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Belaunzaran M, Raslan S, Ali A, Newsome K, McKenney M, Elkbuli A. Utilization and Efficacy of Resuscitation Endpoints in Trauma and Burn Patients: A Review Article. Am Surg 2021; 88:10-19. [PMID: 34761698 DOI: 10.1177/00031348211060424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Shock is a sequelae in trauma and burn patients that substantially increases the risk for morbidity and mortality. The use of resuscitation endpoints allows for improved management of these patients, with the potential to prevent further morbidity/mortality. We conducted a review of the current literature on the efficacy of hemodynamic, metabolic, and regional resuscitation endpoints for use in trauma and burn patients. Hemodynamic endpoints included mean arterial pressure (MAP), heart rate (HR), urinary output (UO), compensatory reserve index (CRI), intrathoracic blood volume, and stroke volume variation (SVV). Metabolic endpoints measure cellular responses to decreased oxygen delivery and include serum lactic acid (LA), base deficit (BD), bicarbonate, anion gap, apparent strong ion difference, and serum pH. Mean arterial pressure, HR, UO, and LA are the most established markers of trauma and burn resuscitation. The evidence suggests LA is a superior metabolic endpoint marker. Newer resuscitation endpoint technologies such as point-of-care ultrasound (PoCUS), thromboelastography (TEG), and rotational thromboelastometry (ROTEM) may improve patient outcomes; however, additional research is needed to establish the efficacy in trauma and burn patients. The endpoints discussed have situational strengths and weaknesses and no single universal resuscitation endpoint has yet emerged. This review may increase knowledge and aid in guideline development. We recommend clinicians continue to integrate multiple endpoints with emphasis on MAP, HR, UO, LA, and BD. Future investigation should aim to standardize endpoints for each clinical presentation. The search for universal and novel resuscitation parameters in trauma and burns should also continue.
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Affiliation(s)
- Miguel Belaunzaran
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Shahm Raslan
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Aleeza Ali
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Kevin Newsome
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.,University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA
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Ngo JP, Lankadeva YR, Zhu MZL, Martin A, Kanki M, Cochrane AD, Smith JA, Thrift AG, May CN, Evans RG. Factors that confound the prediction of renal medullary oxygenation and risk of acute kidney injury from measurement of bladder urine oxygen tension. Acta Physiol (Oxf) 2019; 227:e13294. [PMID: 31066975 DOI: 10.1111/apha.13294] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/07/2019] [Accepted: 05/02/2019] [Indexed: 02/01/2023]
Abstract
AIM Urinary oxygen tension (uPO2 ) may provide an estimate of renal medullary PO2 (mPO2 ) and thus risk of acute kidney injury (AKI). We assessed the potential for variations in urine flow and arterial PO2 (aPO2 ) to confound these estimates. METHODS In 28 sheep urine flow, uPO2 , aPO2 and mPO2 were measured during development of septic AKI. In 65 human patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) uPO2 and aPO2 were measured continuously during CPB, and in a subset of 20 patients, urine flow was estimated every 5 minutes. RESULTS In conscious sheep breathing room air, uPO2 was more closely correlated with mPO2 than with aPO2 or urine flow. The difference between mPO2 and uPO2 varied little with urine flow or aPO2 . In patients, urine flow increased abruptly from 3.42 ± 0.29 mL min-1 to 6.94 ± 0.26 mL min-1 upon commencement of CPB, usually coincident with reduced uPO2 . During hyperoxic CPB high values of uPO2 were often observed at low urine flow. Low urinary PO2 during CPB (<10 mm Hg at any time during CPB) was associated with greater (4.5-fold) risk of AKI. However, low urine flow during CPB was not significantly associated with risk of AKI. CONCLUSIONS uPO2 provides a robust estimate of mPO2 , but this relationship is confounded by the simultaneous presence of systemic hyperoxia and low urine flow. Urine flow increases and uPO2 decreases during CPB. Thus, CPB is probably the best time to use uPO2 to detect renal medullary hypoxia and risk of post-operative AKI.
