Acute kidney injury is a common cause of morbidity in liver transplant recipients. In critically ill patients who received an orthotopic liver transplant, we examined whether those with acute kidney ...injury had a greater deficit between pretransplant and posttransplant hemodynamic pressure-related parameters compared with those without acute kidney injury in the early postoperative period.
We included patients who underwent an orthotopic liver transplant during the study period. We obtained premorbid and intensive care unit time-weighted average values for hemodynamic pressure-related parameters (systolic, diastolic, and mean arterial pressure; central venous pressure; mean perfusion pressure; and diastolic perfusion pressure) and calculated deficits in those values. We defined acute kidney injury progression as an increase of ≥1 Kidney Disease: Improving Global Outcomes stage.
We included 150 eligible transplantrecipients, with 88 (59%) having acute kidney injury progression. Acute kidney injury was associated with worse clinical outcomes. All achieved pressure-related values were similar between transplant recipients with or without acute kidney injury progression. However, those with acute kidney injury versus those without progression had greater diastolic perfusion pressure deficit at 12 hours (-8.33% vs 1.93%; P = .037) and 24 hours (-7.38% vs 5.11%; P = .002) and increased central venous pressure at 24 hours (46.13% vs 15%; P = .043) and 48 hours (40% vs 20.87%; P = .039).
Patients with acute kidney injury progression had a greater diastolic perfusion pressure deficit and increased central venous pressure compared with patients without progression. Such deficits might be modifiable risk factors for the prevention of acute kidney injury progression.
The impact of co-management on clinical outcomes in neurosurgical patients is uncertain. This study aims to describe the implementation of a hospitalist co-management program in a neurosurgery ...department and its impact on the incidence of complications, mortality, and length of stay.
The authors used a quasi-experimental study design that compared a historical control period (July-December 2017) to a prospective intervention arm. During the intervention period, patients admitted to a neurosurgery inpatient unit who were older than 65 years, suffered certain conditions, or were admitted from ICUs were included in the co-management program. Two hospitalists joined the surgical staff and intervened in the diagnostic and therapeutical plan of patients, participating in clinical decisions and coordinating patient navigation with neurosurgeons. The incidence of moderate or severe complications measured by the Accordion Severity Grading System, in-hospital mortality, and length of stay of the two cohorts were compared. Multivariate regression was used to adjust for confounders, and the average treatment effect was estimated using inverse probability of treatment weighting.
The adjusted incidence of moderate or severe complications was lower among co-managed patients (odds ratio OR 0.60, 95% confidence interval CI 0.39-0.91). Mortality was unchanged (OR 0.83, 95% CI 0.15-4.17). Length of stay was lower in co-managed patients, with a 1.3-day reduction observed after inverse probability of treatment weighting analysis.
Hospitalist co-management was associated with a reduced incidence of complications and length of stay in neurosurgical patients, but there was no difference in in-hospital mortality.
A case of myoclonic status treated with plasmapheresis in a patient of 63 years of age who was admitted to a Spanish intensive care unit is reported. The patient showed clinical and radiological ...evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; molecular tests did not verify this.
Purpose
We examined the ability of the P(v‐a)CO2/Da‐vO2 ratio combined with elevated lactate levels to predict early allograft dysfunction (EAD).
Materials and methods
Patients were classified into ...four groups according to lactate levels and P(v‐a)CO2/Da‐vO2 ratio: Group 1; lactate >2.0 mmol/L and P(v‐a)CO2/Da‐vO2 ratio >1.0; Group 2; lactate >2.0 mmol/L and P(v‐a)CO2/Da‐vO2 ratio <1.0; group 3; lactate<2.0 mmol/L and P(v‐a)CO2/Da‐vO2 ratio >1.0; group 4; lactate<2.0 mmol/L and P(v‐a)CO2/Da‐vO2 ratio <1.0. We defined EAD according to Olthoff criteria.
