The intravascular volume effect of ringer's lactate is below 20%: a prospective study in humans.

Crit Care. 2012 May 16;16(3):R86

Authors: Jacob M, Chappell D, Hofmann-Kiefer K, Helfen T, Schuelke A, Jacob B, Burges A, Conzen P, Rehm M

Abstract
ABSTRACT: Introduction Isotonic crystalloids play a central role in perioperative fluid management. Isooncotic preparations of colloids (e.g. human albumin or hydroxyethyl starch) remain nearly completely intravascular when infused to compensate for acute blood losses. Recent data were interpreted to indicate a comparable intravascular volume effect for crystalloids, challenging the occasionally suggested advantage of using colloids to treat hypovolemia. General physiological knowledge and clinical experience, however, suggest otherwise. Methods In a prospective study, double-tracer blood volume measurements were performed before and after intended normovolemic hemodilution in ten female adults, simultaneously substituting the three-fold amount of withdrawn blood with ringer's lactate. Any originated deficits were substituted with half the volume of 20% human albumin, followed by a further assessment of blood volume. To assess significance between the measurements, repeated measures analysis of variance (ANOVA) according to Fisher were performed. If significant results were shown, paired t-tests (according to Student) for the singular measurements were taken. P<0.05 was considered to be significant. Results 1,097+/-285 ml of whole blood were withdrawn (641+/-155 ml/m2 body surface area) and simultaneously replaced by 3,430+/-806 ml of ringer's lactate. All patients showed a significant decrease in blood volume after hemodilution (-459+/-185 ml; p<0.05) which did not involve relevant hemodynamical changes, and a significant increase in interstitial water content (+2,157+/-606 ml; p<0.05). The volume effect of ringer's lactate was 17+/-10%. The infusion of 245+/-64 ml of 20% human albumin in this situation restored blood volume back to baseline values, the volume effect being 184+/-63%. Conclusions Substitution of isolated intravascular deficits in cardiopulmonary healthy adults with the 3-fold amount of ringer's lactate impedes maintenance of intravascular normovolemia. Main side effect was an impressive interstitial fluid accumulation, which was partly restored by the intravenous infusion of 20% human albumin. We recommend to substitute the 5-fold amount of crystalloids or to use an isooncotic preparation in the face of acute bleeding in patients where edema prevention might be advantageous.

PMID: 22591647 [PubMed - as supplied by publisher]

Antipsychotic use and diagnosis of delirium in the intensive care unit.

Crit Care. 2012 May 16;16(3):R84

Authors: Swan JT, Fitousis K, Hall JB, Todd SR, Turner KL

Abstract
ABSTRACT: INTRODUCTION: Delirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has lead to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU. METHODS: Retrospective observational cohort study conducted at seventy-one United States academic medical centers that reported data to the University HealthSystem Consortium Clinical Database/Resource Manager. Included all patients 18 years of age and older admitted to the hospital between January 1, 2010 and June 30, 2010 with at least one day in the ICU. RESULTS: Delirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n=10,958) and quetiapine (31%; n=5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P<0.001) and hospital LOS (11 vs. 6 days, P<0.001), but not in-hospital mortality (8% vs. 9%, P=0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P<0.001), hospital LOS (14 vs. 5 days, P<0.001) and mortality (12% vs. 8%, P<0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n=5,760) was associated with increased ICU LOS (9 vs. 7 days, P<0.001), hospital LOS (16 vs. 13 days, P<0.001) and in-hospital mortality (19% vs. 9%, P<0.001) compared to patients with a documented mental disorder (68%, n=12,004). CONCLUSIONS: The incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to one in every ten ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.

PMID: 22591601 [PubMed - as supplied by publisher]

Apolipoprotein M - a new biomarker in sepsis.

