Abstract Purpose The aim was to investigate the effects of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) and compare the results with those of ...in-hospital cardiac arrest (IHCA). Methods We analyzed our extracorporeal membrane oxygenation (ECMO) results for patients who received ECPR for OHCA or IHCA in the last 5 years. Pre-arrest, resuscitation, and post-resuscitative data were evaluated. Results In the last 5 years, ECPR was used 230 times for OHCA ( n = 31) and IHCA ( n = 199). The basic demographic data showed significant differences in age, cardiomyopathy, and location of the initial CPR. Duration of ischemia was shorter in the IHCA group (44.4 ± 24.7 min vs. 67.5 ± 30.6 min, p < 0.05). About 50% of each group underwent a further intervention to treat the underlying etiology. ECMO was maintained for a shorter duration in the OHCA patients (61 ± 48 h vs. 94 ± 122 h, p < 0.05). Survival to discharge was similar in the two groups (38.7% for OHCA vs. 31.2% for IHCA, p > 0.05), as was the favorable outcome rate (25.5% for OHCA vs. 25.1% for IHCA, p > 0.05). Survival was acceptable (about 33%) in both groups when the duration of ischemia was no longer than 75 min. Conclusions In addition to having a beneficial effect in IHCA, ECPR can lead to survival and a positive neurological outcome in selected OHCA patients after prolonged resuscitation. Our results suggest that further investigation of the use of ECMO in OHCA is warranted.
Background
The incidence of acute kidney injury (AKI) requiring dialysis in hospitalized patients is increasing; however, information on the long‐term incidence of stroke in patients surviving to ...discharge after recovering from AKI after dialysis has not been reported.
Methods and Results
Patients that survived after recovery from dialysis‐requiring AKI during index hospitalizations from 1999 to 2008 were identified in nationwide administrative registries. The risk of de novo stroke and death were analyzed with time‐varying Cox proportional hazard models. The results were validated by a critical care database. We enrolled 4315 patients in the AKI‐recovery group (men, 57.7%; mean age, 62.8±16.8 years) and matched 4315 control subjects as the non‐AKI group by propensity scores. After a median follow‐up period of 3.36 years, the incident stroke rate was 15.6 per 1000 person‐years. The AKI‐recovery group had higher risk (hazard ratio: 1.25; P=0.037) and higher severity of stroke events than the non‐AKI group, regardless of progression to subsequent chronic kidney disease. The rate of incident stroke was not statistically different in those with diabetes alone (without AKI) and in those with AKI alone (without diabetes) after hospital discharge (P=0.086). Furthermore, the risk of mortality in the AKI‐recovery group was higher than in the non‐AKI group (hazard ratio: 2.4; P<0.001).
Conclusions
The patients who recovered from AKI had a higher incidence of developing incident stroke and mortality than the patients without AKI, and the impact was similar to diabetes. Our results suggest that a public health initiative is needed to enhance postdischarge follow‐up of renal function and to control the subsequent incidence of stroke among patients who recover from AKI after dialysis.
Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The ...objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients.
Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT.
Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05).
Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.
Abstract
Objectives: Acute fulminant myocarditis (AFM) is a disease category that is easily neglected. Circulatory mechanical support is sometimes required for this devastating condition. We analyzed ...our experience in managing AFM with mechanical circulatory support. Methods: We applied extracorporeal membrane oxygenation (ECMO) as a first-line rescue for AFM. The diagnosis was mainly derived from clinical results and biopsy. Results: Seventy-five patients were enrolled in the age range of 29.6 ± 18.6 years and the pediatric group (≪18 years) comprised 32% (n = 24) of our patient group. Thirty-five patients (47%) underwent cardiopulmonary resuscitation (CPR) before ECMO. The indication for ECMO included high inotropic support 69% (n = 54) and continuous CPR at ECMO setup 31% (n = 23). The ECMO duration was 171 ± 121 h. Survival to discharge was 64% (n = 48), 61% in adult group, and 70.8% in pediatric group. Six patients were later bridged to ventricular assist device use (5 left ventricular assist device (LVAD) and 1 bi-ventricular assist device (BVAD)) but three died of multiple-organ failure. Three patients (4%) underwent heart transplantation and all of them survived to discharge. Resuscitation did not have a significant factor for survival. Only two patients (3%) developed late mortality due to a cardiac event. Conclusions: AFM still carries high mortality rates in spite of advanced mechanical support. Most of the survivors did not require transplantation and could return to good lifestyle. Due to its simplicity and effectiveness, ECMO can be a first-line tool to rescue this group of patients.
