As we were taught, for decades, that iodinated contrast-induced acute kidney injury should be dreaded, considerable efforts were made to find out effective measures in mitigating the renal risk of ...iodinated contrast media. Imaging procedures were frequently either downgraded (unenhanced imaging) or deferred as clinicians felt that the renal risk pertaining to contrast administration outweighed the benefits of an enhanced imaging. However, could we have missed the point? Among the abundant literature about iodinated contrast-associated acute kidney injury, recent meaningful advances may help sort out facts from false beliefs. Hence, there is increasing evidence that the nephrotoxicity directly attributable to modern iodinated CM has been exaggerated. Failure to demonstrate a clear benefit from most of the tested prophylactic measures might be an indirect consequence. However, the toxic potential of iodinated contrast media is well established experimentally and should not be overlooked completely when making clinical decisions. We herein review these advances in disease and pathophysiologic understanding and the associated clinical crossroads through a typical case vignette in the critical care setting. Keywords: Contrast media (MeSH: D003287), Intensive care units (MeSH D007362), Drug-related side effects and adverse reactions (MeSH D064420), Tomography scanners, X-ray computed (MeSH: D015898), Percutaneous coronary interventions (MeSH: D062645), Contrast-induced nephropathy, Post-contrast acute kidney injury
Although its reliability is often questioned, noninvasive BP (NIBP)-monitoring with an oscillometric arm cuff is widely used, even in critically ill patients in shock. When correctly implemented, ...modern arm NIBP devices can provide accurate and precise measurements of mean BP, as well as clinically meaningful information such as identification of hypotension and hypertension and monitoring of patient response to therapy. Even in specific circumstances such as arrhythmia, hypotension, vasopressor infusion, and possibly in obese patients, arm NIBP may be useful, contrary to widespread belief. Hence, postponing the arterial catheter insertion pending the initiation of more urgent diagnostic and therapeutic measures could be a suitable strategy. Given the arterial catheter-related burden, fully managing critically ill patients without any arterial catheter may also be an option. Indeed, the benefit that patients may experience from an arterial catheter has been questioned in studies failing to show that its use reduces mortality. However, randomized controlled trials to confirm that NIBP can safely fully replace the arterial catheter have yet to be performed. In addition to intermittent measurements, continuous NIBP monitoring is a booming field, as illustrated by the release onto the market of user-friendly devices, based on digital volume clamp and applanation tonometry. Although the imperfect accuracy and precision of these devices would probably benefit from technical refinements, their good ability to track, in real time, the direction of changes in BP is an undeniable asset. Their drawbacks and advantages and whether these devices are currently ready to use in the critically ill patient are discussed in this review.
In the critically ill, blood pressure measurements mostly rely on automated oscillometric devices pending the intra-arterial catheter insertion or after its removal. If the arms are inaccessible, the ...cuff is placed at the ankle or the thigh, but this common practice has never been assessed. We evaluated the reliability of noninvasive blood pressure readings at these anatomic sites.
Prospective observational study.
Medical-surgical intensive care unit.
Patients carrying an arterial line with no severe occlusive arterial disease.
Each patient underwent a set of three pairs of noninvasive and intra-arterial measurements at each site (arm, ankle, thigh if Ramsay sedation scale >4) and, in case of circulatory failure, a second set of measurements after a cardiovascular intervention (volume expansion, change in catecholamine dosage).
In 150 patients, whatever the cuff site, the agreement between invasive and noninvasive readings was markedly higher for mean arterial pressure than for systolic or diastolic pressure. For mean arterial pressure measurement, arm noninvasive blood pressure was reliable (mean bias of 3.4 ± 5.0 mm Hg, lower/upper limit of agreement of -6.3/13.1 mm Hg) contrary to ankle or thigh noninvasive blood pressure (mean bias of 3.1 ± 7.7 mm Hg and 5.7 ± 6.8 mm Hg and lower/upper limits of agreement of -12.1/18.3 mm Hg and -7.7/19.2 mm Hg, respectively). During acute circulatory failure (n = 83), arm noninvasive blood pressure but also ankle and thigh noninvasive blood pressure allowed a reliable detection of 1) invasive mean arterial pressure <65 mm Hg (area under the receiver operating characteristic curve of 0.98 0.92-1, 0.93 0.85-0.97, and 0.93 0.85-0.98 for arm, ankle, and thigh noninvasive blood pressure, respectively); and 2) a significant (>10%) increase in invasive mean arterial pressure after a cardiovascular intervention (area under the receiver operating characteristic curve of 0.99 0.92-1, 0.90 0.80-0.97, and 0.96 0.87-0.99, respectively).
In our population, arm noninvasive mean arterial pressure readings were accurate. Either the ankle or the thigh may be reliable alternatives, only to detect hypotensive and therapy-responding patients.
...these patients showed poor performance in the assessment of the vasospasm-related impact on brain perfusion. Besides methods at the bedside that are not devoid of limitations (brain tissue oxygen ...monitoring, electroencephalography, and near-infrared spectroscopy, for instance), CT perfusion causes exposure to significant irradiation and is therefore only proposed once or twice to a given patient. ...when vasospasm is confirmed, we frequently opt for an intensive treatment that encompasses induced hypertension (via vasopressor infusion and/or fluid boluses), IV milrinone, and, if necessary, endovascular angioplasty. ...vasospasm-related neurological deterioration encourages a high degree of intensive therapy.
•The incidence of early AKI after non-traumatic subarachnoid hemorrhage (SAH) is unclear.•Among 499 patients who underwent catheter angiography for SAH, 1/4 developed early AKI, mostly oliguria.•The ...incidence of early AKI was even higher in patients with severe SAH.•Early AKI persisted beyond the 48th hour in one third of cases.•ICU and hospital lengths of stay were longer in patients who developed early AKI.
After subarachnoid hemorrhage (SAH), potential renal insults are numerous but the burden of early acute kidney injury (AKI) is unclear. We determined its incidence, rate of persistence, risk factors, and impact on patients’ outcomes.
Patients with non-traumatic SAH were retrospectively included if they underwent catheter angiography within the 48 h after their admission to the intensive care unit. Early AKI was defined according to Kidney Disease Improving Global Outcome (KDIGO) criteria, analyzed from the time of catheter angiography. Early AKI was considered as persistent if the KDIGO stage did not decrease between the 48th and the 60th hour.
Among 499 consecutive patients, early AKI (mostly oliguria) occurred in 132 (26%): stage 1, 2 and 3 in 72 (14%), 44 (9%), and 16 (3%) patients, respectively. It persisted in 36% of cases. Early AKI occurred more likely when SAH was severe or renal function was impaired at hospital admission: adjusted odds ratio of 2.76 95% 1.77–4.30 and 3.32 1.17–9.46, respectively. ICU and hospital lengths of stay were longer in patients who developed early AKI than in patients who did not: 16 9–29 versus 12 4–24 days (p = 0.0003) and 21 14–43 versus 16 11–32 days (p = 0.007), respectively. There was an independent link between early AKI and renal outcome (n = 274 in the model) but not with hospital mortality (n = 453).
One quarter of our population developed early AKI, mostly oliguria. It persisted beyond the 48th hour in one third of cases. The associated risk factors we identified were non-modifiable.
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