Objective The application of extracorporeal membrane oxygenation in adults has been increasing, but infections occurring during extracorporeal membrane oxygenation use are rarely described. Methods ...We retrospectively analyzed the prospectively collected data on nosocomial infection surveillance of 334 patients aged 16 years or more undergoing their first extracorporeal membrane oxygenation for more than 48 hours at a university hospital from 1996 to 2007 for respiratory (20.4%) and cardiac (79.6%) support. Results During a total of 2559 extracorporeal membrane oxygenation days, 55 episodes of infections occurred in 45 patients (13.5%), including 38 bloodstream (14.85 per 1000 extracorporeal membrane oxygenation days), 6 surgical site, 4 respiratory tract, 3 urinary tract, and 4 other infections. Stenotrophomonas maltophilia (16.7%) and Candida species (14.6%) were the predominant blood isolates. In stepwise logistic regression analysis, longer duration of extracorporeal membrane oxygenation use (odds ratio 1.003; 95% confidence interval, 1.001–1.005; P = . 004), mechanical complications (odds ratio, 4.849; 95% confidence interval, 1.569–14.991; P = . 006), autoimmune disease (odds ratio, 6.997; 95% confidence interval, 1.541–31.766; P = . 012), and venovenous mode (odds ratio, 4.473; 95% confidence interval, 1.001–19.977; P = . 050) were independently associated with a higher risk for infections during extracorporeal membrane oxygenation use. Overall in-hospital mortality was 68.3%, and its independent risk factors included older age (odds ratio, 1.037; 95% confidence interval, 1.021–1.054; P < . 001), neurologic complications (odds ratio, 51.153; 95% confidence interval, 6.773–386.329; P < . 001), and vascular complications (odds ratio, 1.922; 95% confidence interval, 1.112–3.320; P < . 001), but not infections during extracorporeal membrane oxygenation use. Conclusions Bloodstream infection was the most common infection during extracorporeal membrane oxygenation use. Duration of extracorporeal membrane oxygenation, mechanical complications, autoimmune disease, and venovenous mode seemed to be independently associated with infections.
Summary Background Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the ...benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin. Methods We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18–75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov , number NCT00173615. Findings Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0·0001) and a better 1-year survival than those who received conventional CPR (log rank p=0·007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio HR 0·51, 95% CI 0·35–0·74, p<0·0001), 30-day survival (HR 0·47, 95% CI 0·28–0·77, p=0·003), and 1-year survival (HR 0·53, 95% CI 0·33–0·83, p=0·006) favouring extracorporeal CPR over conventional CPR. Interpretation Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin. Funding National Science Council, Taiwan.
Severe sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on ...care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan.
A retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care.
Sixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66-14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients.
From the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Long-Term Risk of Coronary Events after AKI WU, Vin-Cent; WU, Che-Hsiung; CHU, Tzong-Shinn ...
Journal of the American Society of Nephrology,
03/2014, Letnik:
25, Številka:
3
Journal Article
Recenzirano
Odprti dostop
The incidence rate of AKI in hospitalized patients is increasing. However, relatively little attention has been paid to the association of AKI with long-term risk of adverse coronary events. Our ...study investigated hospitalized patients who recovered from de novo dialysis-requiring AKI between 1999 and 2008 using patient data collected from inpatient claims from Taiwan National Health Insurance. We used Cox regression with time-varying covariates to adjust for subsequent CKD and ESRD after discharge. Results were further validated by analysis of a prospectively constructed database. Among 17,106 acute dialysis patients who were discharged, 4869 patients recovered from dialysis-requiring AKI (AKI recovery group) and were matched with 4869 patients without AKI (non-AKI group). The incidence rates of coronary events were 19.8 and 10.3 per 1000 person-years in the AKI recovery and non-AKI groups, respectively. AKI recovery associated with higher risk of coronary events (hazard ratio HR, 1.67; 95% confidence interval 95% CI, 1.36 to 2.04) and all-cause mortality (HR, 1.67; 95% CI, 1.57 to 1.79) independent of the effects of subsequent progression to CKD and ESRD. The risk levels of de novo coronary events after hospital discharge were similar in patients with diabetes alone and patients with AKI alone (P=0.23). Our results reveal that AKI with recovery associated with higher long-term risks of coronary events and death in this cohort, suggesting that AKI may identify patients with high risk of future coronary events. Enhanced postdischarge follow-up of renal function of patients who have recovered from temporary dialysis may be warranted.
