Protocoled resuscitation and the prevention of acute kidney injury

Effectiveness of First-Line Therapy with Old and Novel Antibiotics in Ventilator-Associated Pneumonia Caused by Carbapenem-Resistant Acinetobacter baumannii: A Real Life, Prospective, Observational, Single-Center Study

Evidence-based, standard antibiotic therapy for ventilator-associated pneumonia (VAP) caused by carbapenem-resistant Acinetobacter baumannii (CRAB) is a relevant unmet clinical need in the intensive care unit (ICU). We aimed to evaluate the effectiveness of first-line therapy with old and novel CRAB active antibiotics in monomicrobial VAP caused by CRAB. A prospective, observational study was performed in a mixed non-COVID-19 ICU. The primary outcome measure was clinical failure upon first-line targeted therapy. Features independently influencing failure occurrence were also investigated via Cox proportional multivariable analysis. To account for the imbalance in antibiotic treatment allocation, a propensity score analysis with an inverse probability treatment weighting approach was adopted. Of the 90 enrolled patients, 34 (38%) experienced clinical failure. Compared to patients who experienced a clinical resolution of VAP, those who had clinical failure were of an older age (median age 71 (IQR 64-78) vs. 62 (IQR 52-69) years), and showed greater burden of comorbidities (median Charlson comorbidity index 8 (IQR 6-8) vs. 4 (IQR 2-6)), higher frequency of immunodepression (44% vs. 21%), and greater clinical severity at VAP onset (median SOFA score 10 (IQR 9-11) vs. 9 (IQR 7-11)). Lower rates of use of fast molecular diagnostics for nosocomial pneumonia (8.8% vs. 30.3%) and of timely CRAB active therapy administration (65% vs. 89%), and higher rates of colistin-based targeted therapy (71% vs. 46%) were also observed in patients who failed first-line therapy. Overall, CRAB active iv regimens were colistin-based in 50 patients and cefiderocol-based in 40 patients, both always combined with inhaled colistin. According to the backbone agent of first-line regimens, clinical failure was lower in the cefiderocol group, compared to that in the colistin group (25% vs. 48%, respectively). In multivariable Cox regression analysis, the burden of comorbid conditions independently predicted clinical failure occurrence (Charlson index aHR = 1.21, 95% CI = 1.04-1.42, p = 0.01), while timely targeted antibiotic treatment (aHR = 0.40, 95% CI = 0.19-0.84, p = 0.01) and cefiderocol-based first-line regimens (aHR = 0.38, 95% CI = 0.17-0.85, p = 0.02) strongly reduced failure risk. In patients with VAP caused by CRAB, timely active therapy improves infection outcomes and cefiderocol holds promise as a first-line therapeutic option.

Effect of goal-directed fluid therapy on renal function in critically ill patients: a systematic review and meta-analysis

Objective

To evaluate whether goal-directed fluid therapy (GDFT) reduces the risk of renal injury in critical illness.

Methods

MEDLINE via PubMed, EMBASE, CENTRAL and CBM was searched from inception to 13 March 2022, for studies comparing the effect of GDFT with usual care on renal function in critically ill patients. GDFT was defined as a protocolized intervention based on hemodynamic and/or oxygen delivery parameters. A fixed or random effects model was applied to calculate the pooled odds ratio (OR) based on heterogeneity through the included studies.

Results

A total of 28 studies with 9,019 patients were included. The pooled data showed that compared with usual care, GDFT reduced the incidence of acute kidney injury (AKI) in critical illness (OR 0.62, 95% confidence interval (CI) 0.47 to 0.80, p< 0.001). Sensitivity analysis with only low risk of bias studies showed the same result. Subgroup analyses found that GDFT was associated with a lower AKI incidence in both postoperative and medical patients. The reduction was significant in GDFT aimed at dynamic indicators. However, no significant difference was found between groups in RRT support (OR 0.88, 95% CI 0.74 to 1.05, p= 0.17). GDFT tended to increase fluid administration within the first 6 h, decrease fluid administration after 24 h, and was associated with more vasopressor requirements.

Conclusions

This meta-analysis suggests that GDFT aimed at dynamic indicators may be an effective way to prevent AKI in critical illness. This may indicate a benefit from early adequate fluid resuscitation and the combined effect of vasopressors.

Physiologic and hemodynamic changes in patients undergoing open abdominal cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

Objective

We aimed to determine the physiological and hemodynamic changes in patients who were undergoing hyperthermic intraperitoneal chemotherapy (HIPEC) cytoreductive surgeries.