Abstract Background Particular attention should be paid to postoperative patients that suffer from severe acute kidney injury (AKI) requiring renal replacement therapy (RRT). Methods This multicenter ...prospective observational study included 342 patients with postoperative AKI requiring RRT from January 2002 to December 2006. Results There were 137 (40%) survivors at 90 days after the commencement of RRT. Independent predictors of 90-day mortality were older age, presence of sepsis, status post–cardiopulmonary resuscitation, necessity of continuous renal replacement therapy (CRRT), requirement of total parenteral nutrition, lower body mass index, higher Sequential Organ Failure Assessment score, and higher serum lactate level at the commencement of RRT. Further analysis among the survivors showed that lower serum creatinine at intensive care unit admission, lower Simplified Acute Physiology Score II and inotropic equivalent score at the commencement of RRT, and using CRRT were independent predictors for subsequent renal recovery. Conclusions The development of AKI requiring RRT in postoperative critical patients represents a substantial risk for mortality and morbidity.
Existing chronic kidney disease (CKD) is among the most potent predictors of postoperative acute kidney injury (AKI). Here we quantified this risk in a multicenter, observational study of 9425 ...patients who survived to hospital discharge after major surgery. CKD was defined as a baseline estimated glomerular filtration rate <45ml/min per 1.73m2. AKI was stratified according to the maximum simplified RIFLE classification at hospitalization and unresolved AKI defined as a persistent increase in serum creatinine of more than half above the baseline or the need for dialysis at discharge. A Cox proportional hazard model showed that patients with AKI-on-CKD during hospitalization had significantly worse long-term survival over a median follow-up of 4.8 years (hazard ratio, 3.3) than patients with AKI but without CKD. The incidence of long-term dialysis was 22.4 and 0.17 per 100 person-years among patients with and without existing CKD, respectively. The adjusted hazard ratio for long-term dialysis in patients with AKI-on-CKD was 19.8 compared to patients who developed AKI without existing CKD. Furthermore, AKI-on-CKD but without kidney recovery at discharge had a worse outcome (hazard ratios of 4.6 and 213, respectively) for mortality and long-term dialysis as compared to patients without CKD or AKI. Thus, in a large cohort of postoperative patients who developed AKI, those with existing CKD were at higher risk for long-term mortality and dialysis after hospital discharge than those without. These outcomes were significantly worse in those with unresolved AKI at discharge.
Background: The benefit of ω-3 fatty acids in fat emulsion remains controversial. This study evaluated the effect of ω-3 fatty acids on immune and inflammatory modulation in surgical intensive care ...unit (SICU) patients. Methods: Thirty-eight patients admitted to the SICU after major surgery were enrolled in this prospective controlled study and randomized to receive parenteral nutrition (PN) with equal volume and calories from glucose, nitrogen, and fat but different lipid components for 7 postoperative days. Group A (n = 12) received a mixture of soybean and medium-chain triglyceride oils; group B (n = 18) received a fat emulsion with part of the lipid replaced by fish oil. Blood tests, including lipid profile, routine biochemistry, inflammatory cytokines, and lymphocyte subpopulations, were evaluated preoperatively and on postoperative days 4 and 7. Results: Both lipid regimens were well tolerated. There was a trend toward reduced serum inflammatory cytokines in group B vs group A with significant differences regarding interleukin (IL)–1, IL-8, and interferon (IFN)–γ on postoperative day 4 (P < .05) and IL-1, IL-8, IFN-γ, IL-6, and tumor necrosis factor–α on postoperative day 7 (P < .05). There was a reduction in postoperative liver dysfunction (A vs B: 50% vs 33.3%) and infection rate (A vs B: 41.7% vs 27.8%) in group B, although this was not statistically significant. There was no mortality in either group. Conclusion: This study suggests that supplementation of parenteral ω-3 fatty acids in PN is safe and may improve immune and hyperinflammatory response for SICU patients after major surgery.