Crit Care. 2012 May 17;16(3):126

Authors: Christoffersen C, Nielsen LB

Abstract
ABSTRACT: Sepsis is one of the leading causes of mortality in non-cardiac intensive care units, and the need for markers of progression and severity are high. Also, treatment of sepsis is highly debated and potential new targets of treatment are of great interest. In the previous issue of Critical Care Kumaraswamy and colleagues have investigated whether plasma apolipoprotein M (apoM) is affected during different grades of sepsis, septic shock and systemic inflammatory response syndrome. Interestingly, plasma apoM was significantly decreased in all groups of patients with a relationship to severity of disease. This identifies apoM as a potential new biomarker in sepsis. It also underscores the possibility that altered high-density lipoprotein in sepsis patients can affect the course of disease. Thus, since apoM is the carrier of Sphingosine-1-P (S1P), a molecule with great influence on vascular barrier function, the study presented raises the interest and relevance for further studies of apoM and S1P in relation to sepsis and inflammation.

PMID: 22587809 [PubMed - as supplied by publisher]

Evaluation of a new pocket echoscopic device for focused-cardiac ultrasonography in emergency setting.

Crit Care. 2012 May 14;16(3):R82

Authors: Biais M, Carrie C, Delaunay F, Morel N, Revel P, Janvier G

Abstract
ABSTRACT: INTRODUCTION: In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initiate emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited in this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (VscanTM, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5TM, GE Healthcare) for a cardiac focused ultrasonography in patients admitted in emergency department. METHODS: During 4 months, patients admitted to our emergency department and requiring transthoracic echocardiography (TTE) were included in this single-center, prospective and observational study. Patients underwent TTE using pocket ultrasound device (PUD) and conventional echocardiography system. Each examination was performed independently by a physician experienced in echocardiography, unaware of the results found by the alternative device. During the focused cardiac echocardiography, the following parameters were assessed: global cardiac systolic function, identification of ventricular enlargement or hypertrophy, assessment for pericardial effusion and estimation of the size and the respiratory changes of the inferior vena cava (IVC) diameter. RESULTS: One hundred and fifty one (151) patients were analysed. Using the tested PUD, the image quality was sufficient to perform focused cardiac ultrasonography in all patients. Examination using PUD adequately qualified with a very good agreement global left ventricular systolic dysfunction (kappa=0.87; 95%CI: 0.76-0.97), severe right ventricular dilation (kappa=0.87; 95%CI: 0.71-1.00), inferior vena cava dilation (kappa=0.90; 95%CI: 0.80-1.00), respiratory induced variations in inferior vena cava size in spontaneous breathing (kappa=0.84; 95%CI: 0.71-0.98), pericardial effusion (kappa=0.75; 95%CI: 0.55-0.95) and compressive pericardial effusion (kappa=1.00; 95%CI: 1.00-1.00). CONCLUSIONS: In emergency setting, this new ultraportable echoscope was reliable for the real-time detection of focused cardiac abnormalities.

PMID: 22583539 [PubMed - as supplied by publisher]

Higher vs. lower fluid volume for septic shock: clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort.

Crit Care. 2012 May 8;16(3):R76

Authors: Smith SH, Perner A

Abstract
ABSTRACT: INTRODUCTION: Patients with septic shock require fluid, but the optimum amount is unknown. Therefore we assessed patient characteristics and outcome associated to fluid volume in unselected patients with septic shock including those with three days of shock. METHODS: We conducted a prospective, multicenter, observational study of all adult patients with septic shock during a 3-month study period at six general ICUs; three in university hospitals and three in regional hospitals. After day 1 and 3 of shock, patients were divided into two groups according to the overall median fluid volumes. Characteristics between these groups were compared using non-parametric and Chi-square statistics. RESULTS: The 164 included patients received median 4.0 l (IQR 2.3-6.3) of fluid during the first day of septic shock. Patients receiving higher volumes (>4.0 l) on day 1 had higher p-lactate (3.4 (2.2-5.5) vs. 2.0 (1.6-3.0) mmol l-1, P < 0.0001) compared to those receiving lower volumes. In contrast simplified acute physiology score (SAPS) II (54 (45-64) vs. 54 (45-67), p = 0.73), sequential organ failure assessment (SOFA) score (11 (9-13) vs. 11 (9-13), P = 0.78) and 90-day mortality (48 vs. 53%, P = 0.27) did not differ between groups. The 95 patients who still had shock on day 3 had received 7.5 l (4.3 - 10.8) of fluid by the end of day 3. Patients receiving higher volumes (>7.5 l) had higher p-lactate (2.6 (1.7-3.4) vs. 1.9 (1.6-2.4) mmol l-1, P < 0.01) on day 3 and lower 90-day mortality (40 vs. 62%, P = 0.03) than those receiving lower volumes in spite of comparable admission SAPS II (53 (46-67) vs. 55 (49-62), P = 0.47) and SOFA scores on day 3 (10 (8-13) vs. 11 (10-14), P = 0.33). CONCLUSIONS: In this cohort of unselected ICU patients with septic shock, initial fluid volume was not associated with mortality. In patients with shock for three days or more, higher fluid volumes including crystalloids, colloids and blood products were associated with reduced mortality.