Methods

This prospective, observational study enrolled 21 patients who were undergoing elective cytoreductive surgery with HIPEC at our hospital over 2 years. We collected vital signs, hemodynamic parameters including global end-diastolic volume index (GEVI) and extravascular lung water index (ELWI) using the VolumeView™ system, and arterial blood gas analysis from all patients. Data were recorded before skin incision (T1); 30 minutes before HIPEC initiation (T2); 30 (T3), 60 (T4), and 90 (T5) minutes after HIPEC initiation; 30 minutes after HIPEC completion (T6); and 10 minutes before surgery completion (T7).

Results

Patients showed an increase in body temperature and cardiac index and a decrease in the systemic vascular resistance index. GEDI was 715.4 (T1) to 809.7 (T6), and ELWI was 6.9 (T1) to 7.3 (T5).

Conclusions

HIPEC increased patients’ body temperature and cardiac output and decreased systemic vascular resistance. Although parameters that were extracted from the VolumeView™ system were within their normal ranges, transpulmonary thermodilution approach is helpful in intraoperative hemodynamic management during open abdominal cytoreductive surgery with HIPEC.

Trial registry name: ClinicalTrials.gov

Trial registration number: NCT02325648

URL: https://clinicaltrials.gov/ct2/results?cond=NCT02325648&term

Evaluation of Urinary NGAL as a Diagnostic Tool for Acute Kidney Injury in Critically Ill Patients With Infection: An Original Study

Background:

Acute kidney injury (AKI) is a common complication in critical care patients. The presence of AKI is a marker for poor outcomes such as longer hospitalization durations, more hospital readmissions, and especially, higher mortality rates. Sepsis is one of the major causes of AKI within the intensive care unit (ICU) population. Sepsis-related AKI occurs in approximately 20% of patients, reaching more than 50% in patients with septic shock. The diagnosis of AKI depends on urine output and/or serum creatinine measurements. Unfortunately, serum creatinine is a late and unreliable (insensitive and nonspecific) indicator of AKI. However, biomarkers of renal damage have great potential in facilitating early diagnosis of AKI. Several biomarkers, including urinary neutrophil gelatinase-associated lipocalin (uNGAL), have been used in the early detection of AKI.

Objectives:

The aim of this study was to evaluate uNGAL for the diagnosis and prognosis of AKI in critical ill patients with infections.

Design:

Original study (Cohort Prospective Observational).

Setting:

Study in 2 ICUs of different Brazilian hospitals, in the city of Curitiba: Hospital de Clínicas da Universidade Federal do Paraná and Hospital da Polícia Militar do Paraná, from November 12, 2016 to May 15, 2018.

Participants:

Critically ill patients with infections, sepsis, or septic shock were selected. The inclusion criteria were patients older than 18 years with infection. They were followed up for 30 days in the analysis of outcomes. We requested that consent forms be signed by all eligible patients or their caregivers.

Measurements:

The urinary neutrophil gelatinase-associated lipocalin (uNGAL) levels of the patients were measured on 4 consecutive days and was assayed using a chemiluminescent microparticle immunoassay system. The screening time occurred within 72 hours of admission to the ICU. The first urine sample was collected within the first 24 hours of the screening hours. Mortality and AKI were assessed during first 30 days.

Methods:

clinical and laboratory data, including daily uNGAL levels, were assessed. The AKI stage using the KDIGO criteria was evaluated. Sensitivity, specificity, and the area under the curve-receiver operating characteristic (AUC-ROC) values were calculated to determine the optimal uNGAL level for predicting AKI.

Results:

We had 38 patients who completed the study during the screening period. The incidence of AKI was 76.3%. The hospitalization period was longer in the group that developed AKI, with 21 days of median (interquartile range [IQR]: 13.5-25); non-AKI group had a median of 13 days (IQR 7-18; P = .019). We found a direct relationship between uNGAL levels and the progression to AKI. Increased values of the biomarker were associated with the worsening of AKI (P < .05). The cutoff levels of uNGAL that identified patients who would progress to AKI were the following: (d1) >116 ng/mL, (d2) >100 ng/mL, and (d3) 284 ng/mL. The value of the fourth and last measurement was not predictive of patients who would progress to AKI. The median urinary uNGAL was also associated with mortality on Days 1, 3, and 4: d1, P = .039; d3, P = .005; d4, P = .005. The performance of uNGAL in detecting AKI patients (AUC-ROC = 0.881). There were no risk factors other than AKI that could be correlated with increased uNGAL levels on Day 1.

