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Ethgen O, Murugan R, Echeverri J, Blackowicz M, Harenski K, Ostermann M. Economic Analysis of Renal Replacement Therapy Modality in Acute Kidney Injury Patients With Fluid Overload. Crit Care Explor 2023; 5:e0921. [PMID: 37637357 PMCID: PMC10456980 DOI: 10.1097/cce.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Acute kidney injury (AKI) and fluid overload (FO) are among the top reasons to initiate intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). Prior research suggests CRRT provides more precise volume control, but whether CRRT is cost-effective remains unclear. We assessed the cost-effectiveness of CRRT for volume control compared with IHD from a U.S. healthcare payer perspective. DESIGN Decision analytical model comparing health outcomes and healthcare costs of CRRT versus IHD initiation for AKI patients with FO. The model had an inpatient phase (over 90-d) followed by post-discharge phase (over lifetime). The 90-day phase had three health states: FO, fluid control, and death. After 90 days, surviving patients entered the lifetime phase with four health states: dialysis independent (DI), dialysis dependent (DD), renal transplantation, and death. Model parameters were informed by current literature. Sensitivity analyses were performed to evaluate results robustness to parametric uncertainty. SETTING ICU. PATIENTS OR SUBJECTS AKI patients with FO. INTERVENTIONS IHD or CRRT. MEASUREMENTS AND MAIN RESULTS The 90-day horizon revealed better outcomes for patients initiated on CRRT (survival: CRRT 59.2% vs IHD 57.5% and DD rate among survivors: CRRT 5.5% vs IHD 6.9%). Healthcare cost was 2.7% (+$2,836) higher for CRRT. Over lifetime, initial CRRT was associated with +0.313 life years (LYs) and +0.187 quality-adjusted life years (QALYs) compared with initial IHD. Even though important savings were observed for initial CRRT with a lower rate of DD among survivors (-$13,437), it did not fully offset the incremental cost of CRRT (+$1,956) and DI survival (+$12,830). The incremental cost-per-QALY gained with CRRT over IRRT was +$10,429/QALY. Results were robust to sensitivity analyses. CONCLUSIONS Our analysis provides an economic rationale for CRRT as the initial modality of choice in AKI patients with FO who require renal replacement therapy. Our finding needs to be confirmed in future research.
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Affiliation(s)
- Olivier Ethgen
- Department of Public Health, Epidemiology & Health Economics, University of Liège, Liège, Belgium
- SERFAN Innovation, Namur, Belgium
| | - Raghavan Murugan
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael Blackowicz
- Department of Public Health, Epidemiology & Health Economics, University of Liège, Liège, Belgium
- Baxter Healthcare Corporation, Deerfield, IL
| | - Kai Harenski
- Baxter Deutschland GmbH, Unterschleissheim, Germany
| | - Marlies Ostermann
- Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
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Guarino M, Perna B, Cesaro AE, Maritati M, Spampinato MD, Contini C, De Giorgio R. 2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department. J Clin Med 2023; 12:jcm12093188. [PMID: 37176628 PMCID: PMC10179263 DOI: 10.3390/jcm12093188] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Sepsis/septic shock is a life-threatening and time-dependent condition that requires timely management to reduce mortality. This review aims to update physicians with regard to the main pillars of treatment for this insidious condition. METHODS PubMed, Scopus, and EMBASE were searched from inception with special attention paid to November 2021-January 2023. RESULTS The management of sepsis/septic shock is challenging and involves different pathophysiological aspects, encompassing empirical antimicrobial treatment (which is promptly administered after microbial tests), fluid (crystalloids) replacement (to be established according to fluid tolerance and fluid responsiveness), and vasoactive agents (e.g., norepinephrine (NE)), which are employed to maintain mean arterial pressure above 65 mmHg and reduce the risk of fluid overload. In cases of refractory shock, vasopressin (rather than epinephrine) should be combined with NE to reach an acceptable level of pressure control. If mechanical ventilation is indicated, the tidal volume should be reduced from 10 to 6 mL/kg. Heparin is administered to prevent venous thromboembolism, and glycemic control is recommended. The efficacy of other treatments (e.g., proton-pump inhibitors, sodium bicarbonate, etc.) is largely debated, and such treatments might be used on a case-to-case basis. CONCLUSIONS The management of sepsis/septic shock has significantly progressed in the last few years. Improving knowledge of the main therapeutic cornerstones of this challenging condition is crucial to achieve better patient outcomes.
