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Labib H, Tjerkstra MA, Coert BA, Post R, Vandertop WP, Verbaan D, Müller MCA. Sodium and Its Impact on Outcome After Aneurysmal Subarachnoid Hemorrhage in Patients With and Without Delayed Cerebral Ischemia. Crit Care Med 2024; 52:752-763. [PMID: 38206089 PMCID: PMC11008454 DOI: 10.1097/ccm.0000000000006182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVES To perform a detailed examination of sodium levels, hyponatremia and sodium fluctuations, and their association with delayed cerebral ischemia (DCI) and poor outcome after aneurysmal subarachnoid hemorrhage (aSAH). DESIGN An observational cohort study from a prospective SAH Registry. SETTING Tertiary referral center focused on SAH treatment in the Amsterdam metropolitan area. PATIENTS A total of 964 adult patients with confirmed aSAH were included between 2011 and 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 277 (29%) developed DCI. Hyponatremia occurred significantly more often in DCI patients compared with no-DCI patients (77% vs. 48%). Sodium levels, hyponatremia, hypernatremia, and sodium fluctuations did not predict DCI. However, higher sodium levels were significantly associated with poor outcome in DCI patients (DCI onset -7, DCI +0, +1, +2, +4, +5, +8, +9 d), and in no-DCI patients (postbleed day 6-10 and 12-14). Also, hypernatremia and greater sodium fluctuations were significantly associated with poor outcome in both DCI and no-DCI patients. CONCLUSIONS Sodium levels, hyponatremia, and sodium fluctuations were not associated with the occurrence of DCI. However, higher sodium levels, hypernatremia, and greater sodium fluctuations were associated with poor outcome after aSAH irrespective of the presence of DCI. Therefore, sodium levels, even with mild changes in levels, warrant close attention.
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Affiliation(s)
- Homeyra Labib
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Neurosurgery, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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van Mourik N, Oomen JJ, van Vught LA, Biemond BJ, van den Bergh WM, Blijlevens NMA, Vlaar APJ, Müller MCA. The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy - A multicenter observational study. Intensive Crit Care Nurs 2023; 79:103486. [PMID: 37441816 DOI: 10.1016/j.iccn.2023.103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVES The modified early warning score (MEWS) is used to detect clinical deterioration of hospitalized patients. We aimed to investigate the predictive value of MEWS and derived quick Sequential Organ Failure Assessment (qSOFA) scores for intensive care unit admission in patients with a hematologic malignancy admitted to the ward. DESIGN Retrospective, observational study in two Dutch university hospitals. SETTING Data from adult patients with a hematologic malignancy, admitted to the ward over a 2-year period, were extracted from electronic patient files. MAIN OUTCOME MEASURES Intensive care admission. RESULTS We included 395 patients with 736 hospital admissions; 2% (n = 15) of admissions resulted in admission to the intensive care unit. A higher MEWS (OR 1.5; 95 %CI 1.3-1.80) and qSOFA (OR 4.4; 95 %CI 2.1-9.3) were associated with admission. Using restricted cubic splines, a rise in the probability of admission for a MEWS ≥ 6 was observed. The AUC of MEWS for predicting admission was 0.830, the AUC of qSOFA was 0.752. MEWS was indicative for intensive care unit admission two days before admission. CONCLUSIONS MEWS was a sensitive predictor of ICU admission in patients with a hematologic malignancy, superior to qSOFA. Future studies should confirm cut-off values and identify potential additional characteristics, to further enhance identification of critically ill hemato-oncology patients. IMPLICATIONS FOR CLINICAL PRACTICE The Modified Early Warning Score (MEWS) can be used as a tool for healthcare providers to monitor clinical deterioration and predict the need for intensive care unit admission in patients with a hematologic malignancy. Yet, consistent application and potential reevaluation of current thresholds is crucial. This will enable bedside nurses to more effectively identify patients needing adjunctive care, facilitating timely interventions and improved outcome.
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Affiliation(s)
- Niels van Mourik
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands.
| | - Jesse J Oomen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
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3
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Raasveld SJ, de Bruin S, Reuland MC, van den Oord C, Schenk J, Aubron C, Bakker J, Cecconi M, Feldheiser A, Meier J, Müller MCA, Scheeren TWL, McQuilten Z, Flint A, Hamid T, Piagnerelli M, Tomić Mahečić T, Benes J, Russell L, Aguirre-Bermeo H, Triantafyllopoulou K, Chantziara V, Gurjar M, Myatra SN, Pota V, Elhadi M, Gawda R, Mourisco M, Lance M, Neskovic V, Podbregar M, Llau JV, Quintana-Diaz M, Cronhjort M, Pfortmueller CA, Yapici N, Nielsen ND, Shah A, de Grooth HJ, Vlaar APJ. Red Blood Cell Transfusion in the Intensive Care Unit. JAMA 2023; 330:1852-1861. [PMID: 37824112 PMCID: PMC10570913 DOI: 10.1001/jama.2023.20737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice. Objective To evaluate and describe ICU RBC transfusion practices worldwide. Design, Setting, and Participants International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks. Exposure ICU stay. Main Outcomes and Measures The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused. Results Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL. Conclusions and Relevance RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Sanne de Bruin
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Merijn C. Reuland
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Claudia van den Oord
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Amsterdam Public Health, University of Amsterdam, Amsterdam, the Netherlands
| | - Cécile Aubron
- Médecine Intensive Réanimation, CHU de Brest, Université de Bretagne Occidentale, Brest, France
| | - Jan Bakker
- Department of Pulmonary and Critical Care, New York University and Columbia University New York
- Department of Intensive Care Adults, Erasmus MC University Medical Centers, Rotterdam, the Netherlands
- Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Aarne Feldheiser
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, EvangKliniken Essen-Mitte, Huyssens-Stiftung/Knappschaft, Essen, Germany
| | - Jens Meier
- Department of Anesthesiology and Intensive Care, Kepler University Clinic, Kepler University, Linz, Austria
| | - Marcella C. A. Müller
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Thomas W. L. Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Zoe McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Flint
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tarikul Hamid
- Department of Critical Care, Asgar Ali Hospital, Dhaka, Bangladesh
| | - Michaël Piagnerelli
- Department of Intensive Care, CHU Charleroi Marie Curie, Université Libre de Brussels, Charleroi, Belgium
| | - Tina Tomić Mahečić
- Department of Anesthesiology and Intensive Care, University Clinical Hospital Center Zagreb, Croatia
| | - Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, University Hospital and Faculty of Medicine in Plzen–Charles University, Plzen, Czech Republic
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care Medicine, Copenhagen University Hospital–Gentofte, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Vasiliki Chantziara
- Intensive Care Unit, First Department of Respiratory Medicine, National and Kapodistrian University of Athens, Sotiria Chest Hospital, Athens, Greece
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vincenzo Pota
- Department of Child, General and Specialistic Surgery, University of Campania, Luigi Vanvitelli, Naples, Italy
| | | | - Ryszard Gawda
- Department of Anesthesiology and Intensive Care, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Mafalda Mourisco
- Department of Intensive Care, Centro Hospitalar de Entro o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Marcus Lance
- Department of Anesthesiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Vojislava Neskovic
- Department of Anesthesia and Intensive Care, Military Medical Academy Belgrade, Belgrade, Serbia
| | - Matej Podbregar
- Department for Internal Intensive Care, General Hospital Celje, Medical Faculty, University of Ljubljana, Slovenia
| | - Juan V. Llau
- Department of Anesthesiology and Post-surgical Critical Care, University Hospital Doctor Peset, Valencia, Spain
| | | | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Carmen A. Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nihan Yapici
- Department of Anesthesiology and Reanimation, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Center, University of Health Sciences, Istanbul, Turkey
| | - Nathan D. Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, and Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque
| | - Akshay Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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4
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van Haeren MMT, Raasveld SJ, Karami M, Miranda DDR, Mandigers L, Dauwe DF, De Troy E, Pappalardo F, Fominskiy E, van den Bergh WM, Oude Lansink-Hartgring A, van der Velde F, Maas JJ, van de Berg P, de Haan M, Donker DW, Meuwese CL, Taccone FS, Peluso L, Lorusso R, Delnoij TSR, Scholten E, Overmars M, Ivancan V, Bojčić R, de Metz J, van den Bogaard B, de Bakker M, Reddi B, Hermans G, Broman LM, Henriques JPS, Schenk J, Vlaar APJ, Müller MCA. Plasma Transfusion and Procoagulant Product Administration in Extracorporeal Membrane Oxygenation: A Secondary Analysis of an International Observational Study on Current Practices. Crit Care Explor 2023; 5:e0949. [PMID: 37614800 PMCID: PMC10443757 DOI: 10.1097/cce.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES To achieve optimal hemostatic balance in patients on extracorporeal membrane oxygenation (ECMO), a liberal transfusion practice is currently applied despite clear evidence. We aimed to give an overview of the current use of plasma, fibrinogen concentrate, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) in patients on ECMO. DESIGN A prespecified subanalysis of a multicenter retrospective study. Venovenous (VV)-ECMO and venoarterial (VA)-ECMO are analyzed as separate populations, comparing patients with and without bleeding and with and without thrombotic complications. SETTING Sixteen international ICUs. PATIENTS Adult patients on VA-ECMO or VV-ECMO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 420 VA-ECMO patients, 59% (n = 247) received plasma, 20% (n = 82) received fibrinogen concentrate, 17% (n = 70) received TXA, and 7% of patients (n = 28) received PCC. Fifty percent of patients (n = 208) suffered bleeding complications and 27% (n = 112) suffered thrombotic complications. More patients with bleeding complications than patients without bleeding complications received plasma (77% vs. 41%, p < 0.001), fibrinogen concentrate (28% vs 11%, p < 0.001), and TXA (23% vs 10%, p < 0.001). More patients with than without thrombotic complications received TXA (24% vs 14%, p = 0.02, odds ratio 1.75) in VA-ECMO, where no difference was seen in VV-ECMO. Of 205 VV-ECMO patients, 40% (n = 81) received plasma, 6% (n = 12) fibrinogen concentrate, 7% (n = 14) TXA, and 5% (n = 10) PCC. Thirty-nine percent (n = 80) of VV-ECMO patients suffered bleeding complications and 23% (n = 48) of patients suffered thrombotic complications. More patients with than without bleeding complications received plasma (58% vs 28%, p < 0.001), fibrinogen concentrate (13% vs 2%, p < 0.01), and TXA (11% vs 2%, p < 0.01). CONCLUSIONS The majority of patients on ECMO receive transfusions of plasma, procoagulant products, or antifibrinolytics. In a significant part of the plasma transfused patients, this was in the absence of bleeding or prolonged international normalized ratio. This poses the question if these plasma transfusions were administered for another indication or could have been avoided.