PMID: 22568926 [PubMed - as supplied by publisher]

Brain natriuretic peptide for prediction of mortality in patients with sepsis: a systematic review and meta-analysis.

Crit Care. 2012 May 6;16(3):R74

Authors: Wang F, Wu Y, Tang L, Zhu W, Chen F, Xu T, Bo L, Li J, Deng X

Abstract
ABSTRACT: INTRODUCTION: Early identification of septic patients at high risk of dying remains a challenge. The prognostic role of brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) in septic patients remains controversial. The purpose of this systematic review and meta-analysis was to investigate the value of elevated BNP or NT-proBNP in predicting mortality in septic patients. METHODS: PubMed, Embase and the Cochrane Central Register of Controlled Trials were searched (up to February 18, 2011). Studies were included if they had prospectively collected data on all-cause mortality in adult septic patients with either plasma BNP or NT-proBNP measurement. Studies that failed to construct a 2 2 table of results were excluded. Two authors independently determined the validity of included studies and extracted data. RESULTS: 12 studies with a total of 1,865 patients were included. Elevated natriuretic peptides were significantly associated with increased risk of mortality (odds ratio (OR) 8.65, 95% confidence interval (CI) 4.94 to 15.13, P < 0.00001). The association was consistent for BNP (OR 10.44, 95% CI 4.99 to 21.58, P < 0.00001) and NT-proBNP (OR 6.62, 95% CI 2.68 to 16.34, P < 0.0001). The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 79% (95% CI 75 to 83), 60% (95% CI 57 to 62), 2.27 (95% CI 1.83 to 2.81) and 0.32 (95% CI 0.22 to 0.46), respectively. CONCLUSIONS: Our results suggested that an elevated BNP or NT-proBNP level may prove to be a powerful predictor of mortality in septic patients. Future larger and more adequately powered prospective studies are warranted to clarify the assay standardization, the optimal cut-off, and the prognostic value of BNPs in conjunction with other biomarkers.

PMID: 22559153 [PubMed - as supplied by publisher]

Nebulized anticoagulants for acute lung injury - a systematic review of pre-clinical and clinical investigations.

Crit Care. 2012 Apr 30;16(2):R70

Authors: Tuinman PR, Dixon B, Levi M, Juffermans NP, Schultz MJ

Abstract
ABSTRACT: BACKGROUND: Data from interventional trials of systemic anticoagulation for sepsis inconsistently suggest beneficial effects in case of acute lung injury (ALI). Severe systemic bleeding due to anticoagulation may have offset the possible positive effects. Nebulization of anticoagulants may allow for improved local biological availability and as such may improve efficacy in the lungs and lower the risk of systemic bleeding complications. METHOD: We performed a systematic review of preclinical studies and clinical trials investigating the efficacy and safety of nebulized anticoagulants in the setting of lung injury in animals and ALI in humans. RESULTS: The efficacy of nebulized activated protein C, antithrombin, heparin and danaparoid has been tested in diverse animal models of direct (e.g., pneumonia-, intra-pulmonary lipopolysaccharide (LPS)-, and smoke inhalation-induced lung injury) and indirect lung injury (e.g., intravenous LPS- and trauma-induced lung injury). Nebulized anticoagulants were found to have the potential to attenuate pulmonary coagulopathy and frequently also inflammation. Notably, nebulized danaparoid and heparin but not activated protein C and antithrombin, were found to have an effect on systemic coagulation. Clinical trials of nebulized anticoagulants are very limited. Nebulized heparin was found to improve survival of patients with smoke inhalation-induced ALI. In a trial of in critically ill patients who needed mechanical ventilation for longer than two days, nebulized heparin was associated with a higher number of ventilator-free days. In line with results from preclinical studies, nebulization of heparin was found to have an effect on systemic coagulation, but without causing systemic bleedings. CONCLUSION: Local anticoagulant therapy through nebulization of anticoagulants attenuates pulmonary coagulopathy and frequently also inflammation in preclinical studies of lung injury. Recent human trials suggest nebulized heparin for ALI to be beneficial and safe, but data are very limited.