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Affiliation(s)
- Matteo Guarino
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Benedetta Perna
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Alice Eleonora Cesaro
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Martina Maritati
- Infectious and Dermatology Diseases, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Michele Domenico Spampinato
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Carlo Contini
- Infectious and Dermatology Diseases, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine, St. Anna University Hospital of Ferrara, University of Ferrara, 44121 Ferrara, Italy
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Ozkaya PY, Taner S, Ersayoğlu I, Turan B, Yildirim Arslan S, Karapinar B, Kaplan Bulut I. Sepsis associated acute kidney injury in pediatric intensive care unit. Ther Apher Dial 2023; 27:73-82. [PMID: 36101487 DOI: 10.1111/1744-9987.13928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/28/2022] [Accepted: 09/08/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND We aimed to compare the acute kidney injury (AKI) incidence in pediatric septic shock patients according to the three different classifications. METHODS We analyzed retrospectively 52 patients with severe sepsis between January 2019 and December 2019. RESULTS While 21 patients have been diagnosed with SA-AKI according to the pRIFLE criteria, 20 children have been diagnosed according to the AKIN criteria, and 21 children have been diagnosed according to the KDIGO criteria. Older age, lower platelet count were determined as independently risk factor for SA-AKI. Older age and higher PRISM score were associated with mortality. According to Canonical correlation coefficients, pRIFLE is the most successful classification to distinguish AKI state. The canonical correlation coefficients for pRIFLE, KDIGO, and AKIN were 0.817, 0.648, and 0.615, respectively. CONCLUSION Although AKI incidence was similar between the three classifications, pRIFLE was the most successful classification to distinguish AKI state.
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Affiliation(s)
- Pinar Yazici Ozkaya
- Department of Pediatrics, Division of Pediatric Intensive Care, Ege University, School of Medicine, Izmir, Turkey
| | - Sevgin Taner
- Department of Pediatrics, Division of Pediatric Nephrology, Ege University, School of Medicine, Izmir, Turkey
| | - Irem Ersayoğlu
- Department of Pediatrics, Division of Pediatric Intensive Care, Ege University, School of Medicine, Izmir, Turkey
| | - Benay Turan
- Department of Pediatrics, Ege University, School of Medicine, Izmir, Turkey
| | - Sema Yildirim Arslan
- Department of Pediatrics, Division of Pediatric Nephrology, Ege University, School of Medicine, Izmir, Turkey
| | - Bülent Karapinar
- Department of Pediatrics, Division of Pediatric Intensive Care, Ege University, School of Medicine, Izmir, Turkey
| | - Ipek Kaplan Bulut
- Department of Pediatrics, Division of Pediatric Nephrology, Ege University, School of Medicine, Izmir, Turkey
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Wrzosek A, Drygalski T, Garlicki J, Woroń J, Szpunar W, Polak M, Droś J, Wordliczek J, Zajączkowska R. The volume of infusion fluids correlates with treatment outcomes in critically ill trauma patients. Front Med (Lausanne) 2023; 9:1040098. [PMID: 36714115 PMCID: PMC9877421 DOI: 10.3389/fmed.2022.1040098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023] Open
Abstract
Background Appropriate fluid management is essential in the treatment of critically ill trauma patients. Both insufficient and excessive fluid volume can be associated with worse outcomes. Intensive fluid resuscitation is a crucial element of early resuscitation in trauma; however, excessive fluid infusion may lead to fluid accumulation and consequent complications such as pulmonary edema, cardiac failure, impaired bowel function, and delayed wound healing. The aim of this study was to examine the volumes of fluids infused in critically ill trauma patients during the first hours and days of treatment and their relationship to survival and outcomes. Methods We retrospectively screened records of all consecutive patients admitted to the intensive care unit (ICU) from the beginning of 2019 to the end of 2020. All adults who were admitted to ICU after trauma and were hospitalized