resources as indicated by shorter entire ICU stay, entire hospital stay, and shorter ICU and hospital stay after the occurrence of the medical uncertainty or conflict regarding value-laden issues. This study also showed that HCEC facilitated achieving a consensus regarding the goal of medical care, which conforms to the goal of HCEC.

Advanced age affects the outcome-predictive power of RIFLE classification in geriatric patients with acute kidney injury.

The RIFLE (risk, injury, failure, loss, and end-stage) classification is widely used to gauge the severity of acute kidney injury, but its efficacy has not been formally tested in geriatric patients. To correct this we conducted a prospective observational study in a multicenter cohort of 3931 elderly patients (65 years of age or older) who developed acute kidney injury in accordance with the RIFLE creatinine criteria after major surgery. We studied the predictive power of the RIFLE classification for in-hospital mortality and investigated the potential interaction between age and RIFLE classification. In general, the survivors were significantly younger than the nonsurvivors and more likely to have hypertension. In patients 76 years of age and younger, RIFLE-R, -I, or -F classifications were significantly associated with increased hospital mortality in a stepwise manner. There was no significant difference, however, in hospital mortality in those over 76 years of age between patients with RIFLE-R and RIFLE-I, although RIFLE-F patients had significantly higher mortality than both groups. Thus, the less severe categorizations of acute kidney injury per RIFLE classification may not truly reflect the adverse impact on elderly patients.

Kidney function decline after a non-dialysis-requiring acute kidney injury is associated with higher long-term mortality in critically ill survivors.

INTRODUCTION: The adverse consequences of a non-dialysis-requiring acute kidney injury (AKI) are unclear. This study aimed to assess the long-term prognoses for critically ill patients experiencing a non-dialysis-requiring AKI. METHODS: This retrospective observational cohort study investigated non-dialysis-requiring AKI survivors in surgical intensive care units between January 2002 and June 2010. All longitudinal post-discharge serum creatinine measurements and information regarding end-stage renal disease (ESRD) and death were collected. We assessed the long-term outcomes of chronic kidney disease (CKD), ESRD and all-cause mortality beyond discharge. RESULTS: Of the 922 identified critically ill patients with a non-dialysis-requiring AKI, 634 (68.8%) patients who survived to discharge were enrolled. A total of 207 patients died after a median follow-up of 700.5 days. The median intervals between the onset of the AKI and the composite endpoints "stage 3 CKD or death", "stage 4 CKD or death", "stage 5 CKD or death", and "ESRD or death" were 685, 1319, 1743, and 2048 days, respectively. This finding shows a steady long-term decline in kidney function after discharge. Using the multivariate Cox proportional hazard model, we found that every 1 mL/min/1.73 m2 decrease from baseline estimated glomerular filtration rate (eGFR) of individuals who progressed to stage 3, 4, and 5 CKD increased the risks of long-term mortality by 0.7%, 2.3%, and 4.1%, respectively (all p < 0.05). This result indicates that the mortality risk increased significantly in a graded manner as kidney function declined from the baseline eGFR to advanced stages of CKD during the follow-up period. CONCLUSIONS: In critically ill patients who survive a non-dialysis-requiring AKI, there is a need for continuous monitoring and kidney function protection beyond discharge.

Preoperative proteinuria predicts adverse renal outcomes after coronary artery bypass grafting.

Whether preoperative proteinuria associates with adverse renal outcomes after cardiac surgery is unknown. Here, we performed a secondary analysis of a prospectively enrolled cohort of adult patients undergoing coronary artery bypass grafting (CABG) at a medical center and its two affiliate hospitals between 2003 and 2007. We excluded patients with stage 5 CKD or those who received dialysis previously. We defined proteinuria, measured with a dipstick, as mild (trace to 1+) or heavy (2+ to 4+). Among a total of 1052 patients, cardiac surgery-associated acute kidney injury (CSA-AKI) developed in 183 (17.4%) patients and required renal replacement therapy (RRT) in 50 (4.8%) patients. In a multiple logistic regression model, mild and heavy proteinuria each associated with an increased odds of CSA-AKI, independent of CKD stage and the presence of diabetes mellitus (mild: OR 1.66, 95% CI 1.09 to 2.52; heavy: OR 2.30, 95% CI 1.35 to 3.90). Heavy proteinuria also associated with increased odds of postoperative RRT (OR 7.29, 95% CI 3.00 to 17.73). In summary, these data suggest that preoperative proteinuria is a predictor of CSA-AKI among patients undergoing CABG.