PMID: 22546487 [PubMed - as supplied by publisher]

Routine chest x-rays in intensive care units: a systematic review and meta-analysis.

Crit Care. 2012 Apr 27;16(2):R68

Authors: Ganapathy A, Adhikari NK, Spiegelman J, Scales DC

Abstract
ABSTRACT: INTRODUCTION: Chest x-rays (CXRs) are the most frequent radiological tests performed in the intensive care unit (ICU). However, the utility of performing daily routine CXRs is unclear. METHODS: We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay). RESULTS: Nine studies (39358 CXRs, 9611 patients) were included in the meta-analysis. Three trials (N=870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only 1 trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% CI 0.84 to 1.28, P=0.72; 2 trials, N=776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P=0.91; 2 trials, N=259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P=0.27; 3 trials, N=870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P=0.23; 2 trials, N= 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P=0.62; 3 trials, N=705). Adding data from 6 observational studies, 1 of which systematically screened for missed findings, gave similar results. CONCLUSIONS: This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain.

PMID: 22541022 [PubMed - as supplied by publisher]

Risk of contrast induced nephropathy in the critically ill: a prospective, case matched study.

Crit Care. 2012 Apr 25;16(2):R67

Authors: Cely CM, Schein RM, Quartin AA

Abstract
ABSTRACT: INTRODUCTION: Computerized tomography is frequently employed in the critically ill, often using intravenous radiocontrast material. Many of these patients have clinical features that are considered risk factors for contrast induced nephropathy, but are simultaneously at risk for renal injury from other factors related to their acute illnesses. The attributable risk for renal dysfunction from radiocontrast exposure has not been well quantified in this population. METHODS: Prospective matched cohort study of patients scanned with or without radiocontrast enhancement while receiving intensive care in a Veterans Affairs Medical Center. Patients were matched for pre-scan measured creatinine clearance, diabetes, mechanical ventilation, and vasopressor use. Measured clearance was followed for 3 days following scanning. Evolution of nephropathy, as determined by change in measured clearance, was compared within matched pairs. RESULTS: 53 pairs of patients satisfied matching criteria. Unmatched characteristics were similar among the pairs, including serum creatinine variability during the week preceding scanning (67+/-85% among contrast recipients, 63+/-62% among others) and clinical risk factors for renal failure. In 29 pairs, pre-scan measured clearances were less than 60 mL/min/1.73 m2. Following scanning measured clearance declined by at least 33% in 14 contrast and 19 non-contrast patients (95% confidence interval for contrast associated difference in nephropathy rates 27% to 9%), while a 50% reduction in clearance persisted 3 days after scanning in 3 contrast and 9 non-contrast patients (95% confidence interval for difference in rates 25% to 2%). CONCLUSIONS: Among established intensive care unit patients declines in glomerular filtration following contrast enhanced scanning are common, but these changes are far more likely to be attributable to factors other than the contrast exposure itself. The upper bound for the incidence of contrast induced renal injury lasting even 3 days was 2% in the population studied.

PMID: 22534554 [PubMed - as supplied by publisher]

Ventilator-associated pneumonia and ICU mortality in severe ARDS patients ventilated according to a lung-protective strategy.