for a minimum of 2 days were included in the study. We used multivariate regression analysis models to assess a relationship between volume of infused fluid or fluid balance, age, ISS or APACHE II score, and mortality. We also compared volumes of fluids in survivors and non-survivors including additional analyses in subgroups depending on disease severity (ISS score, APACHE II score), blood loss, and age. Results A total of 52 patients met the inclusion criteria for the study. The volume of infused fluids and fluid balance were positively correlated with mortality, complication rate, time on mechanical ventilation, length of stay in the ICU, INR, and APTT. Fluid volumes were significantly higher in non-survivors than in survivors at the end of the second day of ICU stay (2.77 vs. 2.14 ml/kg/h) and non-survivors had a highly positive fluid balance (6.21 compared with 2.48 L in survivors). Conclusion In critically ill trauma patients, worse outcomes were associated with higher volumes of infusion fluids and a more positive fluid balance. Although fluid resuscitation is lifesaving, especially in the first hours after trauma, fluid infusion should be limited to a necessary minimum to avoid fluid overload and its negative consequences.
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Affiliation(s)
- Anna Wrzosek
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,*Correspondence: Anna Wrzosek, ; orcid.org/0000-0002-7802-1325
| | - Tomasz Drygalski
- Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław Garlicki
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland
| | - Jarosław Woroń
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,Department of Clinical Pharmacology, Medical College, Jagiellonian University, Kraków, Poland
| | - Wojciech Szpunar
- Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland
| | - Maciej Polak
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland
| | - Jakub Droś
- Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland,Doctoral School in Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy Wordliczek
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland,Department of Anaesthesiology and Intensive Therapy, University Hospital, Kraków, Poland
| | - Renata Zajączkowska
- Department of Interdisciplinary Intensive Care, Jagiellonian University Medical College, Kraków, Poland
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Althobaiti BM, El-Readi MZ, Althubiti M, Alhindi YZ, Alzahrani AR, Al-Ghamdi SS, Ayoub N, Refaat B, Eid SY. Patterns of acute poisoning for children during outbreak of Corona virus in Makkah region Saudi Arabia. Front Pediatr 2023; 11:1087095. [PMID: 37009288 PMCID: PMC10063909 DOI: 10.3389/fped.2023.1087095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/24/2023] [Indexed: 04/04/2023] Open
Abstract
Background Poisoning occurs when a person is exposed to an external substance at a too high dose for them. It is possible for young children to be exposed to chemicals. Lungs, the heart, CNS, the digestive tract, and kidneys can be poisoned. In 2004, over 45,000 children and teenagers died from acute poisoning, representing 13% of all accidental poisoning deaths worldwide. Poisoning patterns vary by exposure type, age group, poison type, and dose. Aim This study assessed the pattern of acute poisoning with drugs, chemicals, and natural toxins among children (<12 years old). The study was done in Makkah region and registered in the poison control center in Makkah, the forensic chemistry center in Haddah during 2020-2021. Methods A retrospective cohort study was done on 122 children exposed to toxic substances in Makkah. The children were 12 years old and had good health for a maximum of one year. Stratified random sampling was used to divide cases into groups of similar poisons (pharmaceutical products, household products, plant envenomation, and animal envenomation). Then each group got a random samples. The data were analysed with SPSS software. Results The mean age of children was 5.2 years, with 59% being boys. The mean temperature, pulse, systolic, diastolic, and respiratory rates were 36.77, 98.29, 109.1, 69.17, and 21.49. The most documented pharmaceutical products (200 mg) were carbamazepine (5 mg), methanol, risperidone (5 mg), propranolol (5 mg), and olanzapine (5 mg). The most common poison forms were tablets (42.6%), syrups (15.6%), capsules (13.9%), and solutions (13.1%). The most common poisoning routes were ingestion (82.8%), dermal (5.7%), injection (4.9%), and inhalation (6.6%). Accidental poisoning was 83%, with a 30-minute lag for 30.3% of children, and most (69.7%) occurred at home. Benzodiazepines were the most commonly used category class drug (18%), with normal pupils and an ECG of 85.2%. Sixty-seven percent had blood tests. Sickness was 9.48, and the positive result was 213.01. The most common presenting symptoms were GIT and neurological (23.8%). 