Acute-on-chronic kidney injury at hospital discharge is associated with long-term dialysis and mortality.

Existing chronic kidney disease (CKD) is among the most potent predictors of postoperative acute kidney injury (AKI). Here we quantified this risk in a multicenter, observational study of 9425 patients who survived to hospital discharge after major surgery. CKD was defined as a baseline estimated glomerular filtration rate <45 ml/min per 1.73 m(2). AKI was stratified according to the maximum simplified RIFLE classification at hospitalization and unresolved AKI defined as a persistent increase in serum creatinine of more than half above the baseline or the need for dialysis at discharge. A Cox proportional hazard model showed that patients with AKI-on-CKD during hospitalization had significantly worse long-term survival over a median follow-up of 4.8 years (hazard ratio, 1.7) [corrected] than patients with AKI but without CKD.The incidence of long-term dialysis was 22.4 and 0.17 per 100 person-years among patients with and without existing CKD, respectively. The adjusted hazard ratio for long-term dialysis in patients with AKI-on-CKD was 19.8 compared to patients who developed AKI without existing CKD. Furthermore, AKI-on-CKD but without kidney recovery at discharge had a worse outcome (hazard ratios of 4.6 and 213, respectively) for mortality and long-term dialysis as compared to patients without CKD or AKI. Thus, in a large cohort of postoperative patients who developed AKI, those with existing CKD were at higher risk for long-term mortality and dialysis after hospital discharge than those without. These outcomes were significantly worse in those with unresolved AKI at discharge.

Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury.

INTRODUCTION: Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients. METHODS: Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT. RESULTS: Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05). CONCLUSIONS: Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

Extracorporeal membrane oxygenation bridge to adult heart transplantation.

Extracorporeal membrane oxygenation (ECMO) can rescue some critical patients with circulatory collapse when intra-aortic balloon pump (IABP) and ventricular assist devices (VAD) are not suitable. A subset of these patients can use ECMO for direct bridging, or indirect double bridging via VAD to heart transplantation (HTx). For these patients, we identified risk factors for unsuccessful ECMO bridging, with survival to receiving either HTx or VAD as the measure of success. The characteristics evaluated were age, sex, body mass index, pre-ECMO cardiopulmonary resuscitation (CPR), IABP use, dialysis use, sequential organ failure assessment (SOFA) score, and the etiology of cardiomyopathy. From January 1995 to August 2007, there were 70 adult ECMO patients with the intent to bridge to HTx (male: 55, age: 46 +/- 14 yr). Thirty-one patients (44%) were successful in bridging. A stepwise multivariate logistic regression analysis found that age > 50 yr (p = 0.003), pre-ECMO CPR (p = 0.001) and SOFA score > 10 at ECMO initiation (p = 0.018) were significant independent predictors of unsuccessful bridging. Direct VAD implantation, if possible, is preferable to double bridging in patients over 50 yr. Also, elective ECMO support before hemodynamic deterioration to cardiac arrest or multiple organ dysfunction would improve rates of successful ECMO bridging.

Prognostic factors for adult patients receiving extracorporeal membrane oxygenation as mechanical circulatory support--a 14-year experience at a medical center.

Extracorporeal membrane oxygenation (ECMO) is a resource-consuming and highly invasive treatment. There were 1100 ECMO cases at the National Taiwan University Hospital between August 1994 and November 2008. Of these, 607 were adults (>18 years old) who received ECMO as mechanical circulatory support. In this study, patient characteristics and complications during the ECMO course were evaluated for their correlation with prognosis. The following factors were significantly different between survivors and nonsurvivors: age, coronary artery disease, diabetes mellitus, brain death, stroke during ECMO, the need for dialysis during ECMO, pre-ECMO infection, hypoglycemia, acidosis, alkalosis, the need for a distal perfusion catheter, and the amount of red blood cells transfused. Six independent predictors of mortality were identified: age, stroke, the need for dialysis during ECMO, pre-ECMO infection, hypoglycemia, and alkalosis. Our institution has comparatively extensive experience with adult patients, which may be quite different from other medical centers with respect to distribution of patient age. The findings should lead to better utilization of ECMO for adult patients in the future.