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Affiliation(s)
- Maite M T van Haeren
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Mina Karami
- Department of Cardiology, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Loes Mandigers
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Dieter F Dauwe
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Erwin De Troy
- Department of Intensive Care Medicine, Surgical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Allesandria, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Jacinta J Maas
- Adult Intensive Care Unit, Leiden University Medical Center, Leiden, the Netherlands
| | - Pablo van de Berg
- Adult Intensive Care Unit, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Maarten de Haan
- Department of Extracorporeal Circulation, Catharina hospital Eindhoven, the Netherlands
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, the Netherlands
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - Christiaan L Meuwese
- Adult Intensive Care Unit, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Erasme Bruxelles, Brussels, Belgium
| | - Roberto Lorusso
- Cardiothoracic Surgery, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Erik Scholten
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Martijn Overmars
- Department of Intensive Care, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Višnja Ivancan
- Department of Anesthesia and Intensive care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Robert Bojčić
- Department of Anesthesia and Intensive care, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jesse de Metz
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | | | - Martin de Bakker
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Benjamin Reddi
- Department of Critical Care, Royal Adelaide Hospital, Adelaide, Australia
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Jimmy Schenk
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, location AMC, Amsterdam Public Health, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Critical Care, Amsterdam University Medical Centers, location Academic Medical Centers, Amsterdam, the Netherlands
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5
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Tjerkstra MA, Müller MCA, Coert BA, Hoefnagels FWA, Vergouwen MDI, van Vliet P, Ooms L, Rinkel GJE, Slooter AJC, Moojen WA, Jellema K, Vandertop WP, Verbaan D. Clinical Response following Hypertension-Induction for clinical Delayed Cerebral Ischemia following Subarachnoid Haemorrhage - a retrospective multicentre cohort study. Eur J Neurol 2023. [PMID: 37151098 DOI: 10.1111/ene.15833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/24/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Hypertension-induction is often used for treating delayed cerebral ischemia (DCI) following aneurysmal subarachnoid haemorrhage (aSAH), however, high-quality studies on its efficacy are lacking. We studied immediate and 3-/6-month clinical efficacy of hypertension-induction in aSAH patients with clinical DCI. METHODS A retrospective, multicentre, comparative, observational cohort study in aSAH patients with clinical deterioration due to DCI, admitted to three tertiary referral hospitals in the Netherlands from 2015-2019. Two hospitals used a strategy of hypertension-induction (HTI group) and one hospital had no such strategy (control group). We calculated adjusted relative risks (aRR) using Poisson regression analyses for the two primary (clinical improvement of DCI-symptoms at day 1 and 5 after DCI-onset) and secondary outcomes (DCI-related cerebral infarction, in-hospital mortality and poor clinical outcome (modified Rankin Scale 4-6) assessed at 3 or 6 months), using the intention-to-treat principle. We also performed as-treated and per-protocol analyses. RESULTS The aRR for clinical improvement on day 1 after DCI in the HTI group was 1.63, 95% C.I. 1.17-2.27 and at day 5 after DCI 1.04, 95% C.I. 0.84 to 1.29. Secondary outcomes were comparable between the groups. The as-treated and per-protocol analyses yielded similar results. CONCLUSIONS No clinical benefit of hypertension-induction is observed five days after DCI due to spontaneous reversal of DCI-symptoms in patients treated without hypertension-induction. 3-/6-Month clinical outcome was similar between both groups. Therefore, these data suggest that one may consider to not apply hypertension-induction in aSAH patients with clinical DCI.
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Affiliation(s)
- Maud A Tjerkstra
- Amsterdam UMC location University of Amsterdam, Department of Neurosurgery, Meibergdreef 9, Amsterdam, the Netherlands
- Neuroscience Amsterdam, Neurovascular disorders, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care, Meibergdreef 9, Amsterdam, the Netherlands
| | - Bert A Coert
- Amsterdam UMC location University of Amsterdam, Department of Neurosurgery, Meibergdreef 9, Amsterdam, the Netherlands
- Neuroscience Amsterdam, Neurovascular disorders, Amsterdam, the Netherlands
| | - Friso W A Hoefnagels
- Amsterdam UMC location University of Amsterdam, Department of Neurosurgery, Meibergdreef 9, Amsterdam, the Netherlands
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter van Vliet
- Department of Intensive Care, Haaglanden Medical Center, The Hague, the Netherlands
| | - Lizzy Ooms
- Department of Intensive Care, Haaglanden Medical Center, The Hague, the Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Arjen J C Slooter
- Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands, Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, Department of Neurosurgery, Haga Teaching Hospital; Department of Neurosurgery, Leiden University Medical Center, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
| | - W Peter Vandertop
- Amsterdam UMC location University of Amsterdam, Department of Neurosurgery, Meibergdreef 9, Amsterdam, the Netherlands
- Neuroscience Amsterdam, Neurovascular disorders, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Amsterdam UMC location University of Amsterdam, Department of Neurosurgery, Meibergdreef 9, Amsterdam, the Netherlands
- Neuroscience Amsterdam, Neurovascular disorders, Amsterdam, the Netherlands
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6
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Tjerkstra MA, Wolfs AE, Verbaan D, Vandertop WP, Horn J, Müller MCA, Juffermans NP. A systematic review on viscoelastic testing in subarachnoid haemorrhage patients. World Neurosurg 2023:S1878-8750(23)00430-8. [PMID: 37004882 DOI: 10.1016/j.wneu.2023.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES Bleeding and thromboembolic complications frequently occur following subarachnoid haemorrhage (SAH) and substantially contribute to poor outcome. Viscoelastic testing could be used for detection of coagulopathies following SAH. This review summarizes literature on the utility of viscoelastic testing to detect coagulopathy in SAH patients and explores whether viscoelastic parameters are associated with SAH-related complications and clinical outcome. MATERIALS AND METHODS PUBMED, EMBASE and Google Scholar were systematically searched on August 18th, 2022. Two authors independently selected studies which performed viscoelastic testing in SAH patients and assessed the quality of studies using the Newcastle Ottawa Scale or a previously published framework for quality assessment. Data was meta-analysed if methodologically possible. RESULTS The search yielded 19 studies (1160 SAH patients). Pooling of data including all relevant studies was not possible for any of the outcome measurements due to methodological differences. Thirteen of 19 studies evaluated the association of coagulation profiles and SAH, of which 11 studies showed a hypercoagulable profile. Rebleeding was associated with platelet dysfunction, deep venous thrombosis was associated with faster clot initiation and both delayed cerebral ischemia and poor outcome were associated with increased clot strength. CONCLUSIONS This explorative review shows that SAH patients frequently have a hypercoagulable profile. TEG- and ROTEM-parameters are associated with rebleeding, delayed cerebral ischemia, deep venous thrombosis and poor clinical outcome after SAH, however more research on the subject is needed. Future studies should focus on determining the optimal time frame and cut-off values for TEG or ROTEM to predict these complications.
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Affiliation(s)
- Maud A Tjerkstra
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands.
| | - Anne E Wolfs
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Amsterdam UMC, University of Amsterdam, Department of Neurosurgery, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Janneke Horn
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Amsterdam UMC, University of Amsterdam, Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam Neuroscience, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
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7
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Breel JS, Wensing AGCL, Eberl S, Preckel B, Schober P, Müller MCA, Klautz RJM, Hollmann MW, Hermanns H. Patients with infective endocarditis undergoing cardiac surgery have distinct ROTEM profiles and more bleeding complications compared to patients without infective endocarditis. PLoS One 2023; 18:e0284329. [PMID: 37053130 PMCID: PMC10101476 DOI: 10.1371/journal.pone.0284329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The coagulation system is crucial in the pathogenesis of infective endocarditis and undergoes significant changes during course of the disease. However, little is known about the implications of those changes in the perioperative period. Aim of the present study was to delineate the specific coagulation patterns and their clinical consequence in patients undergoing cardiac surgery due to infective endocarditis. METHODS In this single-centre, exploratory, prospective observational study, we investigated the incidence and degree of coagulopathy in patients with (n = 31) and without infective endocarditis (n = 39) undergoing cardiac valve surgery. The primary outcome was the differences between these two groups in rotational thromboelastometry (ROTEM) results before, during and after surgery. The secondary outcomes were the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements. RESULTS Most ROTEM parameters in EXTEM, INTEM and FIBTEM assays were significantly altered in patients with infective endocarditis. Clotting time in the EXTEM assay was significantly prolonged in the endocarditis group at all time-points, while all clot firmness parameters (A5, A10 and MCF) were significantly increased. The heparin sensitivity index was significantly lower in the endocarditis group (median index 0.99 vs 1.17s. IU-1.kg-1, p = .008), indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications as assessed by the universal definition of perioperative bleeding score (OR 3.0, p = .018), and more patients with endocarditis underwent early re-exploration (p = .018). CONCLUSIONS The findings of this exploratory investigation show significantly altered coagulation profiles in patients with infective endocarditis, with concomitant hyper- and hypocoagulability. Furthermore, the incidence of bleeding complications and transfusion requirements were increased in patients with endocarditis. These results show the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis. Existing point-of-care coagulation testing guided algorithms for optimizing perioperative coagulation management possibly need to be adjusted for these high-risk patients undergoing cardiac surgery.