31.1% had mild, moderate, or severe toxicity. Most cases (68%) were complex. 34.4% were intubated, 9.8% had repeated-dose-activated charcoal for enhanced elimination, and 27.8% were on IV fluids. Children with GIT, CVS, respiratory, dermal, and neurological symptoms had a higher percentage of severe toxicity (p < 0.05). Slight toxicity was associated with whole bowel irrigation, intubation for oxygen therapy, N-acetylcysteine or sedation, fluids, and phenytoin (P < 0.05). Complicated cases had a higher mean AST/IUL than non-complicated cases (75.5 vs. 20.08, p < 0.05). The level of toxicity did not correlate with the mean of all lab tests (p > 0.05). The age of the children correlated positively with their systolic BP (r = 0.22, p < 0.01). Conclusion The results show how important it is to teach the public about poisoning and make rules for tracking and dealing with poisonings in Saudi Arabia.
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Affiliation(s)
- Bashayer Mohammed Althobaiti
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Mahmoud Zaki El-Readi
- Department of Biochemistry, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Biochemistry Department, Faculty of Pharmacy, Al-Azhar University, Assuit, Egypt
- Correspondence: Mahmoud Zaki El-Readi Safaa Yehia Eid
| | - Mohammad Althubiti
- Department of Biochemistry, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Yosra Zakariyya Alhindi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Abdullah R Alzahrani
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Saeed S Al-Ghamdi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Nahla Ayoub
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Saudi Toxicology Society, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Safaa Yehia Eid
- Department of Biochemistry, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Correspondence: Mahmoud Zaki El-Readi Safaa Yehia Eid
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赖 志, 杨 文, 马 可. Effect of fluid load on the prognosis of children with sepsis-associated acute kidney injury undergoing continuous renal replacement therapy. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:279-284. [PMID: 35351258 PMCID: PMC8974647 DOI: 10.7499/j.issn.1008-8830.2111001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/03/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To evaluate the effect of fluid load on the prognosis of children with sepsis-associated acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). METHODS A total of 121 children who underwent CRRT for sepsis-associated AKI from August 2018 to March 2021 were enrolled in the retrospective study. According to the fluid load from admission or disease progression to CRRT, they were divided into three groups: low fluid load (fluid load: <5%; n=35), high fluid load (fluid load: 5% - <10%; n=35), and fluid overload (fluid load: ≥10%; n=51). Baseline data and clinical biochemical data before CRRT were collected for comparison and analysis. The Kaplan-Meier survival curve analysis was used for comparison of 28-day survival between groups. The multivariate logistic regression model was used to identify the influencing factors for the prognosis of the children. RESULTS The survival analysis showed that the fluid overload group had a significantly higher 28-day mortality rate than the low fluid load and high fluid load groups (P<0.05). The multivariate logistic regression analysis showed that an increase in fluid overload volume was a risk factor for increased 28-day mortality in the fluid overload group, while earlier initiation of CRRT was a protective factor (P<0.05). CONCLUSIONS Fluid overload before CRRT may increase the mortality in children with sepsis-associated AKI, and CRRT should be performed for these children as early as possible.
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