Abdominal surgery is probably associated with more likelihood to cause acute kidney injury (AKI). The aim of this study was to evaluate whether early or late start of renal replacement therapy (RRT) ...defined by simplified RIFLE (sRIFLE) classification in AKI patients after major abdominal surgery will affect outcome.
A multicenter prospective observational study based on the NSARF (National Taiwan University Surgical ICU Associated Renal Failure) Study Group database. 98 patients (41 female, mean age 66.4 +/- 13.9 years) who underwent acute RRT according to local indications for post-major abdominal surgery AKI between 1 January, 2002 and 31 December, 2005 were enrolled The demographic data, comorbid diseases, types of surgery and RRT, as well as the indications for RRT were documented. The patients were divided into early dialysis (sRIFLE-0 or Risk) and late dialysis (LD, sRIFLE -Injury or Failure) groups. Then we measured and recorded patients' outcome including in-hospital mortality and RRT wean-off until 30 June, 2006.
The in-hospital mortality was compared as endpoint. Fifty-seven patients (58.2%) died during hospitalization. LD (hazard ratio (HR) 1.846; P = 0.027), old age (HR 2.090; P = 0.010), cardiac failure (HR 4.620; P < 0.001), pre-RRT SOFA score (HR 1.152; P < 0.001) were independent indicators for in-hospital mortality.
The findings of this study support earlier initiation of acute RRT, and also underscore the importance of predicting prognoses of major abdominal surgical patients with AKI by using RIFLE classification.
Extracellular peroxiredoxin 1 (Prdx1) has been implicated to play a pivotal role in regulating inflammation; however, its function in tissue hypoxia-induced inflammation, such as severe cardiogenic ...shock patients, has not yet been defined. Thus, the objective of this study was to test the hypothesis that Prdx1 possesses prognostic value and instigates systemic inflammatory response syndrome in cardiogenic shock patients undergoing extracorporeal membrane oxygenation (ECMO) support.
We documented the early time course evolution of circulatory Prdx1, hypoxic marker carbonic anhydrase IX, inflammatory cytokines including IL-6, IL-8, IL-10, MCP-1, TNF-α, IL-1β, and danger signaling receptors (TLR4 and CD14) in a cohort of cardiogenic shock patients within 1 day after ECMO support. In vitro investigations employing cultured murine macrophage cell lines and human monocytes were applied to clarify the relationship between Prdx1 and inflammatory response.
Prdx1 not only peaked earlier than all the other cytokines we studied during the initial course, but also predicted a worse outcome in patients who had higher initial Prdx1 plasma levels. The Prdx1 levels in patients positively correlated with hypoxic markers carbonic anhydrase IX and lactate, and inflammatory cytokines. In vitro study demonstrated that hypoxia/reoxygenation induced Prdx1 release from human monocytes and enhanced the responsiveness of the monocytes in Prdx1-induced cytokine secretions. Furthermore, functional inhibition by Prdx1 antibody implicated a crucial role of Prdx1 in hypoxia/reoxygenation-induced IL-6 secretion.
Prdx1 release during the early phase of ECMO support in cardiogenic shock patients is associated with the development of systemic inflammatory response syndrome and poor clinical outcomes. Thus, circulating Prdx1 provides not only prognostic information but may be a promising target against ischemia/reperfusion injury.
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