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Affiliation(s)
- Jennifer S Breel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Agnes G C L Wensing
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Susanne Eberl
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Patrick Schober
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Robert J M Klautz
- Department of Cardiac Surgery, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Henning Hermanns
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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8
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Kotsaki A, Pickkers P, Bauer M, Calandra T, Lupse M, Wiersinga WJ, Meylan S, Bloos F, van der Poll T, Slim MA, van Mourik N, Müller MCA, van Vught L, Vlaar APJ, de Nooijer A, Bakkerus L, Weis S, Antonakos N, Netea MG, Giamarellos-Bourboulis EJ. ImmunoSep (Personalised Immunotherapy in Sepsis) international double-blind, double-dummy, placebo-controlled randomised clinical trial: study protocol. BMJ Open 2022; 12:e067251. [PMID: 36600424 PMCID: PMC9772655 DOI: 10.1136/bmjopen-2022-067251] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Sepsis is a major cause of death among hospitalised patients. Accumulating evidence suggests that immune response during sepsis cascade lies within a spectrum of dysregulated host responses. On the one side of the spectrum there are patients whose response is characterised by fulminant hyperinflammation or macrophage activation-like syndrome (MALS), and on the other side patients whose immune response is characterised by immunoparalysis. A sizeable group of patients are situated between the two extremes. Recognising immune endotype is very important in order to choose the appropriate immunotherapeutic approach for each patient resulting in the best chance to improve the outcome. METHODS AND ANALYSIS ImmunoSep is a randomised placebo-controlled phase 2 clinical trial with a double-dummy design in which the effect of precision immunotherapy on sepsis phenotypes with MALS and immunoparalysis is studied. Patients are stratified using biomarkers. Specifically, 280 patients will be 1:1 randomly assigned to placebo or active immunotherapy as adjunct to standard-of-care treatment. In the active immunotherapy arm, patients with MALS will receive anakinra (recombinant interleukin-1 receptor antagonist) intravenously, and patients with immunoparalysis will receive subcutaneous recombinant human interferon-gamma. Τhe primary endpoint is the comparative decrease of the mean total Sequential Organ Failure Assessment score by at least 1.4 points by day 9 from randomisation. ETHICS AND DISSEMINATION The protocol is approved by the German Federal Institute for Drugs and Medical Devices; the National Ethics Committee of Greece and by the National Organization for Medicines of Greece; the Central Committee on Research Involving Human Subjects and METC Oost Netherland for the Netherlands; the National Agency for Medicine and Medical Products of Romania; and the Commission Cantonale d'éthique de la recherche sur l'être human of Switzerland. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04990232.
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Affiliation(s)
- Antigone Kotsaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Michael Bauer
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Jena, Germany
| | | | - Mihaela Lupse
- Department of Internal Medicine, University of Cluj-Napoca, Cluj, Romania
| | - W Joost Wiersinga
- Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
| | - Sylvain Meylan
- Department of Infectious Diseases, CHUV, Lausanne, Switzerland
| | - Frank Bloos
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Jena, Germany
| | - Tom van der Poll
- Department of Internal Medicine, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
- The Center of Experimental and Molecular Medicine, Amsterdam University Medical Centres, Duivendrecht, The Netherlands
- Department of Infectious Diseases, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marleen A Slim
- Intensive Care Unit, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Niels van Mourik
- Intensive Care Unit, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Lonneke van Vught
- Department of Infectious Diseases, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Aline de Nooijer
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lieke Bakkerus
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sebastian Weis
- Center for Infectious Disease and Infection Control, Jena University Hospital, Jena, Germany
| | - Nikolaos Antonakos
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Mihai G Netea
- Radboud University Medical Center, Nijmegen, The Netherlands
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9
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Slim MA, Appelman B, Peters-Sengers H, Dongelmans DA, de Keizer NF, Schade RP, de Boer MGJ, Müller MCA, Vlaar APJ, Wiersinga WJ, van Vught LA. Real-world Evidence of the Effects of Novel Treatments for COVID-19 on Mortality: A Nationwide Comparative Cohort Study of Hospitalized Patients in the First, Second, Third, and Fourth Waves in the Netherlands. Open Forum Infect Dis 2022; 9:ofac632. [PMID: 36519114 PMCID: PMC9745783 DOI: 10.1093/ofid/ofac632] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/20/2022] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Large clinical trials on drugs for hospitalized coronavirus disease 2019 (COVID-19) patients have shown significant effects on mortality. There may be a discrepancy with the observed real-world effect. We describe the clinical characteristics and outcomes of hospitalized COVID-19 patients in the Netherlands during 4 pandemic waves and analyze the association of the newly introduced treatments with mortality, intensive care unit (ICU) admission, and discharge alive. METHODS We conducted a nationwide retrospective analysis of hospitalized COVID-19 patients between February 27, 2020, and December 31, 2021. Patients were categorized into waves and into treatment groups (hydroxychloroquine, remdesivir, neutralizing severe acute respiratory syndrome coronavirus 2 monoclonal antibodies, corticosteroids, and interleukin [IL]-6 antagonists). Four types of Cox regression analyses were used: unadjusted, adjusted, propensity matched, and propensity weighted. RESULTS Among 5643 patients from 11 hospitals, we observed a changing epidemiology during 4 pandemic waves, with a decrease in median age (67-64 years; P < .001), in in-hospital mortality on the ward (21%-15%; P < .001), and a trend in the ICU (24%-16%; P = .148). In ward patients, hydroxychloroquine was associated with increased mortality (1.54; 95% CI, 1.22-1.96), and remdesivir was associated with a higher rate of discharge alive within 29 days (1.16; 95% CI, 1.03-1.31). Corticosteroids were associated with a decrease in mortality (0.82; 95% CI, 0.69-0.96); the results of IL-6 antagonists were inconclusive. In patients directly admitted to the ICU, hydroxychloroquine, corticosteroids, and IL-6 antagonists were not associated with decreased mortality. CONCLUSIONS Both remdesivir and corticosteroids were associated with better outcomes in ward patients with COVID-19. Continuous evaluation of real-world treatment effects is needed.
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Affiliation(s)
- Marleen A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Brent Appelman
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Hessel Peters-Sengers
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
| | - Nicolette F de Keizer
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands
- Department of Medical Informatics, Amsterdam University Medical Centers, University of Amsterdam—Location AMC, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Rogier P Schade
- Department of Medical Microbiology and Infection Prevention, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
- Division of Infectious Diseases, Department of Medicine, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers—Location AMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
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10
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Gathier CS, Zijlstra IJAJ, Rinkel GJE, Groenhof TKJ, Verbaan D, Coert BA, Müller MCA, van den Bergh WM, Slooter AJC, Eijkemans MJC. Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2022; 72:154124. [PMID: 36208555 DOI: 10.1016/j.jcrc.2022.154124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/04/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVE Blood pressure is presumably related to rebleeding and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (aSAH) and could serve as a target to improve outcome. We assessed the associations between blood pressure and rebleeding or DCI in aSAH-patients. MATERIALS AND METHODS In this observational study in 1167 aSAH-patients admitted to the intensive care unit (ICU), adjusted hazard ratio's (aHR) were calculated for the time-dependent association of blood pressure and rebleeding or DCI. The aHRs were presented graphically, relative to a reference mean arterial pressure (MAP) of 100 mmHg and systolic blood pressure (sBP) of 150 mmHg. RESULTS A MAP below 100 mmHg in the 6, 3 and 1 h before each moment in time was associated with a decreased risk of rebleeding (e.g. within 6 h preceding rebleeding: MAP = 80 mmHg: aHR 0.30 (95% confidence interval (CI) 0.11-0.80)). A MAP below 60 mmHg in the 24 h before each moment in time was associated with an increased risk of DCI (e.g. MAP = 50 mmHg: aHR 2.59 (95% CI 1.12-5.96)). CONCLUSIONS Our results suggest that a MAP below 100 mmHg is associated with decreased risk of rebleeding, and a MAP below 60 mmHg with increased risk of DCI.
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Affiliation(s)
- Celine S Gathier
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - IJsbrand A J Zijlstra
- Department of Radiology, Amsterdam University Medical Center, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - T Katrien J Groenhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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11
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Dorresteijn KRIS, Verheul RJ, Ponjee GAE, Tewarie RN, Müller MCA, van de Beek D, Brouwer MC, Jellema K. Diagnostic Accuracy of Clinical Signs and Biochemical Parameters for External Ventricular Cerebrospinal Fluid Catheter-Associated Infection. Neurol Clin Pract 2022; 12:298-306. [PMID: 36382125 PMCID: PMC9647825 DOI: 10.1212/cpj.0000000000200059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 04/28/2022] [Indexed: 12/03/2022]
Abstract
Background and Objectives Few prospective well-designed diagnostic accuracy studies have been performed to study the parameters of infection in patients suspected for external ventricular catheter-associated infection. Our objective was to analyze the diagnostic accuracy of clinical characteristics and biochemical and microbiological parameters in diagnosing external ventricular CSF catheter-associated infection. Methods From 2014 to 2017, we performed a single-center cohort study in consecutive patients at the intensive care unit who required an external ventricular CSF catheter in the Hague, the Netherlands. CSF was sampled and analyzed daily. Ventricular catheter-associated infection was defined according to the 2017 Infectious Diseases Society of America's Clinical Practice Guidelines. We compared clinical characteristics and biochemical parameters between patients with and without infection from 3 days before to 3 days after the day the CSF sample was collected that grew bacteria. Results A total of 103 patients were included of whom 15 developed a catheter-associated infection (15%). The median day cultures were positive was 3 days after CSF collection (interquartile range [IQR] +2 to +4). On day 0, none of the tests could differentiate between patients with and without infection. The CSF leukocyte count was increased in patients with ventricular catheter-associated infection as compared with patients without on days +2 and +3. The difference was most prominent on day +2 (1,703 × 106/L [IQR 480–6,296] vs 80 × 106/L [IQR 27–251]; p < 0.001; area under the curve [AUC] 0.87 [95% confidence interval (CI) 0.71–1.00]). Sensitivity for the CSF leukocyte count at a cutoff level >1,000 × 106/L was 67% (95% CI 30–93), and specificity was 100% (95% CI 90–100); the positive predictive value was 100%, and the negative predictive value was 92% (95% CI 83–97). The percentage of polymorphonuclear cells (PMNs) was higher in patients with infection on days +1 and +2 (day +2 89% [IQR 78–94] vs 59% [IQR 39–75]; p < 0.01; AUC 0.91 [95% CI 0.81–1.0]). Discussion An elevated CSF leukocyte count and increased percentage of PMNs are the strongest indicators for external catheter-associated infections on the days before culture positivity. New CSF markers of drain-associated infection should be studied to enable earlier diagnosis and treatment in patients with an infection and reduce antibiotic treatment in those with no infection. Classification of Evidence This study provides Class I evidence that in individuals requiring an external ventricular CSF catheter, an elevated CSF leukocyte count and an increased percentage of PMNs are the strongest indicators of catheter-associated infections in the days before CSF culture positivity.
