Abstract Introduction Fluid accumulation is associated with adverse outcomes in critically ill patients admitted to the intensive care unit (ICU). Fluid administration in the ICU may be a clinically ...relevant source of fluid accumulation in ICU patients. However, the extent is unknown, and no standard definition exists. We aim to provide epidemiological data on fluid accumulation, risk factors, use of fluid removal strategies, patient outcomes and describe current fluid administration practices in the ICU. Methods We will conduct an international 14‐day inception cohort study including a minimum of 1000 acutely admitted adult ICU patients. Data will be collected from medical records and laboratory reports at baseline and daily from ICU admission to discharge with a maximum of 28 days. Follow‐up will be performed on day 90 after inclusion. The primary outcome is the number of patients with fluid accumulation. Secondary outcomes include the number of days with fluid accumulation, use of active fluid removal, days alive without life support at day 28, days alive and out of hospital day 90, and all‐cause mortality at day 90. Furthermore, we will assess risk factors for fluid accumulation and its association with 90‐day mortality and report on the types of fluid administration. Conclusion This international inception cohort study will provide contemporary epidemiological data on fluid administration and fluid accumulation in adult ICU patients.
Hydroxyethyl starch (HES) corrected is widely used for fluid resuscitation in intensive care units (ICUs), but its safety and efficacy have not been established in patients with severe sepsis.
In ...this multicenter, parallel-group, blinded trial, we randomly assigned patients with severe sepsis to fluid resuscitation in the ICU with either 6% HES 130/0.42 (Tetraspan) or Ringer's acetate at a dose of up to 33 ml per kilogram of ideal body weight per day. The primary outcome measure was either death or end-stage kidney failure (dependence on dialysis) at 90 days after randomization.
Of the 804 patients who underwent randomization, 798 were included in the modified intention-to-treat population. The two intervention groups had similar baseline characteristics. At 90 days after randomization, 201 of 398 patients (51%) assigned to HES 130/0.42 had died, as compared with 172 of 400 patients (43%) assigned to Ringer's acetate (relative risk, 1.17; 95% confidence interval CI, 1.01 to 1.36; P=0.03); 1 patient in each group had end-stage kidney failure. In the 90-day period, 87 patients (22%) assigned to HES 130/0.42 were treated with renal-replacement therapy versus 65 patients (16%) assigned to Ringer's acetate (relative risk, 1.35; 95% CI, 1.01 to 1.80; P=0.04), and 38 patients (10%) and 25 patients (6%), respectively, had severe bleeding (relative risk, 1.52; 95% CI, 0.94 to 2.48; P=0.09). The results were supported by multivariate analyses, with adjustment for known risk factors for death or acute kidney injury at baseline.
Patients with severe sepsis assigned to fluid resuscitation with HES 130/0.42 had an increased risk of death at day 90 and were more likely to require renal-replacement therapy, as compared with those receiving Ringer's acetate. (Funded by the Danish Research Council and others; 6S ClinicalTrials.gov number, NCT00962156.).
Abstract Background Hypernatremia is a common electrolyte disturbance in hospitalised patients associated with adverse outcomes. The aetiology is diverse but often related to fluid therapy and ...sodium‐containing medicaments. We aim to outline the evidence base on hypernatremia in adult hospitalised patients. Methods We will conduct a scoping review and adhere to the preferred reporting items for systematic and meta‐analysis extension for scoping reviews (PRISMA‐ScR). We will systematically search the Cochrane Library, Medline, Pubmed, and Embase from inception with no limitations to language, and include all study designs. We will use the population, exposure, comparator, and outcome‐based approach to define eligibility criteria. The population: adult hospitalised patients; exposure: hypernatremia; comparator: no hypernatremia or all types of treatments of hypernatremia; and outcomes: all reported outcomes. Two authors will independently screen and select studies followed by full‐text assessment and data extraction in duplicate. All outcome measures will be reported, and descriptive analyses will be performed. The certainty of evidence will be assessed according to an adapted grading of recommendations assessment, development, and evaluation (GRADE) approach. Discussion This scoping review will provide an overview of the current evidence regarding the incidence of hypernatremia, treatment modalities, and outcomes reported for hospitalised adult patients with hypernatremia.
In this study, patients with severe sepsis were assigned to fluid resuscitation with starch (HES 130/0.4) or Ringer's acetate. The starch group had an increased risk of death at day 90 and increased ...use of renal-replacement therapy, as compared with the Ringer's acetate group.
Intravenous fluids are the mainstay of treatment for patients with hypovolemia due to severe sepsis. Colloid solutions are used to obtain rapid and lasting circulatory stabilization, but there are limited data to support this practice.