Results
One‐hundred and fifty patients were included. EAD occurred in 41 patients (27.3%), and was associated with worse graft survival at 1 year (92% vs. 73%; P = ,003) as well as a higher re‐transplantation rate (4,6% vs. 17,1%; P = ,019). The multivariate analysis revealed that P(v‐a)CO2/Da‐vO2 ratio at T6 OR 7.05(CI95% 2.77–19.01, P<.001) was an independent predictor for EAD. Belonging to group 1 at 6 h was associated with worse clinical outcomes but no association was found with 1‐year graft survival or 1‐year patient survival.
Conclusions
In this single center, prospective, observational study in patients who received an OLT, we found that elevated lactate levels combined with a high Cv‐aCO2/Da‐vO2 after 6 h was associated with the development of EAD and worse clinical outcomes in the early postoperative period.
Prone position (PP) has been widely used in the COVID-19 pandemic for ARDS management. However, the optimal length of a PP session is still controversial. This study aimed to evaluate the effects of ...prolonged versus standard PP duration in subjects with ARDS due to COVID-19.
This was a single-center, randomized controlled, parallel, and open pilot trial including adult subjects diagnosed with severe ARDS due to COVID-19 receiving invasive mechanical ventilation that met criteria for PP between March-September 2021. Subjects were randomized to the intervention group of prolonged PP (48 h) versus the standard of care PP (∼16 h). The primary outcome variable for the trial was ventilator-free days (VFDs) to day 28.
We enrolled 60 subjects. VFDs were not significantly different in the standard PP group (18 interquartile range IQR 0-23 VFDs vs 7.5 IQR 0-19.0 VFDs; difference, -10.5 (95% CI -3.5 to 19.0,
= .08). Prolonged PP was associated with longer time to successful extubation in survivors (13.00 IQR 8.75-26.00 d vs 8.00 IQR 5.00-10.25 d; difference, 5 95% CI 0-15,
= .001). Prolonged PP was also significantly associated with longer ICU stay (18.5 IQR 11.8-25.3 d vs 11.50 IQR 7.75-25.00 d,
= .050) and extended administration of neuromuscular blockers (12.50 IQR 5.75-20.00 d vs 5.0 IQR 2.0-14.5 d,
= .005). Prolonged PP was associated with significant muscular impairment according to lower Medical Research Council values (59.6 IQR 59.1-60.0 vs 56.5 IQR 54.1-58.9,
= .02).
Among subjects with severe ARDS due to COVID-19, there was no difference in 28-d VFDs between prolonged and standard PP strategy. However, prolonged PP was associated with a longer ICU stay, increased use of neuromuscular blockers, and greater muscular impairment. This suggests that prolonged PP is not superior to the current recommended standard of care.
OBJECTIVEThe condition of critically ill patients in the emergency department (ED) varies from moment to moment. The aims of this study are to quantify sequential organ failure assessment (SOFA) and ...changes in SOFA scores over time and determine its prognostic impact.
PATIENTS AND METHODSThis is a prospective observational cohort study. We included 269 patients consecutively admitted to the ICU from the ED over 18 months. The SOFA scores at ED admission (ED-SOFA) and ICU admission (ICU-SOFA) were obtained. Relative changes in SOFA scores were calculated as followsΔ-SOFA=ICU-SOFA−ED-SOFA. Patients were divided into two groups depending on the Δ-SOFA score(a) Δ-SOFA=0–1; and (b) Δ-SOFA more than or equal to 2.
RESULTSThe median ED-SOFA score was two points (interquartile range1–4.5) and the Δ-SOFA score was 2 points (interquartile range0–3). The Δ-SOFA score was more powerful (area under the curve0.81) than the ED-SOFA score (area under the curve0.75) in predicting hospital mortality. Sixteen (6%) patients had a Δ-SOFA score less than 0, 116 (43%) patients had a Δ-SOFA=0–1, and 137 (51%) patients had a Δ-SOFA of at least 2 points. The probability of being alive at hospital discharge was 51 and 86.5% in Δ-SOFA of at least 2 and Δ-SOFA=0–1 groups, respectively (P<0.001). Risk factors for an increase of two or more SOFA points were age, cirrhosis, a diagnosis of sepsis, and a prolonged ED stay.