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Affiliation(s)
- Kirsten R I S Dorresteijn
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Rolf J Verheul
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Gabriëlle A E Ponjee
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Rishi Nandoe Tewarie
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Marcella C A Müller
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Diederik van de Beek
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Matthijs C Brouwer
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
| | - Korné Jellema
- Department of Neurology (KRISD), Franciscus Gasthuis & Vlietland, Rotterdam; Department of Clinical Chemistry and Laboratory Medicine (RJV, GAEP), and Department of Neurosurgery (RNT), Haaglanden Medical Center, The Hague; Department of Intensive Care Medicine (MCAM), and Department of Neurology (DvdB, MCB), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; and Department of Neurology (KJ), Haaglanden Medical Center, The Hague, the Netherlands
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12
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Slim MA, van Mourik N, Dionne JC, Oczkowski SJW, Netea MG, Pickkers P, Giamarellos-Bourboulis EJ, Müller MCA, van der Poll T, Wiersinga WJ, Vlaar APJ, van Vught LA. Personalised immunotherapy in sepsis: a scoping review protocol. BMJ Open 2022; 12:e060411. [PMID: 35534059 PMCID: PMC9086601 DOI: 10.1136/bmjopen-2021-060411] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Sepsis, a life-threatening organ dysfunction syndrome occurring in the context of severe infections, remains a major burden on global health with high morbidity and high mortality rates. Despite recent advances in the understanding of its pathophysiology, the treatment of sepsis remains supportive of nature with few interventions specifically designed for treating this complex syndrome. The focus of sepsis trials has increasingly shifted towards targeting excessive inflammation and immunosuppression using immunomodulatory agents. However, it remains uncertain how to identify patients that could benefit from such treatment, whether treatments can be tailored to an individual's immune profile, or at which stage of the disease the intervention should be initiated. In this scoping review, we provide a comprehensive overview of current available literature on immunostimulatory and immunosuppressive therapies against sepsis. METHODS AND ANALYSIS The aim of this scoping review is to describe and summarise current literature evaluating immunotherapy in adult patients with sepsis. The review will be performed using the framework formulated by Arksey and O'Malley. A comprehensive literature and study collection will be executed by searching PubMed, Embase, Cochrane CENTRAL and ClinicalTrials.gov to identify clinical trials and cohort studies concerning immunotherapy in adult patients with sepsis. Screening will be performed independently and in duplicate by two reviewers who will also independently extract data into prespecified spreadsheets. We will summarise evidence in tabular format with descriptive statistics. The reported evidence will convey knowledge on the types of immunotherapies studied, and currently being studied, in adult patients with sepsis. ETHICS AND DISSEMINATION Approval from a medical ethics committee is not required. Once completed, the review will be submitted for publication in a peer-reviewed journal. These results will be of value to clinicians and researchers with an interest in advancing sepsis care.
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Affiliation(s)
- Marleen A Slim
- Intensive Care, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Niels van Mourik
- Intensive Care, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Joanna C Dionne
- Medicine, McMaster University, Hamilton, Ontario, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | - Simon J W Oczkowski
- Medicine, McMaster University, Hamilton, Ontario, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - M G Netea
- Internal Medicine, Radboudumc, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Internal Medicine, Division of Infectious Diseases, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Internal Medicine, Division of Infectious Diseases, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | | | - Lonneke A van Vught
- Intensive Care, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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13
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van Os HJA, Verbaan D, Ruigrok YM, Dennesen P, Müller MCA, Coert BA, Vergouwen MDI, Wermer MJH. Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage in Young Patients With a History of Migraine. Stroke 2022; 53:2075-2077. [PMID: 35514282 DOI: 10.1161/strokeaha.121.038350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Young patients with aneurysmal subarachnoid hemorrhage (aSAH) and a history of migraine may have an increased risk of delayed cerebral ischemia. We investigated this potential association in a prospective cohort of aSAH patients under 50 years of age. METHODS In our prospective cohort study, we included patients with aSAH under 50 years of age from 3 hospitals in the Netherlands. We assessed lifetime migraine history with a short screener. Delayed cerebral ischemia was defined as neurological deterioration lasting >1 hour not attributable to other causes by diagnostic workup. Adjustments were made for possible confounders in multivariable Cox regression analyses, and adjusted hazard ratios were calculated. RESULTS We included 236 young aSAH patients (mean age, 41 years; 64% women) of whom 44 (19%) had a history of migraine (16 with aura). Patients with aSAH and a history of migraine were not at increased risk of developing delayed cerebral ischemia compared with patients without migraine (25% versus 20%; adjusted hazard ratio, 1.16 [95% CI, 0.57-2.35]). Additionally, no increased risk was found in migraine patients with aura (adjusted hazard ratio, 0.85 [95% CI, 0.30-2.44]) or in women (adjusted hazard ratio, 1.24 [95% CI, 0.58-2.68]). CONCLUSIONS Patients with aSAH under the age of 50 years with a history of migraine are not at increased risk of delayed cerebral ischemia.
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Affiliation(s)
- Hendrikus J A van Os
- Department of Neurology, Leiden University Medical Center, the Netherlands (H.J.A.v.O., M.J.H.W.)
| | - Dagmar Verbaan
- Department of Neurosurgery and Amsterdam Neuroscience, Amsterdam UMC (D.V., B.A.C.)
| | - Ynte M Ruigrok
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands (Y.M.R., M.D.I.V.)
| | - Paul Dennesen
- Department of Intensive Care, Haaglanden Medical Center, The Hague, the Netherlands (P.D.)
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, the Netherlands (M.C.A.M.)
| | - Bert A Coert
- Department of Neurosurgery and Amsterdam Neuroscience, Amsterdam UMC (D.V., B.A.C.)
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, the Netherlands (Y.M.R., M.D.I.V.)
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, the Netherlands (H.J.A.v.O., M.J.H.W.)
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14
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Slim MA, Appelman B, Müller MCA, Brouwer MC, Vlaar APJ, Wiersinga WJ, van Vught LA. Inflammatory biomarkers at hospital discharge are associated with readmission and death in patients hospitalized for COVID-19. Eur J Clin Microbiol Infect Dis 2021; 40:2677-2683. [PMID: 34713349 PMCID: PMC8552978 DOI: 10.1007/s10096-021-04355-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Marleen A Slim
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Brent Appelman
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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15
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Müller MCA, Dujardin RWG, Thachil J, van Mierlo G, Zeerleder SS, Juffermans NP. The relation between fibrinogen level, neutrophil activity and nucleosomes in the onset of disseminated intravascular coagulation in the critically ill. J Intern Med 2021; 290:922-927. [PMID: 34137469 DOI: 10.1111/joim.13346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nucleosomes and neutrophil extracellular traps (NETs) are important in the pathophysiology of disseminated intravascular coagulation (DIC). Fibrinogen, as an acute phase reactant, may be protective by engaging neutrophils. We hypothesize that DIC can occur when NET formation becomes uncontrolled in relation to low fibrinogen levels. PATIENTS/METHOD The ratio of both circulating nucleosomes and human neutrophil elastase alpha-1-antitrypsine complexes (HNE-a1ATc) to fibrinogen was correlated to thrombocytopenia, DIC and organ failure in 64 critically ill coagulopathic patients. RESULTS A high nucleosome to fibrinogen ratio correlated with thrombocytopenia and organ failure (ρ -0.391, p 0.01 and ρ 0.556, p 0.01, respectively). A high HNE-a1ATc to fibrinogen ratio correlated with thrombocytopenia, DIC and organ failure (ρ -0.418, p 0.01, ρ 0.391, p 0.01 and ρ 0.477, p 0.01 respectively). CONCLUSION These findings support the hypothesis that fibrinogen is protective against DIC by counterbalancing excessive neutrophil activation.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Romein W G Dujardin
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jecko Thachil
- Department of Hematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Sacha S Zeerleder
- Sanquin Research, Amsterdam, The Netherlands.,Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, The Netherlands
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16
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Haksteen WE, Hilderink BN, Dujardin RWG, Jansen RR, Hodiamont CJ, Tuinman PR, Smit JM, Müller MCA, Juffermans NP. Venous thromboembolism is not a risk factor for the development of bloodstream infections in critically ill COVID-19 patients. Thromb Res 2021; 206:128-130. [PMID: 34461426 PMCID: PMC8384728 DOI: 10.1016/j.thromres.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/16/2021] [Accepted: 08/19/2021] [Indexed: 12/03/2022]
Affiliation(s)
- Wolmet E Haksteen
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
| | | | - Romein W G Dujardin
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
| | - Rogier R Jansen
- Department of Medical Microbiology, OLVG Hospital, Amsterdam, the Netherlands
| | - Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands; Department of Medical Microbiology, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Jasper M Smit
- Department of Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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17
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Smit JM, Lopez Matta JE, Vink R, Müller MCA, Choi KF, van Baarle FEHP, Vlaar APJ, Klok FA, Huisman MV, Elzo Kraemer CV, Girbes ARJ, Van Westerloo DJ, Tuinman PR. Coronavirus disease 2019 is associated with catheter-related thrombosis in critically ill patients: A multicenter case-control study. Thromb Res 2021; 200:87-90. [PMID: 33549899 PMCID: PMC7835604 DOI: 10.1016/j.thromres.2021.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Jasper M Smit
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com), the Netherlands.