1
The Surviving Sepsis Campaign guidelines recommend the use of either colloids or crystalloids,
2
but high-molecular-weight hydroxyethyl starch (HES) may cause acute kidney failure in patients with severe sepsis, as observed in two randomized trials.
3
,
4
Those trials had substantial limitations, and participants received HES solutions with a molecular weight of 200 kD and a substitution ratio (the number of hydroxyethyl groups per glucose molecule) of . . .
Endothelial damage contributes to organ failure and mortality in sepsis, but the extent of the contribution remains poorly quantified. Here, we examine the association between biomarkers of ...superficial and profound endothelial damage (syndecan-1 and soluble thrombomodulin sTM, respectively), organ failure, and death in sepsis. The data from a clinical trial, including critically ill patients predominantly suffering sepsis (Clinicaltrials.gov: NCT00271752) were studied. Syndecan-1 and sTM levels at the time of study enrollment were determined. The predictive ability of biomarker levels on death and organ failures during follow-up were assessed in Cox models adjusted for potential confounders including key organ dysfunction measures assessed at enrollment. Of the 1,103 included patients, 418 died. sTM levels at the time of enrollment independently predicted risk of death in adjusted models (hazard ratio HR highest quartile > 14 ng/mL vs. lowest quartile < 7 ng/mL 2.2 95% confidence interval CI: 1.2-4.0, p = 0.02, respectively). Conversely, syndecan-1 levels failed to predict death (adjusted HR > 240 vs. < 70 ng/mL 1.0 95% CI: 0.6-1.5, p = 0.67). sTM but not syndecan-1 levels at enrollment predicted risk of multiple organ failure during follow-up (HR > 14 ng/mL vs. < 7 ng/mL 3.5 95% CI: 1.5-8.3, p = 0.005 and 2.0 95% CI: 0.8-5.0, p = 0.1321, respectively). Profound damage to the endothelium independently predicts risk of multiple organ failure and death in septic patients. Our findings also suggest that the detrimental effect of profound endothelial damage on risk of death operates via mechanisms other than causing organ failures per se. Therefore, damage to the endothelium appears centrally involved in the pathogenesis of death in sepsis and could be a target for intervention.
Septic shock is common in the intensive care unit (ICU). The pathophysiology is poorly understood but prolonged sympathetic activation leading to autonomic dysfunction may be involved. Pupillary ...light response (PLR) is a fast, inexpensive, noninvasive way to measure autonomic nervous system function. The aim of the study was to observe dilation velocity of the PLR (PLR
) in patients with and without septic shock and explore whether other factors influenced the possible association. We hypothesized that the presence of septic shock in intensive care patients is associated with changes in sympathetic autonomic tone, which can be observed as changes in PLR
METHODS: In this prospective observational cohort study, we included 91 adult patients acutely admitted to a mixed ICU. The patients were followed for the development of septic shock until ICU discharge. PLR
was measured with a portable pupillometer two times a day. We used linear mixed models to analyze for an association between PLR
and septic shock along with several covariables.
Ninety-one patients were enrolled and of these, 35 were in septic shock. Septic shock was associated with a slowed PLR
of 0.3 mm/s (95% confidence intervals CI -0.4; -0.2).
Septic shock may be associated with changes in sympathetic autonomic tone which is supported by the findings from this study that septic shock was associated with a slower dilation velocity in the pupillary light reflex. Further studies should examine if the pupillary dilation velocity may serve as surrogate marker for changes in sympathetic autonomic nervous system activity in intensive care patients in septic shock. If so, future interventional studies should test if use of the pupillary dilation velocity may be used for earlier detection of septic shock, which could mean earlier institution of treatment measures for this condition.
Background and Aims
Vital sign monitoring needs to be timely and correct to recognize deteriorating patients early and trigger the relevant clinical response. The aim of this study is to ...retrospectively evaluate compliance specifically toward the regional vital sign monitoring protocol the so called early warning score protocol (EWS‐protocol) 72 h before a medical emergency team response (MET‐response) and thereby illuminate whether poor compliance translates into a worse patient outcome.
Methods
It was investigated all eligible patients that underwent MET responses during the calendar year 2019. The inclusion criteria encompassed somatic patients above 18 years of age admitted to the hospital and detailed evaluations of the medical records of the included patients were conducted.