Limitations:

The study was carried out in 2 centers, having used only 1 biomarker, and our small number of patients were limitations.

Conclusion:

the uNGAL had an association in its values with the diagnosis and prognosis of patients with severe infections and AKI. We suggest that studies with a greater number of patients could better establish the cutoff values of uNGAL and/or serum NGAL in the identification of infected patients who are at a high risk of developing AKI.

Impact on Outcomes across KDIGO-2012 AKI Criteria According to Baseline Renal Function

Acute kidney injury (AKI) and Chronic Kidney Disease (CKD) are global health problems. The pathophysiology of acute-on-chronic kidney disease (AoCKD) is not well understood. We aimed to study clinical outcomes in patients with previous normal (pure acute kidney injury; P-AKI) or impaired kidney function (AoCKD) across the 2012 Kidney Disease Improving Global Outcomes (KDIGO) AKI classification. We performed a retrospective study of patients with AKI, divided into P-AKI and AoCKD groups, evaluating clinical and epidemiological features, distribution across KDIGO-2012 criteria, in-hospital mortality and need for dialysis. One thousand, two hundred and sixty-nine subjects were included. AoCKD individuals were older and had higher comorbidity. P-AKI individuals fulfilled more often the serum creatinine (SCr) ≥ 3.0× criterion in AKI-Stage3, AoCKD subjects reached SCr ≥ 4.0 mg/dL criterion more frequently. AKI severity was associated with in-hospital mortality independently of baseline renal function. AoCKD subjects presented higher mortality when fulfilling AKI-Stage1 criteria or SCr ≥ 3.0× criterion within AKI-Stage3. The relationship between mortality and associated risk factors, such as the net increase of SCr or AoCKD status, fluctuated depending on AKI stage and stage criteria sub-strata. AoCKD patients that fulfil SCr increment rate criteria may be exposed to more severe insults, possibly explaining the higher mortality. AoCKD may constitute a unique clinical syndrome. Adequate staging criteria may help prompt diagnosis and administration of appropriate therapy.

Perioperative management of renal transplant patients undergoing total joint arthroplasty

The success of renal transplantation depends on lifelong immunosuppression. This can lead to a high incidence of avascular necrosis of major joints in the body for which arthroplasty is the treatment of choice. The risk of surgical complications is high in these patients, and there is no current set of cohesive perioperative management guidelines. In this review, we discuss the perioperative management of renal transplant patients undergoing elective total joint arthroplasty.

In-Hospital Outcomes of Patients With Advanced Chronic Kidney Disease, Dialysis, and Kidney Transplant Undergoing Spinal Fusion: Analysis of a Nationwide Database

STUDY DESIGN

A retrospective analysis of population-based national hospital discharge data collected for the nationwide inpatient sample (NIS).

OBJECTIVES

To examine the in-hospital outcomes of patients with advanced chronic kidney disease (CKD), dialysis, and kidney transplant undergoing spinal fusion on a national level.

SUMMARY OF BACKGROUND DATA

Patients with advanced CKD have been living longer with the support and improvement of medical treatment, dialysis, and organ transplant. Some of those patients undergo spinal fusion surgery. However, there is limited information regarding the outcomes of patients with advanced CKD, dialysis, and kidney transplant, undergoing spinal fusion.

METHODS

Clinical data were derived from the US Nationwide Inpatient Sample (NIS) between 2000 and 2009. Patients who underwent spinal fusion were identified and divided into 4 groups: those with advanced CKD, dialysis, and kidney transplant, and those without advanced CKD. Data regarding, patient-system and health care system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved and analyzed. In-hospital outcomes were compared between the groups and analyzed with the use of multivariate logistic regression.

RESULTS

Among the all groups, overall in-hospital complications rate was the highest (42.0%) for patients with advanced CKD and in-hospital mortality rate was the highest (5.2%) for those with dialysis, undergoing spinal fusion. Patients with dialysis had 8.7 and 9.5 times higher risk of in-hospital mortality compared with those with kidney transplant and those without advanced CKD.

CONCLUSIONS

Patients with advanced CKD, dialysis, and kidney transplant had significant higher rates and risks of in-hospital morbidity or mortality than those without advanced CKD, undergoing spinal fusion. Particularly, patients with dialysis undergoing spinal fusion need to be informed with high mortality risk.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

National Trends and In-Hospital Outcomes of Patients With Solid Organ Transplant Undergoing Spinal Fusion

STUDY DESIGN

A retrospective analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample.

