Background
Continuous renal replacement therapy (CRRT) support is crucial for critically ill patients and it is underexplored in specific situations. Experimental CRRT offers a means to gain insights ...into these scenarios, but the prohibitive cost of CRRT machines limits their accessibility. This study aimed to develop and validate a low-cost and precise dialysate controller for experimental CRRT.
Results
Our results demonstrate a commendable level of precision in affluent flow control, with a robust correlation (
R
2
= 0.99) for continuous flow and a strong correlation (
R
2
= 0.95) for intermittent flow. Additionally, we observed acceptable agreement with a bias = 3.4 mL (upper limit 95% = 43.9 mL and lower limit 95% = − 37 mL) for continuous flow and bias = − 20.9 mL (upper limit 95% = 54 mL and lower limit 95% = − 95.7 mL) for intermittent flow, in this way, offering a precise CRRT dose for the subjects. Furthermore, we achieved excellent precision in the cumulative ultrafiltration net (UFnet), with a bias = − 2.8 mL (upper limit 95% = 6.5 mL and lower limit 95% = − 12 mL). These results remained consistent even at low affluent flow rates of 8, 12, and 20 mL/min, which are compatible with CRRT doses of 25–30 mL/kg for medium-sized animals. Moreover, the acceptable precision of our findings persisted when the dialysate controller was subjected to high filter dialysate chamber pressure for an extended duration, up to 797 min.
Conclusions
The low-cost dialysate controller developed and tested in this study offers a precise means of regulating CRRT in experimental settings. Its affordability and accuracy render it a valuable instrument for studying CRRT support in unconventional clinical scenarios, particularly in middle-income countries’ experimental ICU laboratories.
There is no consensual definition of refractory shock. The use of more than 0.5 mcg/kg/min of norepinephrine or epinephrine to maintain target blood pressure is often used in clinical trials as a ...threshold. Nearly 6% of critically ill patients will develop refractory shock, which accounts for 18% of deaths in intensive care unit. Mortality rates are usually greater than 50%. The assessment of fluid responsiveness and cardiac function can help to guide therapy, and inotropes may be used if hypoperfusion signs persist after initial resuscitation. Arginine vasopressin is frequently used in refractory shock, although definite evidence to support this practice is still missing. Its associations with corticosteroids improved outcome in observational studies and are therefore promising alternatives. Other rescue therapies such as terlipressin, methylene blue, and high-volume isovolemic hemofiltration await more evidence before use in routine practice.
Extracorporeal membrane oxygenation (ECMO) has gained renewed interest in the treatment of respiratory failure since the advent of the modern polymethylpentene membranes. Limited information exists, ...however, on the performance of these membranes in terms of gas transfers during multiple organ failure (MOF). We investigated determinants of oxygen and carbon dioxide transfer as well as biochemical alterations after the circulation of blood through the circuit in a pig model under ECMO support before and after induction of MOF. A predefined sequence of blood and sweep flows was tested before and after the induction of MOF with fecal peritonitis and saline lavage lung injury. In the multivariate analysis, oxygen transfer had a positive association with blood flow (slope = 66, P<0.001) and a negative association with pre-membrane PaCO(2) (slope = -0.96, P = 0.001) and SatO(2) (slope = -1.7, P<0.001). Carbon dioxide transfer had a positive association with blood flow (slope = 17, P<0.001), gas flow (slope = 33, P<0.001), pre-membrane PaCO(2) (slope = 1.2, P<0.001) and a negative association with the hemoglobin (slope = -3.478, P = 0.042). We found an increase in pH in the baseline from 7.507.46,7.54 to 7.607.55,7.65 (P<0.001), and during the MOF from 7.196.92,7.32 to 7.417.13,7.5 (P<0.001). Likewise, the PCO(2) fell in the baseline from 35 32,39 to 25 22,27 mmHg (P<0.001), and during the MOF from 59 47,91 to 34 28,45 mmHg (P<0.001). In conclusion, both oxygen and carbon dioxide transfers were significantly determined by blood flow. Oxygen transfer was modulated by the pre-membrane SatO(2) and CO(2), while carbon dioxide transfer was affected by the gas flow, pre-membrane CO(2) and hemoglobin.