| | - Jorge E Lopez Matta
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands; Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com), the Netherlands
| | - Roel Vink
- Department of Intensive Care Medicine, Tergooi Hospital, Hilversum, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Kee F Choi
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frank E H P van Baarle
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands; Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com), the Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - David J Van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands; Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com), the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, VU University, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Amsterdam Leiden Intensive care Focused Echography (ALIFE, www.alifeofpocus.com), the Netherlands
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18
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Dujardin RWG, Hilderink BN, Haksteen WE, Middeldorp S, Vlaar APJ, Thachil J, Müller MCA, Juffermans NP. Biomarkers for the prediction of venous thromboembolism in critically ill COVID-19 patients. Thromb Res 2020; 196:308-312. [PMID: 32977128 PMCID: PMC7491463 DOI: 10.1016/j.thromres.2020.09.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
Background Venous thromboembolism (VTE) is a frequent complication in critically ill patients with coronavirus disease 2019 (COVID-19) and is associated with mortality. Early diagnosis and treatment of VTE is warranted. Objective To develop a prediction model for VTE in critically ill COVID-19 patients. Patients and methods In this retrospective cohort study, 127 adult patients with confirmed COVID-19 infection admitted to the intensive care unit of two teaching hospitals were included. VTE was diagnosed with either ultrasound or computed tomography scan. Univariate receiver operating characteristic (ROC) curves were constructed for Positive End Expiratory Pressure, PaO2/FiO2 ratio, platelet count, international normalized ratio, activated partial thromboplastin time as well as levels of fibrinogen, antithrombin, D-dimer and C-reactive protein (CRP). Multivariate analysis was done using binary linear regression. Results Variables associated with VTE in both univariate and multivariate analysis were D-dimer and CRP with an area under the curve (AUC) of 0.64, P = 0.023 and 0.75, P = 0.045, respectively. Variables indicating hypoxemia were not predictive. The ROC curve of D-dimer and CRP combined had an AUC of 0.83, P < 0.05. Categorized values of D-dimer and CRP were used to compute a mean absolute risk for the combination of these variables with a high positive predictive value. The predicted probability of VTE with a D-dimer > 15 in combination with a CRP > 280 was 98%. The negative predictive value of D-dimer was low. Conclusion Elevated CRP and D-dimer have a high positive predictive value for VTE in critically ill COVID-19 patients. We developed a prediction table with these biomarkers that can aid clinicians in the timing of imaging in patients with suspected VTE. Venous thromboembolisms are a frequently observed complication of COVID-19. Markers of oxygenation are not predictive of venous thromboembolism. Elevated C-reactive protein and D-dimer have the potential to predict venous thromboembolism. We created a prediction tool based on elevations in both CRP and D-dimer to optimize time of imaging.
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Affiliation(s)
- Romein W G Dujardin
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands.
| | | | - Wolmet E Haksteen
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - S Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - J Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Intensive Care, OLVG Hospital, Amsterdam, the Netherlands
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19
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Middeldorp S, Coppens M, van Haaps TF, Foppen M, Vlaar AP, Müller MCA, Bouman CCS, Beenen LFM, Kootte RS, Heijmans J, Smits LP, Bonta PI, van Es N. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost 2020; 18:1995-2002. [PMID: 32369666 PMCID: PMC7497052 DOI: 10.1111/jth.14888] [Citation(s) in RCA: 1037] [Impact Index Per Article: 259.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/01/2020] [Accepted: 05/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) can lead to systemic coagulation activation and thrombotic complications. OBJECTIVES To investigate the incidence of objectively confirmed venous thromboembolism (VTE) in hospitalized patients with COVID-19. METHODS Single-center cohort study of 198 hospitalized patients with COVID-19. RESULTS Seventy-five patients (38%) were admitted to the intensive care unit (ICU). At time of data collection, 16 (8%) were still hospitalized and 19% had died. During a median follow-up of 7 days (IQR, 3-13), 39 patients (20%) were diagnosed with VTE of whom 25 (13%) had symptomatic VTE, despite routine thrombosis prophylaxis. The cumulative incidences of VTE at 7, 14 and 21 days were 16% (95% CI, 10-22), 33% (95% CI, 23-43) and 42% (95% CI 30-54) respectively. For symptomatic VTE, these were 10% (95% CI, 5.8-16), 21% (95% CI, 14-30) and 25% (95% CI 16-36). VTE appeared to be associated with death (adjusted HR, 2.4; 95% CI, 1.02-5.5). The cumulative incidence of VTE was higher in the ICU (26% (95% CI, 17-37), 47% (95% CI, 34-58), and 59% (95% CI, 42-72) at 7, 14 and 21 days) than on the wards (any VTE and symptomatic VTE 5.8% (95% CI, 1.4-15), 9.2% (95% CI, 2.6-21), and 9.2% (2.6-21) at 7, 14, and 21 days). CONCLUSIONS The observed risk for VTE in COVID-19 is high, particularly in ICU patients, which should lead to a high level of clinical suspicion and low threshold for diagnostic imaging for DVT or PE. Future research should focus on optimal diagnostic and prophylactic strategies to prevent VTE and potentially improve survival.
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Affiliation(s)
- Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thijs F van Haaps
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Merijn Foppen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Catherine C S Bouman
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ruud S Kootte
- Department of Acute Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jarom Heijmans
- Department of Acute Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Loek P Smits
- Department of Acute Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter I Bonta
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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20
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van Wagenberg L, Beurskens CJP, Stegeman I, Müller MCA. Program on high value cost-conscious education in intensive care: Educational program on prediction of outcome and cost awareness on Intensive Care admission. BMC Med Educ 2020; 20:186. [PMID: 32513162 PMCID: PMC7282117 DOI: 10.1186/s12909-020-02100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 05/29/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Intensive Care (ICU) involves extended and long lasting support of vital functions and organs. However, current training programs of ICU residents mainly focus on extended support of vital functions and barely involve training on cost-awareness and outcome. We incorporated an educational program on high-value cost-conscious care for residents and fellows on our ICU and measured the effect of education. METHODS A cohort study with factorial survey design, in which ICU residents and fellows were asked to evaluate clinical vignettes, was performed on the mixed surgical-medical ICU of the Amsterdam University Medical Centre. Residents were offered an educational program focusing on outcome and costs of ICU care. Before and after the program they filled out a questionnaire, which consisted of 23 vignettes, in which known predictors of outcome of community acquired pneumonia (CAP), pancreatitis, acute respiratory distress syndrome (ARDS) and cardiac arrest were presented, together with varying patient factors (age, body mass index (BMI), acute kidney failure (AKI) and haemato-oncological malignancy). Participants were asked to either admit the patient or estimate mortality. RESULTS BMI, haemato-oncological malignancy and severity of pancreatitis were discriminative for admission to ICU in clinical vignettes on pancreatitis and CAP. After education, only severity of pancreatitis was judged as discriminative. Before the intervention only location of cardiac arrest (in- vs out of hospital) was distinctive for mortality, afterwards this changed to presence of haemato-oncological malignancy. CONCLUSION We incorporated an educational program on high-value cost-conscious care in the training of ICU physicians. Based on our vignette study, we conclude that the improvement of knowledge of costs and prognosis after this program was limited.
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Affiliation(s)
- L van Wagenberg
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
- Department of Paediatrics, Paediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EC, Utrecht, the Netherlands.
| | - C J P Beurskens
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - I Stegeman
- Department of Otorhinolaryngology and Head & Neck Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Brain Centre Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - M C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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21
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Dorresteijn KRIS, Verheul RJ, Ponjee GAE, Tewarie RN, Müller MCA, van de Beek D, Brouwer MC, Jellema K. Cerebrospinal fluid analysis from bilateral external ventricular drains in suspected nosocomial infection. J Infect 2020; 81:147-178. [PMID: 32092389 DOI: 10.1016/j.jinf.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/06/2020] [Accepted: 02/08/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Kirsten R I S Dorresteijn
- Department of Neurology, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
| | - Rolf J Verheul
- Department of Clinical Chemistry and Laboratory Medicine, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
| | - Gabriëlle A E Ponjee
- Department of Clinical Chemistry and Laboratory Medicine, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
| | - Rishi Nandoe Tewarie
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
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22
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van Baarle FEHP, van de Weerdt EK, Suurmond B, Müller MCA, Vlaar APJ, Biemond BJ. Bleeding assessment and bleeding severity in thrombocytopenic patients undergoing invasive procedures. Transfusion 2020; 60:637-649. [PMID: 32003910 PMCID: PMC7079124 DOI: 10.1111/trf.15670] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/04/2019] [Accepted: 12/18/2019] [Indexed: 01/11/2023]
Affiliation(s)
- Frank E H P van Baarle
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Emma K van de Weerdt
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bram Suurmond
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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23
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Müller MCA, Meijers JC, van Meenen DM, Thachil J, Juffermans NP. Thromboelastometry in critically ill patients with disseminated intravascular coagulation. Blood Coagul Fibrinolysis 2019; 30:181-187. [PMID: 31157682 DOI: 10.1097/mbc.0000000000000808] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Coagulopathy has a high incidence in critically ill patients and is often caused by disseminated intravascular coagulation (DIC). Although the clinical picture of DIC ranges from a prothrombotic state to severe consumption coagulopathy with an increased bleeding tendency, there are no clinical tests that reflect of in-vivo hemostatic profile. Rotational thromboelastometry (ROTEM) may be able to indicate whether a patient has a hypocoagulable or hypercoagulable profile and possibly be able to discriminate patients with and without DIC. The aim of this article was to study the diagnostic ability of thromboelastometry to detect DIC. A predefined subgroup analysis of a clinical trial in critically ill patients with a coagulopathy was done. ROTEM and markers of coagulation and levels of natural anticoagulants were measured in patients with and without DIC. Twenty-three patients were included, 13 fulfilled criteria for overt DIC. Patients with DIC had lower platelet count, lower levels of fibrinogen, factors II, VII and VIII compared with those without DIC. Antithrombin, protein C and S were also reduced in DIC patients. Receiver operator characteristic analyses showed that EXTEM CFT, alpha angle and MCF were capable of discriminating patients with and without DIC. Combination of ROTEM values with protein C or antithrombin further improved discriminatory ability. In patients with DIC, thromboelastometry profiles were more hypocoagulable compared with those without DIC. ROTEM correlates well with ISTH DIC score, diagnostic strength improves when ROTEM values are combined with antithrombin or protein C levels. Thereby, ROTEM may be a useful tool in diagnosing DIC in the critically ill.