Patients supported by extracorporeal membrane oxygenation and acute dialysis: acute physiology and chronic health evaluation score in predicting hospital mortality.

Extracorporeal membrane oxygenation (ECMO) can provide short-term cardiopulmonary support to critically ill patients. Among ECMO patients, acute renal failure requiring dialysis has an ominous prognosis. However, a prognostic scoring system and risk factors adjustment for hospital mortality in these patients have not been elucidated previously. A multicenter observational cohort study was conducted from January 2002 to December 2006. Information obtained included demographics, biochemical variables, Acute Physiology and Chronic Health Evaluation (APACHE) II, III, and IV scores at ICU admission and initial acute dialysis, and hospital mortality in 102 non-coronary artery bypass graft (CABG) patients receiving ECMO support with acute dialysis. This retrospective cohort study included 70 men and 32 women with a mean age of 47.9 ± 15.7 years. Seventy-two patients (70.6%) had hospital mortality. The area under the receiver operating characteristic curve showed APACHE IV (0.653) had a better discriminative power to predict hospital mortality than APACHE II (0.584) and APACHE III (0.634) at initializing dialysis. Hosmer-Lemeshow statistics showed good calibration for all three scores to predict hospital mortality at initializing dialysis (APACHE IV, P = 0.392; APACHE III, P = 0.094; and APACHE II, P = 0.673). Independent predictors for hospital mortality by multivariate logistic regression analysis were higher central venous pressure (odds ratio [OR], 1.11; confidence interval [CI] 95%, 1.02-1.20; P = 0.016), higher APACHE IV score at initializing dialysis (OR, 1.03; CI 95%, 1.01-1.05; P = 0.003), and latency from hospital admission to dialysis (OR, 1.04; CI 95%, 1.00-1.08; P = 0.033). High mortality rate was noted in non-CABG patients receiving ECMO and acute dialysis. Predialysis APACHE IV scores had good calibration and moderate discrimination in predicting hospital mortality in these patients. Because ECMO support could stabilize cardiopulmonary status, APACHE IV scores would likewise underestimate disease severity at lower score ranges in these patients.

Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.

BACKGROUND: Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin. METHODS: We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18-75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00173615. FINDINGS: Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0.0001) and a better 1-year survival than those who received conventional CPR (log rank p=0.007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0.51, 95% CI 0.35-0.74, p<0.0001), 30-day survival (HR 0.47, 95% CI 0.28-0.77, p=0.003), and 1-year survival (HR 0.53, 95% CI 0.33-0.83, p=0.006) favouring extracorporeal CPR over conventional CPR. INTERPRETATION: Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.

Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery.

INTRODUCTION: Abdominal surgery is probably associated with more likelihood to cause acute kidney injury (AKI). The aim of this study was to evaluate whether early or late start of renal replacement therapy (RRT) defined by simplified RIFLE (sRIFLE) classification in AKI patients after major abdominal surgery will affect outcome. METHODS: A multicenter prospective observational study based on the NSARF (National Taiwan University Surgical ICU Associated Renal Failure) Study Group database. 98 patients (41 female, mean age 66.4 +/- 13.9 years) who underwent acute RRT according to local indications for post-major abdominal surgery AKI between 1 January, 2002 and 31 December, 2005 were enrolled The demographic data, comorbid diseases, types of surgery and RRT, as well as the indications for RRT were documented. The patients were divided into early dialysis (sRIFLE-0 or Risk) and late dialysis (LD, sRIFLE -Injury or Failure) groups. Then we measured and recorded patients' outcome including in-hospital mortality and RRT wean-off until 30 June, 2006. RESULTS: The in-hospital mortality was compared as endpoint. Fifty-seven patients (58.2%) died during hospitalization. LD (hazard ratio (HR) 1.846; P = 0.027), old age (HR 2.090; P = 0.010), cardiac failure (HR 4.620; P < 0.001), pre-RRT SOFA score (HR 1.152; P < 0.001) were independent indicators for in-hospital mortality. CONCLUSIONS: The findings of this study support earlier initiation of acute RRT, and also underscore the importance of predicting prognoses of major abdominal surgical patients with AKI by using RIFLE classification.