Objectives Experience with extracorporeal membrane oxygenation for adult patients with refractory septic shock remains limited. We aimed to study the clinical features and outcomes of this patient ...group in an extracorporeal membrane oxygenation referral center in Taiwan. Methods From January 2005 to December 2010, all adult patients in refractory septic shock and requiring venoarterial extracorporeal membrane oxygenation for circulatory support were included in the present study. The variables analyzed included patient demographics; comorbidities; smoking status; hemodynamic, ventilatory, and laboratory parameters just before extracorporeal membrane oxygenation support; clinical course; extracorporeal membrane oxygenation details; complications; microbiology results; and outcomes. The primary endpoint was survival to hospital discharge. Results A total of 52 patients, 39 men and 13 women, were included during a 6-year period. Their median age and body mass index was 56.8 years and 24.1 kg/m2 , respectively. Of the 52 patients, 39 (75%) had failure of at least 3 organ systems and 21 (40%) had developed cardiac arrest and received cardiopulmonary resuscitation at extracorporeal membrane oxygenation implantation. Of these 52 patients, 8 (15%) survived to hospital discharge. The nonsurvivors were significantly older than the survivors (59.3 vs 43.8 years; P = .009), and all 20 patients (38%) aged 60 years or older died. Conclusions In our single-center experience with extracorporeal membrane oxygenation for adults with refractory septic shock, the outcomes of these patients remain unsatisfactory. From our findings, we suggest that if extracorporeal membrane oxygenation were to be used in this patient population, age 60 years or older might be a contraindication. Also, central extracorporeal membrane oxygenation could possibly be beneficial according to the favorable pediatric experience in published studies.
Whether preoperative proteinuria associates with adverse renal outcomes after cardiac surgery is unknown. Here, we performed a secondary analysis of a prospectively enrolled cohort of adult patients ...undergoing coronary artery bypass grafting (CABG) at a medical center and its two affiliate hospitals between 2003 and 2007. We excluded patients with stage 5 CKD or those who received dialysis previously. We defined proteinuria, measured with a dipstick, as mild (trace to 1+) or heavy (2+ to 4+). Among a total of 1052 patients, cardiac surgery-associated acute kidney injury (CSA-AKI) developed in 183 (17.4%) patients and required renal replacement therapy (RRT) in 50 (4.8%) patients. In a multiple logistic regression model, mild and heavy proteinuria each associated with an increased odds of CSA-AKI, independent of CKD stage and the presence of diabetes mellitus (mild: OR 1.66, 95% CI 1.09 to 2.52; heavy: OR 2.30, 95% CI 1.35 to 3.90). Heavy proteinuria also associated with increased odds of postoperative RRT (OR 7.29, 95% CI 3.00 to 17.73). In summary, these data suggest that preoperative proteinuria is a predictor of CSA-AKI among patients undergoing CABG.
OBJECTIVES:Hyperoxia could lead to a worse outcome after cardiac arrest. Few studies have investigated the impact of oxygenation status on patient outcomes following extracorporeal cardiopulmonary ...resuscitation. We sought to delineate the association between oxygenation status and neurologic outcomes in patients receiving extracorporeal cardiopulmonary resuscitation.
DESIGN:Retrospective analysis of a prospective extracorporeal cardiopulmonary resuscitation registry database.
SETTING:An academic tertiary care hospital.
PATIENTS:Patients receiving extracorporeal cardiopulmonary resuscitation between 2000 and 2014.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:A total of 291 patients were included, and 80.1% were male. Their mean age was 56.0 years. The arterial blood gas data employed in the primary analysis were recorded from the first sample over the first 24 hours in the ICUs after return of spontaneous circulation. The mean PaO2 after initiation of venoarterial extracorporeal membrane oxygenation was 178.0 mm Hg, and the mean PaO2/FIO2 ratio was 322.0. Only 88 patients (30.2%) demonstrated favorable neurologic status at hospital discharge. Multivariate logistic regression analysis indicated that PaO2 between 77 and 220 mm Hg (odds ratio, 2.29; 95% CI, 1.01–5.22; p = 0.05) and PaO2/FIO2 ratio between 314 and 788 (odds ratio, 5.09; 95% CI, 2.13–12.14; p < 0.001) were both positively associated with favorable neurologic outcomes.
CONCLUSIONS:Oxygenation status during extracorporeal membrane oxygenation affects neurologic outcomes in patients receiving extracorporeal cardiopulmonary resuscitation. The PaO2 range of 77 to 220 mm Hg, which is slightly narrower than previously defined, seems optimal. The PaO2/FIO2 ratio was also associated with outcomes in our analysis, indicating that both PaO2 and the PaO2/FIO2 ratio should be closely monitored during the early postcardiac arrest phase for postextracorporeal cardiopulmonary resuscitation patients.