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Affiliation(s)
| | - Joost C Meijers
- Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam.,Department of Molecular and Cellular Hemostasis, Sanquin, Amsterdam, the Netherlands
| | | | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
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24
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van Bockel EAP, Walstock PA, van Mook WNKA, Arbous MS, Tepaske R, van Hemel TJD, Müller MCA, Delwig H, Tulleken JE. Entrustable professional activities (EPAs) for postgraduate competency based intensive care medicine training in the Netherlands: The next step towards excellence in intensive care medicine training. J Crit Care 2019; 54:261-267. [PMID: 31733630 DOI: 10.1016/j.jcrc.2019.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/30/2019] [Accepted: 09/11/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The Competency Based Training in Intensive Care Education (CoBaTrICE) programme developed common standards of ICM training by describing competencies of an intensivist. Entrustable Professional Activities (EPAs) of Intensive Care Medicine (ICM) (EPAsICM) are presented as a new workplace-based assessment tool in competency-based training of intensivists. EPAs are activities to be entrusted to a trainee once he (or she) has attained competence. EPAs emphasise the role of trust between trainees and supervisors. EPAs bridge the gap between competencies and competence. METHODS An expert panel of ICM (vice)programme directors and intensivists in The Netherlands integrated the CoBaTrICE and CanMEDS competencies into EPAsICM. Comment and feedback was sought from other ICM programme directors and educational experts and processed in the final version of EPAsICM before implementation in the Dutch ICM training programme. RESULTS A list of 15 EPAsICM are considered to reflect the spectrum of clinical practice while incorporating the competencies of CoBaTrICE and CanMEDS. The grading system is designed as a 5-point entrustment scale based on the amount of supervision a trainee needs, aligning with daily judgement of trainees by intensivists. CONCLUSION EPAsICM is an assessment tool that formalises entrustment decisions and can be a valuable addition in international ICM training.
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Affiliation(s)
- Esther A P van Bockel
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands.
| | - Pieter A Walstock
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands
| | - Walther N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center, P. Debyelaan 25, 6202, AZ, Maastricht, the Netherlands; School of Health Professions Education, Maastricht University, the Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Robert Tepaske
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Tina J D van Hemel
- Department of Intensive Care Medicine, Leiden University Medical Center, Albinusdreef 2, 2333, ZA, Leiden, the Netherlands
| | - Marcella C A Müller
- Amsterdam UMC, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands
| | - Hans Delwig
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands
| | - Jaap E Tulleken
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700, RB, Groningen, the Netherlands
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25
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van der Heiden PLJ, Arbous MS, van Beers EJ, van den Bergh WM, le Cessie S, Demandt AMP, Eefting M, Hess C, Kusadasi N, Marijt WAF, van Mook WNKA, Müller MCA, Tuinman PR, van Vliet M, van Westerloo DJ, Blijlevens NMA. Predictors of short-term and long-term mortality in critically ill patients admitted to the intensive care unit following allogeneic stem cell transplantation. Bone Marrow Transplant 2018; 54:418-424. [PMID: 30082850 DOI: 10.1038/s41409-018-0277-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 04/23/2018] [Accepted: 06/20/2018] [Indexed: 01/01/2023]
Abstract
Historically, the mortality of patients admitted to the ICU after allogeneic stem cell transplantation (alloSCT) is high. Advancements in transplantation procedures, infectious monitoring and supportive care may have improved the outcome. This study aimed to determine short-term and long-term mortality after ICU admission of patients after alloSCT and to identify prognostic clinical and transplantation-related determinants present at ICU admission for long-term outcome. A multicenter cohort study was performed to determine 30-day and 1-year mortality within 2 years following alloSCT. A total of 251 patients were included. The 30-day and 1-year mortality was 55% and 80%, respectively. Platelet count <25 × 109/L (OR: 2.26, CI: 1.02-5.01) and serum bilirubin >19 μmol/L (OR: 2.47 CI: 1.08-5.65) at admission, other donor than a HLA-matched-related or HLA-matched-unrelated donor (OR: 4.59, CI: 1.49-14.1) and vasoactive medication within 24 h (OR: 2.35, CI: 1.28-4.31) were associated with increased 30-day mortality. Other donor than a HLA-matched-related or HLA-matched-unrelated donor (OR: 1.9, CI: 1.13-3.19), serum bilirubin >77 (OR: 2.05, CI: 1.28-3.30) and vasoactive medication within 24 h (OR: 1.65, CI: 1.12-2.43) were associated with increased 1-year mortality. Neutropenia was associated with decreased 30-day and 1-year mortality (OR: 0.29, CI: 0.14-0.59 and OR: 0.70, CI: 0.48-0.98). Myeloablative conditioning and T cell-depleted transplantation were not associated with increased mortality.
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Affiliation(s)
- P L J van der Heiden
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.
| | - M S Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E J van Beers
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - A M P Demandt
- Department of Hematology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M Eefting
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - C Hess
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N Kusadasi
- Departement of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - W A F Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - W N K A van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - M C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - P R Tuinman
- Department of Intensive Care Medicine, VU university Medical Center, Amsterdam, The Netherlands
| | - M van Vliet
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - N M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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26
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de Vries VA, Müller MCA, Sesmu Arbous M, Biemond BJ, Blijlevens NMA, Kusadasi N, Choi GCW, Vlaar APJ, van Westerloo DJ, Kluin-Nelemans HC, van den Bergh WM. Time trend analysis of long term outcome of patients with haematological malignancies admitted at dutch intensive care units. Br J Haematol 2018; 181:68-76. [PMID: 29468848 DOI: 10.1111/bjh.15140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/21/2017] [Indexed: 01/18/2023]
Abstract
A few decades ago, the chances of survival for patients with a haematological malignancy needing Intensive Care Unit (ICU) support were minimal. As a consequence, ICU admission policy was cautious. We hypothesized that the long-term outcome of patients with a haematological malignancy admitted to the ICU has improved in recent years. Furthermore, our objective was to evaluate the predictive value of the Acute Physiology and Chronic Health Evaluation (APACHE) II score. A total of 1095 patients from 5 Dutch university hospitals were included from 2003 until 2015. We studied the prevalence of patients' characteristics over time. By using annual odds ratios, we analysed which patients' characteristics could have had influenced possible trends in time. A approximated mortality rate was compared with the ICU mortality rate, to study the predictive value of the APACHE II score. Overall one-year mortality was 62%. The annual decrease in one-year mortality was 7%, whereas the APACHE II score increased over time. Decreased mortality rates were particularly observed in high-risk patients (acute myeloid leukaemia, old age, low platelet count, bleeding as admission reason and need for mechanical ventilation within 24 h of ICU admission). Furthermore, the APACHE II score overestimates mortality in this patient category.
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Affiliation(s)
- Vera A de Vries
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bart J Biemond
- Department of Haematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole M A Blijlevens
- Department of Haematology, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Nuray Kusadasi
- Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.,University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Goda C W Choi
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - David J van Westerloo
- Department of Intensive Care Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hanneke C Kluin-Nelemans
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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27
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Kusadasi N, Müller MCA, van Westerloo DJ, Broers AEC, Hilkens MGEC, Blijlevens On Behalf Of The Hema-Icu Study Group NMA. The management of critically ill patients with haematological malignancies. Neth J Med 2017; 75:265-271. [PMID: 28956788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The management of critically ill patients with haematological malignancy (HM) still shows inter- and intra-regional differences. Our objective in this updated review was to address the evidence supporting the potential treatment options, based on multidisciplinary processes, of critically ill patients with HM. A stepwise approach to the critical care pathway of this patient population from the triage to ICU admission to ICU discharge was chosen to emphasise certain key findings. Our main focus relied on significant issues of decision-making in daily clinical routine. The plethora of studies shifted the pragmatic treatment policy into an evidence-based approach. The transfer of a patient with HM from the haematology ward to the ICU and vice versa should be based on a well-defined clinical care process in which the haematologists and intensivists are in close collaboration and direct communication. A protocolised clinical approach to treat a critically ill patient with HM seems helpful to optimise patient-oriented care and patient safety.