Risk factors of early redialysis after weaning from postoperative acute renal replacement therapy.

OBJECTIVE: The aim of this study was to identify risk factors for redialysis in postoperative patients with acute renal failure (ARF) who had previously been weaned from acute dialysis. Although recovery of renal function is anticipated in patients with ARF, no data have been reported on successful weaning from acute dialysis. DESIGN AND SETTING: Retrospective observational case-control study in a 64-bed surgical ICU. PATIENTS AND METHODS: Success in discontinuing dialysis was defined as cessation from dialysis for at least 30 days. A total of 304 postoperative patients who underwent acute renal replacement therapy in a surgical ICU between July 2002 and April 2005 were included. SOFA score biochemical data and renal function parameters were assessed on the day after the last session of renal replacement therapy, designated as day 0 (D0). RESULTS: We could wean 94 patients (30.9%) from acute dialysis for more than 5 days, and 64 of these (21.1%) were successfully weaned for at least 30days. The independent predictors for resuming dialysis within 30 days were: (a) longer duration of dialysis (OR 1.06), (b) higher SOFA score on D0 (OR 1.44), (c) oliguria (urine output <100cc/8h; OR 4.17) on D1, and (d) age over 65 years (OR 6.35). The area under the ROC curve was 0.880. Two-way analysis of variance with repeated measurements over time showed a larger decline in SOFA score and an increase in urine output in patients with successful cessation of dialysis. Kaplan-Meier analysis showed a significant difference in early resumption of dialysis between patients with or without oliguria at D0. CONCLUSIONS: More than two-thirds of patients weaned from postoperative acute dialysis for more than 5 days were free of dialysis for at least 30 days. Less urine output, longer duration of dialysis, age over 65 years, and higher disease severity score are predictive of a patient's redialysis after initial weaning from acute dialysis.

Early renal replacement therapy in patients with postoperative acute liver failure associated with acute renal failure: effect on postoperative outcomes.

BACKGROUND: Acute liver failure after major surgical procedures is associated with a high risk of multiple organ failure, including acute renal failure. The optimal time to initiate renal replacement therapy for acute renal failure is controversial because of the poor overall clinical outcomes. STUDY DESIGN: From July 2002 to January 2005, all patients who had no history of liver disease, but developed acute liver failure and subsequent renal failure requiring renal replacement therapy after major surgery, at a surgical intensive care unit, were retrospectively analyzed. Patients were divided into early or late dialysis groups based on an arbitrary blood urea nitrogen cut-off level of 80 mg/dL before renal replacement therapy. RESULTS: Eighty consecutive patients (21 women), with a mean age of 57.8+/-17.0 (SD) years, comprised the study group. The late dialysis group (n=26) had a higher ICU mortality rate (p=0.02) and a lower renal function recovery rate (p=0.02) than the early dialysis group (n=54). Fifty-three (66.3%) patients died during their ICU stay. Independent risk factors for ICU mortality were renal replacement therapy modality (intermittent hemodialysis versus continuous venous-venous hemofiltration; odds ratio [OR]=4.32, 95% CI 1.26 to 14.79; p=0.02), predialysis APACHE II score> 20 (OR=6.52, 95% CI 1.61 to 26.36; p < 0.01), and late dialysis (OR=4.01, 95% CI 1.05 to 15.27; p=0.04). CONCLUSIONS: The mortality rate in postoperative patients with acute liver failure-associated acute renal failure was very high. Earlier initiation of renal replacement therapy, based on the predialysis blood urea nitrogen level, with continuous venous-venous hemofiltration might provide a better ICU survival rate.

Early measurement of IL-10 predicts the outcomes of patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation.