Background/purpose Extracorporeal membrane oxygenation (ECMO) alters the pharmacokinetics (PK) of vancomycin in neonates; but data on adults is limited. Methods This is a prospective, matched cohort, ...single center, pharmacokinetic study. For each adult patient who received vancomycin therapy in the ECMO group (with either centrifugal pump or roller pump), a control patient was matched by age (≥ 60 years or < 60 years), gender, and creatinine clearance (CLCr ) in intensive care units. After vancomycin was administered for at least four doses, serial blood samples were drawn at 0.5 hours, 1 hour, 2 hours, 3 hours, 5 hours, 7 hours, 11 hours, 23 hours, 35 hours, and 47 hours post vancomycin infusion according to the dosing intervals. The serum concentration-time profile was fitted to a noncompartment model and a nonlinear mixed effect model to determine the PK parameters. Results Twenty-two critically ill adults without renal replacement therapy were enrolled. There were no significant differences between the ECMO group and the matched group in demographics, renal function, and PK parameters. However, vancomycin clearance in the roller pump group was significantly lower than that in the matched control (0.83 ± 0.43 mL/min/kg vs. 0.97 ± 0.43 mL/min/kg, p = 0.002). Conclusion Vancomycin clearance in patients receiving ECMO with a roller pump was significantly lower than that in the matched cohort. Vancomycin PK parameters in patients on ECMO with a centrifugal pump were comparable to those in the matched control group.
Abstract Background To identify novel factors associated with the survival of septic adults receiving extracorporeal membrane oxygenation (ECMO) to improve patient selection and outcomes. Methods ...Cases were identified from our ECMO registry from 2001 to 2011 if they were ≥16 years and received ECMO for life-threatening sepsis. Results A total of 151 adults with a median (25th-75th percentile) age of 51 (37-63) years were analyzed. Pneumonia (50%), myocarditis (20%), and primary bloodstream infections (15%) were the main types of infection, caused by predominantly nonfermentative Gram-negative bacteria (NFGNB) (26%), Enterobacteriaceae (24%), and Gram-positive cocci (21%). The in-hospital mortality of patients with NFGNB, enteric, and Gram-positive bacterial pneumonias were 100%, 68%, and 14%, respectively. Using the Cox-proportional hazards model, we found that age >75 years (hazard ratio HR, 1.98, 95% confidence interval 95% CI, 1.30-3.02), pre-ECMO dialysis (HR, 3.20, 95% CI, 1.34-7.63), longer door-to-ECMO intervals (HR, 1.01, 95% CI, 1.00-1.02), venoarterial mode (HR, 2.58, 95% CI, 1.55-4.21), and fungal (HR, 2.83, 95% CI, 1.36-5.88) and NFGNB sepsis (HR, 2.48, 95% CI, 1.44-4.27) were associated with mortality. Gram-positive sepsis (HR, 0.20, 95% CI, 0.08-0.57), myocarditis (HR, 0.12, 95% CI, 0.06-0.27), pneumonia (HR, 0.54, 95% CI, 0.30-0.90), and effective empirical antimicrobial therapy were predictive of survival (HR, 0.57, 95% CI, 0.37-0.89); all P < .05. Excluding the 67 heavily premorbid patients, we found that 54% survived ECMO and 42% survived to discharge, with significantly more survivors with door-to-ECMO times of ≤96 hours than >96 hours (59% vs 15%, P < .0001). Conclusions Better outcomes were associated with door-to ECMO times of 96 hours or less, for Gram-positive rather than Gram-negative sepsis, and for pneumonia rather than primary bloodstream infections.
Aims
To understand the influential factors related to quality of life for adult patients who have undergone extra corporeal membrane oxygenation.
Background
Extracorporeal membrane oxygenation is an ...invasive treatment for critically ill patients requiring temporary cardiac or respiratory support. Most studies have focused on survival outcomes for patients; few have evaluated health‐related quality of life.
Design
A cross‐sectional design.
Methods
Data were collected in 2013 from a convenience sample of adult patients who had survived treatment with extracorporeal membrane oxygenation between 2009–2011. Structured questionnaires collected data about health status. The Short Form 36‐item questionnaire measured quality of life.
Results
The 100 participants averaged 48·95 years of age. Pearson's correlation showed two measures of health status had significant correlations with quality of life: the Barthel Index and the Instrumental Activities of Daily Living; two measures had significant negative correlations: Charlson's Comorbidity Index and the Nottingham Health Profile‐part II. Mean scores for the physical and mental component summaries of the Short Form‐36 questionnaire were 49·25 and 48·13 respectively. These component scores had significant negative correlations with the Nottingham health profile‐part II. Stepwise multiple linear regression analysis indicated the number of life areas affected on the Nottingham health profile‐part II was a common factor influencing both the mental and physical component summaries scores for quality of life.
Conclusions
Social participation was a common factor influencing quality of life. Examining health status and quality of life of extracorporeal membrane oxygenation survivors can help nurses determine interventions for effectively improving health‐related quality of life.
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