OBJECTIVE

To examine the demographics and in-hospital outcomes of patients with solid organ transplant (SOT) undergoing spinal fusion on a national level.

SUMMARY OF BACKGROUND DATA

Solid organ transplantation has become more common in recent years and some of these patients undergo spinal fusion surgery. There is, however, little information regarding the trends and outcomes in such patients.

METHODS

Clinical data were derived from the US Nationwide Inpatient Sample between 2000 and 2009. Patients with or without SOT who underwent spinal fusion were identified. Data regarding, patient- and healthcare system-related characteristics, comorbidities, in-hospital complications, and mortality were retrieved and analyzed. In-hospital outcomes were compared between patients with or without SOT and analyzed with the use of multivariate logistic regression.

RESULTS

A total of 5984 patients with SOT underwent spinal fusion in the United States during the last decade. From 2000 to 2009, population growth-adjusted incidence of patients with SOT who underwent spinal fusion has increased more than two fold (0.102 in 2000 to 0.236 in 2009, per 100,000, P < 0.001). Comparison between patients with or without SOT showed that patients with SOT had significantly higher overall in-hospital complication rate (22.4% vs. 9.5%) and in-hospital mortality rate (1.3% vs. 0.3%). Graft versus host disease occurred in 0.7% of patients with SOT undergoing spinal fusion. Patients with SOT had a significant higher risk of urinary and renal complications and overall in-hospital complications.

CONCLUSION

During the last decade, the incidence of patients with SOT undergoing spinal fusion has increased in the United States. In-hospital outcomes of patients with SOT undergoing spinal fusion were inferior to those of patients without SOT.

LEVEL OF EVIDENCE

3.

Predictive value of the RIFLE urine output criteria on contrast-induced nephropathy in critically ill patients

Background

To investigate the predictive value of decreased urine output based on the Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage renal disease (RIFLE) classification on contrast- induced acute kidney injury (CA-AKI) in intensive care (ICU) patients.

Methods

All patients who received contrast media (CM) injection for CT scan or coronary angiography during a 3-year period in a 24 bed medico-surgical ICU were reviewed.

Results

Daily serum creatinine concentrations and diuresis were measured for 3 days after CM injection. We identified 23 cases of CA-AKI in the 149 patients included (15.4 %). Patients who developed CA-AKI were more likely to require renal replacement therapy and had higher ICU mortality rates. At least one RIFLE urine output criteria was observed in 45 patients (30.2 %) and 14 of these 45 patients (31.1 %) developed CA-AKI based on creatinine concentrations. In 30 % of these cases, urine output decreased or didn’t change after the increase in creatinine concentrations. The RIFLE urine output criteria had low sensitivity (39.1 %) and specificity (67.9 %) for prediction of CA-AKI, a low positive predictive value of 50 % and a negative predictive value of 87.2 %. The maximal dose of vasopressors before CM was the only independent predictive factor for CA-AKI.

Conclusions

CA-AKI is a frequent pathology observed in ICU patients and is associated with increased need for renal replacement therapy and increased mortality. The predictive value of RIFLE urine output criteria for the development of CA-AKI based on creatinine concentrations was low, which limits its use for assessing the effects of therapeutic interventions on the development and progression of AKI.

Low Systemic Oxygen Delivery and BP and Risk of Progression of Early AKI

BACKGROUND AND OBJECTIVES

The optimal hemodynamic management of patients with early AKI is unknown. This study aimed to investigate the association between hemodynamic parameters in early AKI and progression to severe AKI and hospital mortality.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study retrospectively analyzed the data of all patients admitted to the adult intensive care unit in a tertiary care center between July 2007 and June 2009 and identified those with stage 1 AKI (AKI I) per the AKI Network classification. In patients in whom hemodynamic monitoring was performed within 12 hours of AKI I, hemodynamic parameters in the first 12 hours of AKI I and on the day of AKI III (if AKI III developed) or 72 hours after AKI I (if AKI III did not develop) were recorded. Risk factors for AKI III and mortality were identified using univariate and multivariate logistic regression analyses.

RESULTS

Among 790 patients with AKI I, 210 (median age 70 years; 138 men) had hemodynamic monitoring within 12 hours of AKI I; 85 patients (41.5%) progressed to AKI III and 91 (43%) died in the hospital. AKI progressors had a significantly higher Sequential Organ Failure Assessment score (8.0 versus 9.6; P<0.001), lower indexed systemic oxygen delivery (DO2I) (median 325 versus 405 ml/min per m(2); P<0.001), higher central venous pressure (16 versus 13; P=0.02), and lower mean arterial blood pressure (MAP) (median 71 versus 74 mmHg; P=0.01) in the first 12 hours of AKI I compared with nonprogressors. Multivariate analysis confirmed that raised lactate, central venous pressure, and Sequential Organ Failure Assessment score as well as mechanical ventilation were independently associated with progression to AKI III; higher DO2I and MAP were independently associated with a lower risk of AKI III but not survival. The associations were independent of sepsis, heart disease, recent cardiac surgery, or chronic hypertension.