Results
Four hundred and twenty‐nine MET‐responses were included in the final analysis. EWS‐protocol failure was observed for more than half the patients within all the time frames assessed. Thirty‐day mortality was significantly higher for patients subject to EWS protocol failure in the timeframes 24−16, 16−8, 8−0 h before MET response. Adjusting for admission length, age, and gender, patients subject to EWS‐protocol failure had an odds ratio (OR) of 1.9, 2.0, 2.1, 2.3 for mortality in the time frames 72−48, 24−16, 16−8, and 8−0 h before the MET‐response, respectively. The adjusted OR for ICU‐admission was 1.7, and 1.6 for patients subject to EWS‐protocol failure in the time frames 16−8 and 8−0 h before MET‐response, respectively.
Conclusion
According to all the data analysis in this article, there is evidence that compliance toward the NEWS‐protocol is poor. EWS‐protocol failure is associated with a significant higher mortality and ICU‐admission rate.
Endotheliopathy is suggested as pivotal pathophysiology of sepsis and trauma-associated organ failure, but its role in acute respiratory failure is not yet determined. We investigated if ...endotheliopathy biomarkers at ICU admission are associated with illness severity and clinical outcomes in patients with acute respiratory failure requiring mechanical ventilation.
We conducted a prospective single-center cohort study including 459 mechanically ventilated adults at ICU admission. Plasma levels of three endotheliopathy biomarkers were measured at ICU admission: Syndecan-1, soluble Thrombomodulin (sTM), and Platelet Endothelial Cell Adhesion Molecule-1 (PECAM-1). The primary outcome was the rate of liberation from mechanical ventilation, which is presented together with the rate of the competing risk of death while still on mechanical ventilation. Secondary outcomes were PaO
/FiO
-ratios on admission and on last measurement in patients dying within five days, and 30-day all-cause mortality. The primary outcome and 30-day all-cause mortality were analyzed using Cox regression, controlled for gender, age, chronic obstructive pulmonary disease, septic shock, heart failure, PaO
/FiO
-ratio at admission, respiratory infection, acute kidney injury, and bilirubin. PaO
/FiO
-ratios were analyzed using linear regression, controlled for age, chronic obstructive pulmonary disease, respiratory infection, and shock.
Patients with high sTM were liberated from mechanical ventilation at a lower rate (adjusted hazard ratio (HR) 0.71, for an increase from the 25th to the 75th percentile, 95% confidence interval (CI) 0.54-0.93, p = 0.01). Patients with high PECAM-1 were liberated from mechanical ventilation at a lower rate, but only during the first 5 days (adjusted HR 0.72, for an increase from the 25th to the 75th percentile, 95% CI 0.58-0.9, p < 0.01). High levels of Syndecan-1 and PECAM-1 were associated with a higher rate of death while still on mechanical ventilation. sTM and PECAM-1 were negatively associated with PaO
/FiO
-ratio at ICU admission and no biomarker was associated with last measured PaO
/FiO
-ratio. High levels of all biomarkers were associated with higher 30-day all-cause mortality.
In acute respiratory failure, endotheliopathy biomarkers are associated with lower rates of liberation from mechanical ventilation, hypoxemia at ICU admission, and 30-day all-cause mortality.
Objective
Precise measurements of fluid status lack valid methods. Bioimpedance is an attractive diagnostic tool because it is noninvasive, quick, and relatively cheap. This systematic review aims to ...assess the existing evidence of bioimpedance as an accurate measure of fluid status in critically ill patients.
Data sources
PubMed and Embase up till March 2021 were systematically searched (PROSPERO: CRD42020157436).
Study selection
Eligibility criteria were studies reporting original data from cohorts of adult patients in intensive care units and doing at least one whole‐body bioimpedance and one reference test. In addition, studies assessing internal reproducibility were included.
Data extraction
An extraction form was designed for the purpose.
Data synthesis
Nine hundred five studies were screened for eligibility, and 28 studies, comprising 1482 individual patients, were included in the final analysis. Eight studies compared bioimpedance with a gold standard, and two of those reported the results adequate. We found a low mean difference, but the 95% limits of agreements had wide limits. The remaining studies applied different surrogates as reference tests. Correlations ranged from 0.05 to 0.99. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) certainty of evidence for all outcomes was very low.
Conclusions
The accuracy of bioimpedance as a measure for fluids in critically ill patients in the intensive care unit cannot be determined. Due to the lack of a gold standard, numerous studies compared bioimpedance with surrogate outcomes with great variability in both designs and results. Assessing the internal reproducibility of bioimpedance had the same limitations, but the studies overall reported good internal reproducibility.
In this trial, a restrictive approach to intravenous fluid administration in critically ill patients with septic shock did not reduce deaths at 90 days.
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