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Affiliation(s)
- N Kusadasi
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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28
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Müller MCA, Stanworth SJ, Coppens M, Juffermans NP. Recognition and Management of Hemostatic Disorders in Critically Ill Patients Needing to Undergo an Invasive Procedure. Transfus Med Rev 2017. [PMID: 28647217 DOI: 10.1016/j.tmrv.2017.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abnormal laboratory coagulation test results are frequently documented in critically ill patients, and these patients often also need to undergo invasive procedures. Clinicians have an understandable desire to minimize any perceived heightened risk of bleeding complications in those patients who require invasive procedures. In this setting, prophylactic administration of platelets or plasma is commonplace. This review explores the nature of these sequential statements and the degree to which these statements are supported by evidence. We discuss the complexity of managing the low risk of procedure-related bleeding in a setting where coagulation tests fail to reliably predict this risk. The role of prophylactic transfusion of platelets and plasma and correction of medication-induced coagulopathy is also reviewed. New strategies are required to improve the evidence base, including novel methodological approaches or the use of a clinical scoring system.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Simon J Stanworth
- Department of Haematology, NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - Michiel Coppens
- Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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29
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Müller MCA, Ponjee GAE. [Using thromboelastography to measure coagulation following massive blood loss]. Ned Tijdschr Geneeskd 2017; 161:D1380. [PMID: 28745251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thromboelastography is becoming increasingly important for diagnosing coagulation disorders in patients with massive blood loss. This whole-blood measurement provides information about the speed of clot formation, clot strength, and degree of fibrinolysis. The result can be used as a basis for making a faster and better choice of a suitable blood product for the patient with severe blood loss. This technique can be carried out simply and quickly as a rapid test ('point-of-care test') or in a central laboratory. Use of thromboelastography in patients undergoing cardiac surgery results in reduced use of blood products and is proven to be cost effective. A reduction in the use of blood products was also seen in trauma patients and patients undergoing liver transplantation when this technique was used. Studies on other groups of patients with massive blood loss are being conducted at the moment.
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30
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Riedijk M, van den Bergh WM, van Vliet M, Kusadasi N, Span LRF, Tuinman PR, Arbous MS, Müller MCA. Characteristics and outcomes of patients with a haematological malignancy admitted to the intensive care unit for a neurological event. CRIT CARE RESUSC 2015; 17:268-273. [PMID: 26640063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Patients with haematological malignancies are at risk of concomitant critical neurological events warranting intensive care unit admission. We aimed to examine the characteristics and outcomes of this patient population, as more knowledge could facilitate decision making on ICU admission and treatment. DESIGN, SETTING AND PARTICIPANTS A retrospective cohort study of 68 patients in adult ICUs of six Dutch university hospitals between 2003 and 2011. RESULTS The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23 (IQR, 16-27), and 77% of patients needed mechanical ventilation within the first 24 hours of admission. Forty percent of patients had received an allogeneic stem cell transplantation, and 22% were neutropenic on admission. The most frequent underlying haematological condition was non-Hodgkin lymphoma (27%). Seizures were the most common neurological event for ICU admission (29%). The median ICU length of stay was 5 days (IQR, 1-13 days). ICU mortality (28%), hospital mortality (37%) and 3-month mortality (50%) were comparable with other studies of ICU patients with haematological malignancies. Factors associated with 3-month survival were baseline platelet count (113×10(9)/L in survivors v 39×10(9)/L in non-survivors, P<0.01) and APACHE II score (20 in survivors v 25 in non-survivors, P=0.02). CONCLUSIONS Patients with a history of haematological malignancy presenting with a critical neurological event have comparable survival rates with other patients with a haematologic malignancy admitted to the ICU. Our findings suggest that restrictions in ICU care are not justified for this patient population.
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Affiliation(s)
- Martiene Riedijk
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Maarten van Vliet
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nuray Kusadasi
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lambert R F Span
- Department of Haematology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - M Sesmu Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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31
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Iba T, Ito T, Maruyama I, Jilma B, Brenner T, Müller MCA, Juffermans NP, Thachil J. Potential diagnostic markers for disseminated intravascular coagulation of sepsis. Blood Rev 2015; 30:149-55. [PMID: 26574054 DOI: 10.1016/j.blre.2015.10.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 02/08/2023]
Abstract
Disseminated intravascular coagulation (DIC) is an acquired thrombo-haemorrhagic disorder which arises in clinical scenarios like sepsis, trauma and malignancies. The clinic-laboratory diagnosis of DIC is made in a patient who develops the combination of laboratory abnormalities in the appropriate clinical scenario. The most common laboratory parameters in this setting have been the clotting profile, platelet count, serum fibrinogen and fibrin degradation markers. These tests had the advantage that they could be performed easily and in most laboratories. However, with the better understanding of the pathophysiology of DIC, in recent years, more specific tests have been suggested to be useful in this setting. The newer tests can also prove to be useful in prognostication in DIC. In addition, they may provide assistance in the selection and monitoring of patients diagnosed with DIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ito
- Department of Emergency and Critical Care Medicine, Kagoshima, University Graduate School of Medical and Dental Sciences, Kagoshima, Japan; Department of Systems Biology in Thromboregulation, Kagoshima, University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Ikuro Maruyama
- Department of Systems Biology in Thromboregulation, Kagoshima, University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Thorsten Brenner
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Marcella C A Müller
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom.
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32
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Müller MCA, Juffermans NP. Fresh frozen plasma transfusion fails to influence the hemostatic balance in critically ill patients with a coagulopathy: reply. J Thromb Haemost 2015; 13:1943-4. [PMID: 26256567 DOI: 10.1111/jth.13068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- M C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Intensive Care Medicine, MC Haaglanden/Bronovo, The Hague, the Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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33
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Müller MCA, Straat M, Meijers JCM, Klinkspoor JH, de Jonge E, Arbous MS, Schultz MJ, Vroom MB, Juffermans NP. Fresh frozen plasma transfusion fails to influence the hemostatic balance in critically ill patients with a coagulopathy. J Thromb Haemost 2015; 13:989-97. [PMID: 25809519 DOI: 10.1111/jth.12908] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/15/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coagulopathy has a high prevalence in critically ill patients. An increased International Normalized Ratio (INR) is a common trigger to transfuse fresh frozen plasma (FFP), even in the absence of bleeding. Therefore, FFP is frequently administered to these patients. However, the efficacy of FFP in correcting hemostatic disorders in non-bleeding recipients has been questioned. OBJECTIVES To assess whether INR prolongation parallels changes in the results of other tests investigating hemostasis, and to evaluate the coagulant effects of a fixed dose of FFP in non-bleeding critically ill patients with a coagulopathy. METHODS Markers of coagulation, individual factor levels and levels of natural anticoagulants were measured. Also, thrombin generation and thromboelastometry (ROTEM) assays were performed before and after FFP transfusion (12 mL kg(-1) ) to 38 non-bleeding critically ill patients with an increased INR (1.5-3.0). RESULTS At baseline, levels of factor II, FV, FVII, protein C, protein S and antithrombin were reduced, and thrombin generation was impaired. ROTEM variables were within reference ranges, except for a prolonged INTEM clot formation time. FFP transfusion increased the levels of coagulation factors (FII, 34% [interquartile range (IQR) 26-46] before vs. 44% [IQR 38-52] after; FV, 48% [IQR 28-76] before vs. 58% [IQR 44-90] after; and FVII, 25% [IQR 16-38] before vs. 37% [IQR 28-55] after), and the levels of anticoagulant proteins. Thrombin generation was unaffected by FFP transfusion (endogenous thrombin potential, 72% [IQR 51-88] before vs. 71% [IQR 42-89] after), whereas ROTEM EXTEM clotting time and maximum clot firmness slightly improved in response to FFP. CONCLUSION In non-bleeding critically ill patients with a coagulopathy, FFP transfusion failed to induce a more procoagulant state.
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Affiliation(s)
- M C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M Straat
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, the Netherlands
| | - J H Klinkspoor
- Department of Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands
| | - E de Jonge
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M S Arbous
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - M J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - M B Vroom
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - N P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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34
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Müller MCA, Balvers K, Binnekade JM, Curry N, Stanworth S, Gaarder C, Kolstadbraaten KM, Rourke C, Brohi K, Goslings JC, Juffermans NP. Thromboelastometry and organ failure in trauma patients: a prospective cohort study. Crit Care 2014; 18:687. [PMID: 25539910 PMCID: PMC4305250 DOI: 10.1186/s13054-014-0687-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 11/25/2014] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Data on the incidence of a hypercoagulable state in trauma, as measured by thromboelastometry (ROTEM), is limited and the prognostic value of hypercoagulability after trauma on outcome is unclear. We aimed to determine the incidence of hypercoagulability after trauma, and to assess whether early hypercoagulability has prognostic value on the occurrence of multiple organ failure (MOF) and mortality. METHODS This was a prospective observational cohort study in trauma patients who met the highest trauma level team activation. Hypercoagulability was defined as a G value of ≥ 11.7 dynes/cm(2) and hypocoagulability as a G value of <5.0 dynes/cm(2). ROTEM was performed on admission and 24 hours later. RESULTS A total of 1,010 patients were enrolled and 948 patients were analyzed. Median age was 38 (interquartile range (IQR) 26 to 53), 77% were male and median injury severity score was 13 (IQR 8 to 25). On admission, 7% of the patients were hypercoagulable and 8% were hypocoagulable. Altogether, 10% of patients showed hypercoagulability within the first 24 hours of trauma. Hypocoagulability, but not hypercoagulability, was associated with higher sequential organ failure assessment scores, indicating more severe MOF. Mortality in patients with hypercoagulability was 0%, compared to 7% in normocoagulable and 24% in hypocoagulable patients (P <0.001). EXTEM CT, alpha and G were predictors for occurrence of MOF and mortality. CONCLUSIONS The incidence of a hypercoagulable state after trauma is 10% up to 24 hours after admission, which is broadly comparable to the rate of hypocoagulability. Further work in larger studies should define the clinical consequences of identifying hypercoagulability and a possible role for very early, targeted use of anticoagulants.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Kirsten Balvers
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Department of Surgery, Trauma Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Jan M Binnekade
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Nicola Curry
- National Health Service Blood and Transplant/Hematology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9BQ, UK.
| | - Simon Stanworth
- National Health Service Blood and Transplant/Hematology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9BQ, UK.