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Affiliation(s)
- Jennifer P. Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
| | - Yugeesh R. Lankadeva
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Australia
| | - Michael Z. L. Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Monica Kanki
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
| | - Andrew D. Cochrane
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Julian A. Smith
- Department of Cardiothoracic Surgery Monash Health, Monash University Melbourne Australia
- Department of Surgery, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Amanda G. Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Clive N. May
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Australia
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute Monash University Melbourne Australia
- Department of Physiology Monash University Melbourne Australia
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Minute-to-minute urine flow rate variability: a retrospective survey of its ability to provide early warning of acute hypotension in critically ill multiple trauma patients. Eur J Trauma Emerg Surg 2019; 46:1175-1181. [PMID: 30758536 DOI: 10.1007/s00068-019-01090-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Dynamic changes in urine output and neurological status are the recognized clinical signs of hemodynamically significant hemorrhage. In the present study, we analyzed the dynamic minute-to-minute changes in the UFR and also the changes in its minute-to-minute variability in a group of critically ill multiple trauma patients whose blood pressures were normal on admission to the ICU but who subsequently developed hypotension within the first few hours of their ICU admission. PATIENTS AND METHODS The study was retrospective and observational. Demographic and clinical data were extracted from the computerized register information systems initially; the clinical and laboratory data of 100 critically ill patients with multiple trauma who were admitted to the ICU during the study period were analyzed. Of this group, ten patients were eventually included in the study on the basis of the inclusion criteria. RESULTS The minute-to-minute urine flow rate (UFR) and urine flow rate variability (UFRV) both decreased significantly during the periods of hypotension (p values 0.001 and 0.006, respectively). Notably, the decrease in UFRV preceded by at least 30 min a corresponding decline in the systolic and mean arterial blood pressures, which manifested as a flattening of UFRV amplitude which was observed prior to the occurrence of the lowest recorded systolic and mean arterial blood pressures. Statistical analysis by the Pearson method demonstrated a strong direct correlation between the decrease in UFRV and the decrease in the MAP (R = 0.9, p = 0.001), and SBP (R = 0.86, p = 0.001) and the decreasing urine output per hour (R = 0.88, p < 0.001). CONCLUSION We found that changes in UFRV correlate strongly with systolic and mean arterial blood pressures. We feel that this parameter could potentially serve as an early signal of hemodynamic deterioration due to occult bleeding in critically ill trauma patients, and might also be able to identify the optimal end-point of hemodynamic resuscitative measures in these patients.
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Brotfain E, Klein Y, Toledano R, Koyfman L, Frank D, Shamir MY, Klein M. Urine flow rate monitoring in hypovolemic multiple trauma patients. World J Emerg Surg 2017; 12:41. [PMID: 28828035 PMCID: PMC5563012 DOI: 10.1186/s13017-017-0152-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background The urine output is an important clinical parameter of renal function and blood volume status, especially in critically ill multiple trauma patients. In the present study, the minute-to-minute urine flow rate and its variability were analyzed in hypotensive multiple trauma patients during the first 6 h of their ICU (intensive care unit) stay. These parameters have not been previously reported. Methods The study was retrospective and observational. Demographic and clinical data were extracted from the computerized Register Information Systems. A total of 59 patients were included in the study. The patients were divided into two study groups. Group 1 consisted of 29 multiple trauma patients whose systolic blood pressure was greater than 90 mmHg on admission to the ICU and who were consequently deemed to be hemodynamically compromised. Group 2 consisted of 30 patients whose systolic blood pressure was less than 90 mmHg on admission to the ICU and who were therefore regarded as hemodynamically uncompromised. Results The urine output and urine flow rate variability during the first 6 h of the patients’ ICU stay was significantly lower in group 2 than in group 1 (p < 0.001 and 0.006 respectively). Statistical analysis by the Pearson method demonstrated a strong direct correlation between decreased urine flow rate variability and decreased urine output per hour (R = 0.17; P = 0.009), decreased mean arterial blood pressure (R = 0.24; p = 0.001), and increased heart rate (R = 0.205; p = 0.001). Conclusion These findings suggest that minute-to-minute urine flow rate variability is a reliable incipient marker of hypovolemia and that it should therefore take its place among the parameters used to monitor the hemodynamic status of critically ill multiple trauma patients.
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Affiliation(s)
- Evgeni Brotfain
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yoram Klein
- Trauma unit, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Toledano
- Clinical Research Center, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Leonid Koyfman
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Dmitry Frank
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Micha Y Shamir
- Department of Anesthesiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Moti Klein
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Otero A, Cardinal-Fernández P, Nin N, Rojas Y, Oteiza L, Garcia-Carmona R, Caffarena G, Lorente JA. Correlations between physiological parameters related with kidney function and minute-by-minute urine output. Nephrology (Carlton) 2016; 21:1034-1040. [PMID: 26718310 DOI: 10.1111/nep.12712] [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: 10/01/2015] [Revised: 12/11/2015] [Accepted: 12/23/2015] [Indexed: 11/30/2022]
Abstract
AIM Recently, devices capable of measuring minute-by-minute urine output (UOm) have become available. It is not known how UOm correlates with physiological parameters in normal conditions and in disease states characterized by vascular dysfunction. This paper analyzes correlations between UOm and physiological parameters related to kidney perfusion to provide some insight about UOm pathophysiological interpretation and its relationship with renal blood flow. METHODS We studied 14 male pigs were anesthetized, tracheostomized, and mechanically ventilated. Mean systemic blood pressure (PART ), mean pulmonary artery blood pressure (PPA ), carotid artery blood flow (QCA ), as well as total (QREN ), cortical (QCOR ) and medullary (QMED ) renal blood flows, and the renal resistive index (RRI) were measured or calculated. Animals received an intravenous dose of live E. coli for the induction of sepsis (septic group), or an equivalent amount of normal saline (nonseptic group). Three groups were studied: nonseptic (n = 6) and septic (n = 4), both receiving for resuscitation NaCl 0.9% at 4 mL/kg per h; and septic (n = 4), receiving for resuscitation NaCl 0.9% at 17 mL/kg per h. Animals were monitored for 5 h after the induction of sepsis. RESULTS In septic animals, UOm was strongly positively correlated with QREN (Kendall's τ = 0.770, P < 0.05), QCOR (τ = -0.566, P < 0.05) and QMED (τ = 0.632, P < 0.05); and negatively correlated with PPA (τ = -0.524, P < 0.05) and RRI (τ = -0.672, P < 0.05). Control animals exhibited weaker correlations. CONCLUSION UOm is a good physiological surrogate marker of total and regional renal blood flows and vascular resistance, particularly under septic conditions, probably reflecting glomerulo-tubular dysfunction in sepsis.