Patients diagnosed with acute respiratory distress syndrome are generally severely distressed and associated with high morbidity and mortality despite aggressive treatments such as extracorporeal membrane oxygenation (ECMO) support. To identify potential biomarker of predicting value for appropriate use of this intensive care resource, plasma interleukin-10 along with relevant inflammatory cytokines and immune cell populations were examined during the early and subsequent disease courses of 51 critically ill patients who received ECMO support. High interleukin-10 levels at the time of ECMO installation and during the first 6 hours after ECMO support of these patients stand as a promising biomarker associated with grave prognosis. The initial interleukin-10 level is correlated to other conventional risk evaluation scores as a predictive factor for survival, and furthermore, elevated interleukin-10 levels are also related to a delayed recovery of certain immune cell populations such as CD14+CD16+, CD14+TLR4+ monocytes, and T regulator cells. Genetically, high interleukin-10 is associated to two polymorphic nucleotides (-592 C and -819 C) at the interleukin-10 gene promoter area. Our finding provides prognostic and mechanistic information on the outcome of severely respiratory distressed patients, and potentially paves the strategy to develop new therapeutic modality based on the principles of precision medicine.

Prolonged extracorporeal membrane oxygenation support for acute respiratory distress syndrome.

When all conventional treatments for respiratory failure in patients with acute respiratory distress syndrome (ARDS) have failed, extracorporeal membrane oxygenation (ECMO) can provide a chance of survival in these desperately ill patients. A 49-year-old male patient developed septic shock and progressive ARDS after liver abscess drainage. Venovenous ECMO was given due to refractory respiratory failure on postoperative day 6. Initially, two heparin-binding hollow-fiber microporous membrane oxygenators in parallel were used in the ECMO circuit. Twenty-two oxygenators were changed in the first 22 days of ECMO support because of plasma leak in the oxygenators. Each oxygenator had an average life of 48 hours. Thereafter, a single silicone membrane oxygenator was used in the ECMO circuit, which did not require change during the remaining 596 hours of ECMO. The patient's tidal volume was only 90 mL in the nadir and less than 300 mL for 26 days during the ECMO course. The patient required ECMO support for 48 days and survived despite complications, including septic shock, ARDS, acute renal failure, drug-induced leukopenia, and multiple internal bleeding. This patient received an unusually long duration of ECMO support. However, he survived, recovered well, and was in New York Heart Association functional class I-II, with a forced expiratory volume in 1 second of 81% of the predicted level 18 months later. In conclusion, ECMO can provide a chance of survival for patients with refractory ARDS. The reversibility of lung function is possible in ARDS patients regardless of the severity of lung dysfunction at the time of treatment.

Severe Sepsis and Septic Shock: Timing of Septic Shock Onset Matters.

INTRODUCTION: Timing of septic shock onset may play a prognostic role in severe sepsis; however, clinical evidence provides contradictory results. This study aimed to investigate possible associations between timing of onset of septic shock and patient outcome. METHODS: In a university-affiliated hospital, all patients admitted to the intensive care unit (ICU) for severe sepsis or septic shock from November 2007 to March 2011 were included. The primary outcome of interest was the impact of timing of septic shock onset on in-hospital mortality. We also sought to identify potential factors predicting development of septic shock after ICU admission. RESULTS: In total, 772 patients were identified to have severe sepsis; approximately two-thirds (487/772) of them experienced septic shock and overall in-hospital mortality was 57%. Timing of onset of septic shock was an independent predictor of in-hospital outcome, and there was an increasing trend of in-hospital mortality with later onset of septic shock. In addition, timing of septic shock onset provided further mortality risk stratification in patients with APACHE II scores of less than 20 and 20 to 25. We also found that patients who underwent cardiovascular surgery were more likely to experience septic shock after admission and those receiving neurosurgery were at lower risk of developing septic shock. CONCLUSIONS: This study showed the significance of timing of septic shock onset in prognosis among ICU patients with severe sepsis. Timing of shock onset further stratified patients with similar disease severity into different mortality risk groups. These findings deliver useful information regarding risk stratification of septic patients.