Abstract Introduction Percutaneous dilational tracheostomy (PDT) is routinely performed in the intensive care unit with bronchoscopic guidance. Recently, ultrasound (US) has emerged as a new safety ...adjunct tool to increase the efficacy of PDT. However, the available data are limited to case series without any control group. Hence, a retrospective cohort study was designed to evaluate the efficacy of US-guided PDT compared with bronchoscopy-guided PDT. Methods All patients who were submitted to PDT after the standardization of US-guided PDT technique in our institution were analyzed. Demographic and procedure-related variables, complications, and clinical outcomes were collected and compared in patients undergoing US- or bronchoscopy-guided PDT. Results Sixty patients who had been submitted to PDT were studied, including 11 under bronchoscopy guidance and 49 under US guidance. No surgical conversion was necessary in any of the procedures, and bronchoscopy assistance was only required in 1 case in the US group. The procedure length was shorter in the US group than in the bronchoscopy group (12 vs 15 minutes, P = .028). None of the patients had any major complications. The minor complication rates were not significantly different between the groups, nor was the probability of breathing without assistance within 28 days, intensive care unit length of stay, or hospital mortality. Conclusion Ultrasound-guided PDT is effective, safe, and associated with similar complication rates and clinical outcomes compared with bronchoscopy-guided PDT.
* Gaosi Xu We are grateful to Professor Besen for his comments. First of all, we agree it is preferable for a meta-analysis to include original multi-centered randomized controlled trials; however, ...well-designed studies such as these are unfortunately lacking in cardiac surgery. Second, it can be seen in Fig. 1 that the heterogeneity of the multi-centered trials included is moderate (67.7%), and that only three trials are studied. Third, in Li et al.’s study 3, one of the purposes of the research was to investigate timing to RRT initiation, and the indication for RRT was urine output < 240 mL/12 h regardless of other symptoms. Li et al.’s study compared different doses of RRT as well as timing to RRT initiation, and the high-dose group received early RRT 3. In other words, the study indicated that an early higher continuous veno-venous hemofiltration dose was associated with better in-hospital and long-term survival 3. As for the study by Kleinknecht et al. 4, we think that this can be included in our meta-analysis as patients who suffered from acute kidney injury in post-cardiac surgery are included. Fourth, we performed a meta-regression in our meta-analysis 1 but did not find the sources of heterogeneity, so no other subgroup analysis was done. Last but not least, the results of the analysis of early versus late RRT initiation (Additional file 1) and subgroup analysis of the timing to early RRT initiation (Additional file 2) are consistent with our original results even after exclusion of these three studies 2-4. The results are therefore that early RRT initiation decreases 28-day mortality, especially when started within 24 h, in patients with severe acute kidney injury after cardiac surgery.
Background
Sepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria’s accuracy in stratifying mortality as ...compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification.
Methods
Retrospective cohort study conducted between 2010 and 2015 in a public university’s 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated.
Results
The medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 ± 19 years, median SAPS 3 was 65 50,79, respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction—7/103 (7%); sepsis—106/419 (25%); and septic shock—198/435 (46%) (
P
< 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis 43/252-(17%) and septic shock 250/572-(44%) (
P
< 0.001); sepsis had a mortality of 18/135-(13%) (
P
= 0.430 vs. severe sepsis). When combined with lactate, the definitions’ accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsis and septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings.
Conclusions
In a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions’ accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups.