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Affiliation(s)
- Abraham Otero
- Department of Information Systems Engineering, University San Pablo CEU, Madrid, Spain
| | | | - Nicolás Nin
- University Hospital of Getafe, Madrid, Spain
| | - Yeny Rojas
- University Hospital of Getafe, Madrid, Spain
| | | | | | - Gabriel Caffarena
- Department of Information Systems Engineering, University San Pablo CEU, Madrid, Spain
| | - José A Lorente
- University Hospital of Getafe, Madrid, Spain.,CIBER of respiratory diseases, Madrid, Spain.,European University, Madrid, Spain
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Heringlake M, Schön J, Paarmann H. The kidney in critical illness: how to monitor a pivotal organ system. Best Pract Res Clin Anaesthesiol 2014; 27:271-7. [PMID: 24012237 DOI: 10.1016/j.bpa.2013.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 05/08/2013] [Accepted: 06/12/2013] [Indexed: 01/03/2023]
Abstract
Acute kidney injury is an important complication in patients undergoing major and especially cardiac surgery and in the critically ill. Within the last years, several new modalities have been developed for monitoring of renal function that may be used for early detection of patients developing renal dysfunction as well as to monitor the effects of treatments on this pivotal organ. The present manuscript aims to give a critical overview about recent developments in the field.
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Affiliation(s)
- Matthias Heringlake
- Department of Anesthesiology, University of Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
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A new device to automate the monitoring of critical patients' urine output. BIOMED RESEARCH INTERNATIONAL 2014; 2014:587593. [PMID: 24605331 PMCID: PMC3925530 DOI: 10.1155/2014/587593] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 09/08/2013] [Accepted: 11/04/2013] [Indexed: 01/01/2023]
Abstract
Urine output (UO) is usually measured manually each hour in acutely ill patients. This task consumes a substantial amount of time. Furthermore, in the literature there is evidence that more frequent (minute-by-minute) UO measurement could impact clinical decision making and improve patient outcomes. However, it is not feasible to manually take minute-by-minute UO measurements. A device capable of automatically monitoring UO could save precious time of the healthcare staff and improve patient outcomes through a more precise and continuous monitoring of this parameter. This paper presents a device capable of automatically monitoring UO. It provides minute by minute measures and it can generate alarms that warn of deviations from therapeutic goals. It uses a capacitive sensor for the measurement of the UO collected within a rigid container. When the container is full, it automatically empties without requiring any internal or external power supply or any intervention by the nursing staff. In vitro tests have been conducted to verify the proper operation and accuracy in the measures of the device. These tests confirm the viability of the device to automate the monitoring of UO.
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On the minute by minute variations of urine output: a study in a porcine model. J Nephrol 2014; 27:45-50. [PMID: 24424719 DOI: 10.1007/s40620-013-0019-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/11/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Urine output (UO) is usually measured hourly in acutely ill patients. Devices capable of more continuous (minute by minute urine output, UOm) measurements have become available recently. This paper aims to (1) analyze the minute by minute variations of UO, (2) analyze the impact of sepsis on those variations and (3) test if UO measured over periods shorter than 60 min provides information not available in hourly measurements. METHODS Fifteen male pigs were anesthetized, tracheostomized and mechanically ventilated. Sepsis was induced by the administration of live Escherichia coli. Three groups were studied: nonseptic (n = 7) and septic (n = 4), both receiving sodium chloride (NaCl) 0.9 % at 4 ml kg(-1) h(-1); and septic (n = 4) receiving NaCl 0.9 % at 17 ml kg(-1) h(-1). UOm was measured during 6 h. RESULTS There was a significant variation of UOm over time, as assessed by the coefficient of variation of the root-mean-squared error (CV(RMSE)), which was significantly more pronounced under conditions of sepsis than under control conditions. A UO production pattern in sepsis was identified, characterized by low UO production compared to baseline levels for approximately 30 min, followed by high UO production for approximately 30 min after initiation of the septic challenge. This pattern was noticeable if UO was measured every 10 min but not over longer periods of time. CONCLUSIONS UOm provides information not conveyed by hourly measurements, especially under the cardiovascular alterations associated to sepsis. This information could enable an early identification of sepsis.
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