Crit Care. 2012 Apr 23;16(2):R65

Authors: Forel JM, Voillet F, Pulina D, Gacouin A, Perrin G, Barrau K, Jaber S, Arnal JM, Fathallah M, Auquier P, Roch A, Azoulay E, Papazian L

Abstract
ABSTRACT: INTRODUCTION: Ventilator-associated pneumonia (VAP) may contribute to the mortality associated with acute respiratory distress syndrome (ARDS). We aimed to determine the incidence, outcome, and risk factors of bacterial VAP complicating severe ARDS in patients ventilated using a strictly standardized lung-protective strategy. METHODS: This prospective epidemiological study was done in all patients included in the 339 patients with severe ARDS included in a multicenter randomized, placebo-controlled double-blind trial of cisatracurium besylate in severe ARDS patients. Patients with suspected VAP underwent bronchoalveolar lavage to confirm the diagnosis. RESULTS: Ninety-eight patients (28.9%) presented at least one episode of microbiologically documented bacterial VAP, including 41 (41.8%) who died in the ICU, compared to 74 (30.7%) of the 241 patients without VAP (P=0.05). After adjustment, age and severity at baseline, but not VAP, were associated with ICU death. Cisatracurium besylate therapy within 2 days of ARDS onset decreased the risk of ICU death. Factors independently associated with an increased risk to develop a VAP were male sex, and worse admission Glasgow Coma Scale score. Tracheostomy, enteral nutrition and the use of a subglottic secretion drainage device were protective. CONCLUSIONS: In patients with severe ARDS receiving lung-protective ventilation, VAP was associated with an increased crude ICU mortality which did not remain significant after adjustment.

PMID: 22524447 [PubMed - as supplied by publisher]

Protocol-directed care in the ICU: making a future generation of intensivists less knowledgeable?

Crit Care. 2012 Apr 4;16(2):307

Authors: Diringer E, Yende S

Abstract
EXPANDED ABSTRACT: CITATION: Prasad M, Holmboe ES, Lipner RS, Hess BJ, Christie JD, Bellamy SL, Rubenfeld GD, Kahn JM. Clinical Protocols and Trainee Knowledge About Mechanical Ventilation. JAMA. 2011; 306(9):935-941. PubMed PMID: 21900133 This is available on http://www.pubmed.gov BACKGROUND: Clinical protocols are associated with improved patient outcomes; however, they may negatively affect medical education by removing trainees from clinical decision making. METHODS: Objective: To study the relationship between critical care training with mechanical ventilation protocols and subsequent knowledge about ventilator management.Design: A retrospective cohort equivalence study linking a national survey of mechanical ventilation protocol availability with knowledge about mechanical ventilation. Exposure to protocols was defined as high intensity if an intensive care unit had 2 or more protocols for at least 3 years and as low intensity if 0 or 1 protocol.Setting: Accredited US pulmonary and critical care fellowship programs.Subjects: First-time examinees of the American Board of Internal Medicine (ABIM) Critical Care Medicine Certification Examination in 2008 and 2009.Intervention: N/AOutcomes: Knowledge, measured by performance on examination questions specific to mechanical ventilation management, calculated as a mechanical ventilation score using item response theory. The score is standardized to a mean (SD) of 500 (100), and a clinically important difference is defined as 25. Variables included in adjusted analyses were birth country, residency training country, and overall first-attempt score on the ABIM Internal Medicine Certification Examination. RESULTS: The 90 of 129 programs (70%) responded to the survey. Seventy seven programs (86%) had protocols for ventilation liberation, 66 (73%) for sedation management, and 54 (60%) for lung-protective ventilation at the time of the survey. Eighty eight (98%) of these programs had trainees who completed the ABIM Critical Care Medicine Certification Examination, totaling 553 examinees. Of these 88 programs, 27 (31%) had 0 protocols, 19 (22%) had 1 protocol, 24 (27%) had 2 protocols, and 18 (20%) had 3 protocols for at least 3 years. 42 programs (48%) were classified as high intensity and 46 (52%) as low intensity, with 304 trainees (55%) and 249 trainees (45%), respectively. In bi-variable analysis, no difference in mean scores was observed in high-intensity (497; 95% CI, 486-507) vs low-intensity programs (497; 95% CI, 485-509). Mean difference was 0 (95% CI, -16 to 16), with a positive value indicating a higher score in the high-intensity group. In multivariable analyses, no association of training was observed in a high-intensity program with mechanical ventilation score (adjusted mean difference, -5.36; 95% CI, -20.7 to 10.0). CONCLUSIONS: Among first-time ABIM Critical Care Medicine Certification Examination examinees, training in a high-intensity ventilator protocol environment compared with a low-intensity environment was not associated with worse performance on examination questions about mechanical ventilation management.