CONCLUSIONS

Higher DO2I and MAP in early AKI were independently associated with a lower risk of progression.

Total joint arthroplasty in transplant recipients: in-hospital adverse outcomes

This study aims to determine in-hospital complications and mortality in transplant recipients following total joint arthroplasty. The Nationwide Inpatient Sample database was queried for patients with history of transplant and joint arthroplasty (primary or revision) from 1993 to 2011. Kidney transplant increased risk of surgical site infection (SSI) and wound infections (OR=2.03), systemic infection (OR=2.85), deep venous thrombosis (OR=2.07), acute renal failure (ARF) (OR=3.48), respiratory (OR=1.34), and cardiac (OR=1.21) complications. Liver transplant was associated with SSI/wound infections (OR=2.32), respiratory complications (OR=1.68), cardiac complications (OR=1.34), and ARF (OR=4.48). Other transplants grouped together were associated with wound complications (OR=2.13), respiratory complications (OR=2.06), and ARF (OR=4.42). Our study suggests these patients may be at increased risk of in-hospital complications, particularly ARF in renal and liver transplant patients.

Diuretic response to colloid and crystalloid fluid loading in critically ill patients

AIMS

In the critically ill patient, fluid loading is commonly done to stabilise hemodynamics and increase diuresis, whereas the absence of diuresis may predispose to harmful overloading. The goal of the current study was to evaluate the diuretic response and determinants thereof upon crystalloid and colloid fluid loading.

SUBJECTS AND METHODS

This is a substudy on 42 clinically hypovolemic, septic or non-septic patients without acute kidney injury, who were randomly assigned, after stratification for sepsis, to a 90-min fluid loading protocol with either 0.9% saline or a colloid solution (gelatin, hydroxyethyl starch 200/0.5 or albumin). Hemodynamics, biochemical parameters and diuresis were recorded. A response was defined by an increase in diuresis of >10% during fluid loading.

RESULTS

Diuresis increased more during saline than colloid infusion, together with a decline in colloid osmotic pressure (COP) of plasma and less increase in plasma volume and global hemodynamics with saline, at similar fluid balance. Nine patients (82%) receiving saline had a diuretic response, compared to 13 patients (42%) receiving colloids (P = 0.04), and the response was not predicted by underlying condition, global hemodynamics, volume of fluid infused and COP.

CONCLUSION

In critically ill patients with clinical hypovolemia, diuresis increases more during saline than colloid fluid loading, only partly dependent of a fall in plasma COP.

Anaesthesia in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: retrospective analysis of a single centre three-year experience

Background

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option for selected patients with peritoneal carcinomatosis. There are limited data available on anaesthesia management and its impact on patients’ outcome. Our aim was to retrospectively analyze and evaluate perioperative management and the clinical course of patients undergoing CRS/HIPEC within a three-year period.

Methods

After ethic committee approval, patient charts were retrospectively reviewed for patient characteristics, interventions, perioperative management, postoperative course, and complications. Analysis was intervention based. Data are presented as median (range).

Results

Between 2009 and 2011, 54 consecutive patients underwent 57 interventions; median anaesthesia time was 715 (range 370 to 1135) minutes. HIPEC induced hyperthermia with an overall median peak temperature of 38.1 (35.7-40.2)°C with active cooling. Bleeding, expressed as median blood loss was 0.8 (0 to 6) litre and large fluid shifts occurred, requiring a total fluid input of 8.4 (4.2 to 29.4) litres per patient. Postoperative renal function was dependent on preoperative function and the type of fluids used. Administration of hydroxyethyl starch colloid solution had a significant negative impact on renal function, especially in younger patients. Major complications occurred after 12 procedures leading to death in 2 patients. Procedure time and need for blood transfusion were associated with a significantly higher risk for major complications.

Conclusions

Cytoreductive surgery with HIPEC is a high-risk surgical procedure associated with major hemodynamic and metabolic changes. As well as primary disease and complexity of surgery, we have shown that anaesthesia management, the type and amount of fluids used, and blood transfusions may also have a significant effect on patients’ outcome.