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital, Ullevaal, Nydalen, N-0424, Oslo, Norway.
| | - Knut M Kolstadbraaten
- Department of Traumatology, Oslo University Hospital, Ullevaal, Nydalen, N-0424, Oslo, Norway.
| | - Claire Rourke
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University, Turner Street, London, E1 2AD, UK.
| | - Karim Brohi
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University, Turner Street, London, E1 2AD, UK.
| | - J Carel Goslings
- Department of Surgery, Trauma Unit, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Müller MCA, Stroo I, Wouters D, Zeerleder SS, Roelofs JJTH, Boon L, Vroom MB, Juffermans NP. The effect of C1-inhibitor in a murine model of transfusion-related acute lung injury. Vox Sang 2013; 107:71-5. [PMID: 24372323 DOI: 10.1111/vox.12128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/28/2013] [Accepted: 11/29/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality. Specific therapy is lacking. We assessed whether C1-inhibitor attenuates lung injury in a 'two-hit' TRALI model. METHODS Mice were primed with lipopolysaccharide, subsequently TRALI was induced by MHC-I antibodies. In the intervention group, C1-inhibitor was infused concomitantly. Mice were supported with mechanical ventilation. After 2 h, mice were killed, lungs were removed and bronchoalveolar lavage fluid (BALF) was obtained. RESULTS Injection of MHC-I antibodies induced TRALI, illustrated by an increase in wet-to-dry ratio of the lungs, in BALF protein levels and in lung injury scores. TRALI was further characterized by complement activation, demonstrated by increased BALF levels of C3a and C5a. Administration of C1-inhibitor resulted in increased pulmonary C1-inhibitor levels with high activity. C1-inhibitor reduced pulmonary levels of complement C3a associated with improved lung injury scores. However, levels of pro-inflammatory mediators were unaffected. CONCLUSION In a murine model of TRALI, C1-inhibitor attenuated pulmonary levels of C3a associated with improved lung injury scores, but with persistent high levels of inflammatory cytokines.
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Affiliation(s)
- M C A Müller
- Department of Intensive Care Medicine and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, the Netherlands
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Müller MCA, Tuinman PR, van der Sluijs KF, Boon L, Roelofs JJ, Vroom MB, Juffermans NP. Methylprednisolone fails to attenuate lung injury in a mouse model of transfusion related acute lung injury. Transfusion 2013; 54:996-1001. [PMID: 24032748 DOI: 10.1111/trf.12394] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 07/03/2013] [Accepted: 07/09/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality. Anecdotally, TRALI patients have been treated with corticosteroids. However, evidence for its therapeutic rationale in TRALI is lacking. We determined the effects of corticosteroids on lung injury in a "two-hit" mouse model of antibody-mediated TRALI. STUDY DESIGN AND METHODS BALB/c mice were primed with lipopolysaccharide, after which TRALI was induced by injecting major histocompatibility complex (MHC)-I antibody against H2K(d) . Mice infused with phosphate-buffered saline served as controls. Simultaneously, one group of TRALI mice was infused with methylprednisolone (MPS; 2 mg/kg). Mice were supported by mechanical ventilation for 2 hours, after which bronchoalveolar lavage fluid (BALF) and lung homogenate were obtained. Statistics were obtained by one-way analysis of variance or Kruskal-Wallis. RESULTS Injection of MHC-I antibodies resulted in TRALI, indicated by pulmonary edema and increased BALF levels of protein and the proinflammatory mediators macrophage inflammatory protein-2, keratinocyte-derived chemokine, and interleukin (IL)-6. Administration of MPS did not affect the amount of edema nor pulmonary protein and chemokine levels. MPS reduced systemic inflammatory reaction as well as IL-6 levels in the BALF. CONCLUSION In a two-hit model of antibody-mediated TRALI, MPS attenuated the IL-6 host response, but failed to prevent the development of lung injury.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam; Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam
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Abstract
Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality. Recent insights into the pathophysiology of TRALI have led to various preventive strategies. Strategies in donor management range from antibody testing of sensitized donors to the deferral of female plasma donors altogether. However, knowledge on the efficacy of measures to reduce TRALI is limited. In addition, the various measures may lead to a substantial loss of donors, hampering steady blood supply. Thereby, consensus among countries and blood-collecting facilities regarding the optimal strategy to prevent TRALI is lacking. In this review, the advantages and disadvantages of various preventive measures to prevent TRALI are discussed, related to both patient factors as well as blood component-processing strategies, including transfusion policy, donor management and practices of preparation and storage conditions of blood components.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care & Laboratory of Experimental Intensive Care & Anesthesiology, Academic Medical Center Amsterdam, The Netherlands.
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Müller MCA, de Jonge E, Arbous MS, Spoelstra-de Man AME, Karakus A, Vroom MB, Juffermans NP. Transfusion of fresh frozen plasma in non-bleeding ICU patients--TOPIC trial: study protocol for a randomized controlled trial. Trials 2011; 12:266. [PMID: 22196464 PMCID: PMC3284461 DOI: 10.1186/1745-6215-12-266] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 12/23/2011] [Indexed: 12/31/2022] Open
Abstract
Background Fresh frozen plasma (FFP) is an effective therapy to correct for a deficiency of multiple coagulation factors during bleeding. In past years, use of FFP has increased, in particular in patients on the Intensive Care Unit (ICU), and has expanded to include prophylactic use in patients with a coagulopathy prior to undergoing an invasive procedure. Retrospective studies suggest that prophylactic use of FFP does not prevent bleeding, but carries the risk of transfusion-related morbidity. However, up to 50% of FFP is administered to non-bleeding ICU patients. With the aim to investigate whether prophylactic FFP transfusions to critically ill patients can be safely omitted, a multi-center randomized clinical trial is conducted in ICU patients with a coagulopathy undergoing an invasive procedure. Methods A non-inferiority, prospective, multicenter randomized open-label, blinded end point evaluation (PROBE) trial. In the intervention group, a prophylactic transfusion of FFP prior to an invasive procedure is omitted compared to transfusion of a fixed dose of 12 ml/kg in the control group. Primary outcome measure is relevant bleeding. Secondary outcome measures are minor bleeding, correction of International Normalized Ratio, onset of acute lung injury, length of ventilation days and length of Intensive Care Unit stay. Discussion The Transfusion of Fresh Frozen Plasma in non-bleeding ICU patients (TOPIC) trial is the first multi-center randomized controlled trial powered to investigate whether it is safe to withhold FFP transfusion to coagulopathic critically ill patients undergoing an invasive procedure. Trial Registration Trial registration: Dutch Trial Register NTR2262 and ClinicalTrials.gov: NCT01143909
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Müller MCA, Lagarde SM, Germans MR, Juffermans NP. Cerebral air embolism after arthrography of the ankle. Med Sci Monit 2010; 16:CS92-CS94. [PMID: 20581782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND The accidental migration of air from the venous circulation into the systemic arterial circulation is called paradoxical air embolism. This is a potential disastrous complication after diagnostic and surgical procedures. Arthrography has been a useful technique in joint imaging for the past decades. Paradoxical cerebral air embolism is a very rare complication, only a few cases have been reported after arthrography of the hip in children. Here, we describe a patient with progressive encephalopathy after computer tomography (CT) arthrography of the ankle. CASE REPORT We describe a 64-year-old male who underwent CT-arthrography of the left ankle, after the intra-articular injection of 20 ml of air he experienced progressive neurologic and hemodynamic deterioration. A brain CT showed a small amount of air in a right frontal sulcus. Hyperbaric oxygen therapy (HBO) was initiated after a delay of 16 hours and resulted in a complete recovery. A transesophageal echocardiography confirmed the presence of a right-left shunt. CONCLUSIONS This case of paradoxical air embolism with severe neurological manifestations after arthrography of the ankle, emphasizes that air embolism should be considered in all patients with neurologic and/or hemodynamic deterioration after the injection of intra articular air. Furthermore a delay of more then 6 hours is no reason to withhold HBO in these patients.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
The observation of Sakr and colleagues that transfusion may be beneficial in certain subgroups of intensive care unit (ICU) patients [1] is interesting, since large observational studies demonstrate that transfusion is independently associated with an increased risk of death [2]. Also, a systematic review showed that the benefits of transfusion in the ICU do not outweigh the risks [3]. Sakr and colleagues ascribe their discrepant results to the fact that transfused blood was leukoreduced. Of the 17 randomized controlled trials on the association of nonleukoreduced blood with mortality, however, a benefit of leukoreduction was found only in cardiac surgery patients [4]. A meta-analysis confirmed that available evidence does not justify universal leukoreduction [5]. Given the increased risk of nosocomial infection, multiple organ failure and acute respiratory distress syndrome, an explanation of a beneficial effect from transfusion in anemic critically ill patients is tempting. We propose that the results of this study may be related to the indication of transfusion, this being active bleeding and not correction of anemia associated with critical illness. Hereby, transfusion may have prevented adverse events due to postoperative bleeding, explaining the survival benefit. The fact that 76% of patients were referred from the operating/recovery room and that the median length of ICU stay was only 1 day may support this hypothesis. Based on numerous reports on the association of transfusion with adverse outcome, a liberal transfusion strategy in critically ill anemic patients in the absence of acute bleeding should not be advocated.
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Müller MCA, van der Werf SDJ. [A young woman from Cameroon with rectal blood loss, intestinal schistosomiasis and rectosigmoid carcinoma]. Ned Tijdschr Geneeskd 2008; 152:951-955. [PMID: 18561793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
A 32-year-old woman from Cameroon presented with rectal blood loss due to a focally infiltrating adenocarcinoma of the rectosigmoid in the presence of an active intestinal schistosomiasis (Schistosoma intercalatum). A correlation between chronic intestinal schistosomiasis and the development of colorectal cancer has been suggested in the literature, but is not uniformly accepted. However, the case presented here reinforces this suggestion. In a patient with rectal blood loss who comes from an area where intestinal schistosomiasis is endemic, the possibility of a colorectal carcinoma should be considered in the diagnosis.
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Affiliation(s)
- M C A Müller
- Medisch Centrum Haaglanden, locatie Westeinde, afd. Interne Geneeskunde en Maag-, Darm- en Leverziekten, Den Haag.
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