CONCLUSIONSOFA and changes in the SOFA score over time are potentially useful tools for risk stratification when applied to critically ill patients admitted to ICUs from the ED.
After the publication of the new definition for sepsis and septic shock, our objective is to analyse the evolution of patients admitted to ICU with an infection process using the previous and new ...recommendations.
This is a sub-analysis of a previous observational prospective study. We included 98 patients admitted to ICU from the emergency department due to infection during an 18-month period. We studied the clinical evolution during ICU admission and hospital mortality.
According to Sepsis-2 definition, 78% percent had septic shock and using Sepsis-3 criteria, 52%; hospital mortality was 29 and 41%, respectively. The RR of hospital mortality of septic shock was 10.3 (95% CI: 2.8-37.5) compared to patients without shock. The 30-day probability survival of patients with sepsis and septic shock were 78% and 68%, respectively (long rank < 0.001).
In our experience, the incorporation of the SOFA score and lactate levels to the new definition could help improve the evaluation of risk of hospital death.
Diabetic retinopathy (DR) is a neurodegenerative disease characterized by the presence of microcirculatory lesions. Among them, microaneurysms (MAs) are the first observable hallmark of early ...ophthalmological changes. The present work aims to study whether the quantification of MAs, hemorrhages (Hmas) and hard exudates (HEs) in the central retinal field could have a predictive value on DR severity. These retinal lesions were quantified in a single field NM-1 of 160 retinographies of diabetic patients from the IOBA's reading center. Samples included different disease severity levels and excluded proliferating forms: no DR (
= 30), mild non-proliferative (
= 30), moderate (
= 50) and severe (
= 50). Quantification of MAs, Hmas, and HEs revealed an increasing trend as DR severity progresses. Differences between severity levels were statistically significant, suggesting that the analysis of the central field provides valuable information on severity level and could be used as a clinical tool to assess DR grading in the eyecare routine. Even though further validation is needed, counting microvascular lesions in a single retinal field can be proposed as a rapid screening system to classify DR patients with different stages of severity according to the international classification.
Pectin esterases (PE, EC 3.1.1.11) catalyse the demethylation of pectin. As a result of its activity, structural interactions among cell wall components during cell wall turnover and loosening are ...affected. In plants, PEs are typically encoded by a gene family. This family has been studied in strawberry (Fragariaxananassa Duch.) in order to investigate the role of distinct PE genes during fruit ripening and senescence. By a combination of a PCR-based library screening and RT-PCR four different strawberry PE cDNAs, termed FaPE1 to FaPE4, have been isolated. Differential expression of each FaPE gene in various organs and during fruit development was revealed by northern blot. FaPE1 is specifically expressed in fruit, showing an increasing expression during the ripening process up to a maximum in the turning stage. Concerning hormone regulation, auxin treatment increased FaPE1 mRNA levels in green fruit, whereas exogenous ethylene decreased FaPE1 mRNA levels in ripe and senescing fruits. It is proposed that this repression of FaPE1 expression could be involved in textural changes occurring during fruit senescence.
The failure mode and effect analysis (FMEA) may improve the safety of the continuous renal replacement therapies (CRRT) in the intensive care unit. We use this tool in three phases1) Retrospective ...observational study. 2) A process FMEA, with implementation of the improvement measures identified. 3) Cohort study after FMEA. We included 54 patients in the pre-FMEA group and 72 patients in the post-FMEA group. Comparing the risks frequencies per patient in both groups, we got less cases of under 24 hours of filter survival time in the post-FMEA group (31 patients 57.4% vs. 21 patients 29.6%; p < 0.05); less patients suffered circuit coagulation with inability to return the blood to the patient (25 patients 46.3% vs. 16 patients 22.2%; p < 0.05); 54 patients (100%) versus 5 (6.94%) did not get phosphorus levels monitoring (p < 0.05); in 14 patients (25.9%) versus 0 (0%), the CRRT prescription did not appear on medical orders. As a measure of improvement, we adopt a dynamic dosage management. After the process FMEA, there were several improvements in the management of intensive care unit patients receiving CRRT, and we consider it a useful tool for improving the safety of critically ill patients.
PDF