Abstract Purpose Strategies aiming light sedation are associated with decreased length on mechanical ventilation. However, awake or easily arousable patients may be prone to greater prevalence of ...posttraumatic stress disorder (PTSD). These systematic review and meta-analysis aimed to evaluate the safety of light sedation strategies regarding the prevalence of PTSD. Methods We searched MEDLINE, Scopus, and Web of Science from inception to November 2014 for randomized controlled trials that evaluated light sedation strategies and addressed PTSD prevalence in the follow-up as a specific outcome. Because not all trials performed the same comparisons, we performed a network meta-analysis to evaluate indirect comparisons. Results Five studies fulfilled our inclusion criteria and were included in the meta-analysis. Two studies compared daily sedation interruption with usual care (92 patients), 2 studies compared a light sedation protocol with daily sedation interruption (47 patients), and 1 study compared light and deep sedation (102 patients). Compared with usual sedation care/deep sedation, neither daily interruption of sedation (odds ratio = 0.66; 95% confidence interval, 0.22-1.98) nor a light sedation protocol (odds ratio = 0.90, 95% confidence interval, 0.27-3.05) was associated with increased risks on long-term PTSD prevalence. Conclusion Light sedation strategies seem to be safe in terms of PTSD prevalence. However, the small number of included trials and patients may not be sufficient to drive strong statements.
Abstract Background Extracorporeal membrane oxygenation (ECMO) for acute respiratory failure is still a matter of debate. Methods We performed a structured search on Pubmed, EMBASE, Lilacs, and the ...Cochrane Library for randomized controlled trials and observational case-control studies with severity-paired patients, evaluating the use of ECMO on severe acute respiratory failure in adult patients. A random-effect model using DerSimonian and Laird method for variance estimator was performed to evaluate the effect of ECMO use on hospital mortality. Heterogeneity between studies was assessed with Cochran's Q statistic and Higgin's I2. Results Three studies were included on the metanalysis, comprising 353 patients in the main analysis, in which 179 patients were ECMO supported. One study was a randomized controlled trial and two were observational studies with a propensity score matching. The most common reason for acute respiratory failure was influenza H1N1 pneumonia (45%) and pneumonia (33%). ECMO was not associated with a reduction in hospital mortality (OR = 0.71; CI 95% = 0.34 - 1.47; P = 0.358). If alternative severity-pairing method presented by the two observational studies was included, a total of 478 cases were included, in which 228 received ECMO support. In the former analysis, ECMO had a benefit on hospital mortality (OR = 0.52; CI 95% = 0.35 - 0.76; P < 0.001). Conclusion Extracorporeal membrane oxygenation benefit on hospital mortality is unclear. Results were sensitive to statistical analysis, and no definitive conclusion can be drawn from the available data. More studies are needed before the widespread use of ECMO can be recommended.
Mobile phones (MPs) have become an important work tool around the world including
in hospitals. We evaluated whether SARS-CoV-2 can remain on the surface of MPs
of first-line healthcare workers (HCW) ...and also the knowledge of HCWs about
SARS-CoV-2 cross-transmission and conceptions on the virus survival on the MPs
of HCWs. A cross-sectional study was conducted in the COVID-19 Intensive Care
Unit of a teaching hospital. An educational campaign was carried out on
cross-transmission of SARS-CoV-2, and its permanence in fomites, in addition to
the proper use and disinfection of MPs. Herewith an electronic questionnaire was
applied including queried conceptions about hand hygiene and care with MP before
and after the pandemic. The MPs were swabbed with a nylon FLOQ Swab
™
,
in an attempt to increase the recovery of SARS-CoV-2. All MP swab samples were
subjected to SARS-CoV-2 RT-PCR; RT-PCR positive samples were subjected to viral
culture in Vero cells (ATCC
®
CCL-81™). Fifty-one MPs were swabbed and
a questionnaire on hand hygiene and the use and disinfection of MP was applied
after an educational campaign. Most HCWs increased adherence to hand hygiene and
MP disinfection during the pandemic. Fifty-one MP swabs were collected and two
were positive by RT-PCR (4%), with Cycle threshold (C
t
) values of
34-36, however, the cultures of these samples were negative. Although most HCWs
believed in the importance of cross-transmission and increased adherence to hand
hygiene and disinfection of MP during the pandemic, SARS-CoV-2 RNA was detected
in MPs. Our results suggest the need for a universal policy in infection control
guidelines on how to care for electronic devices in hospital settings.
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