PMID: 22494787 [PubMed - as supplied by publisher]

Patterns of C-reactive protein ratio response in severe community-acquired pneumonia: a cohort study.

Crit Care. 2012 Mar 26;16(2):R53

Authors: Coelho LM, Salluh JI, Soares M, Bozza F, Verdeal JC, Castro-Faria-Neto HC, Lapa E Silva JR, Bozza PT, Povoa P

Abstract
ABSTRACT: INTRODUCTION: Community-acquired pneumonia (CAP) requiring intensive care unit (ICU) admission remains a severe medical condition, presenting ICU mortality rates reaching 30%. The aim of this study was to assess the value of different patterns of C-reactive protein (CRP)-ratio response to antibiotic therapy in patients with severe CAP requiring ICU admission as an early maker of outcome. METHODS: A total of 191 patients with severe CAP were prospectively included and CRP was sampled every other day from D1 to D7 of antibiotic prescription. CRP-ratio was calculated in relation to D1 CRP concentration. Patients were classified according to an individual pattern of CRP-ratio response with the following criteria: fast response - when D5 CRP was [less than or equal to]0.4 of D1 CRP concentration; slow response - when D5 CRP was >0.4 and D7 [less than or equal to]0.8 of D1 CRP concentration; nonresponse - when D7 CRP was >0.8 of D1 CRP concentration. Comparison between ICU survivors and non-survivors was performed. RESULTS: CRP-ratio from D1 to D7 decreased faster in survivors than in non-survivors (p=0.01). The ability of CRP-ratio by D5 to predict ICU outcome assessed by the area under the ROC curve was 0.73 (95% Confidence Interval, 0.64 - 0.82). By D5, a CRP concentration above 0.5 of the initial level was a marker of poor outcome (sensitivity 0.81, specificity 0.58, positive likelihood ratio 1.93, negative likelihood ratio 0.33). The time-dependent analysis of CRP-ratio of the three patterns (fast response n=66; slow response n=81; nonresponse n=44) was significantly different between groups (p<0.001). The ICU mortality rate was considerably different according to the patterns of CRP-ratio response: fast response 4.8%, slow response 17.3% and nonresponse 36.4% (p<0.001). CONCLUSIONS: In severe CAP, sequential evaluation of CRP-ratio was useful in the early identification of patients with poor outcome. The evaluation of CRP-ratio pattern of response to antibiotics during the first week of therapy was useful in the recognition of the individual clinical evolution.

PMID: 22449513 [PubMed - as supplied by publisher]

Human albumin in the management of complications of liver cirrhosis.

Crit Care. 2012 Mar 20;16(2):211

Authors: Bernardi M, Maggioli C, Zaccherini G

PMID: 22429536 [PubMed - as supplied by publisher]

A new look at renal dysfunction in the cirrhotic patient.

Crit Care. 2012 Mar 6;16(2):118

Authors: Francoz C, Durand F

Abstract
ABSTRACT: Hepatorenal syndrome (HRS) is a pre-renal azotemia-like acute renal failure occurring in patients with end-stage cirrhosis. HRS results from arteriolar vasodilatation, arteriolar underfilling, and intense renal vasoconstriction. By definition, it is not responsive to volume expansion, and the prognosis is especially poor even with the use of terlipressin or albumin dialysis or both. It may be difficult, on the basis of the current criteria, to clearly differentiate HRS from other causes of acute renal failure in cirrhosis. In addition, patients with HRS frequently have underlying chronic kidney changes that may not be reversible after transplantation. In the previous issue of Critical Care, a group of experts proposed a new classification of acute, acute-on-chronic, or chronic renal impairment in cirrhosis on the basis of the RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria. The group proposed the term 'hepatorenal disorder' to define patients with advanced cirrhosis and kidney dysfunction at an earlier stage, regardless of the mechanisms. As stated by the authors, more data are needed to clearly identify, by non-invasive means, those with a potential for improvement with liver transplantation and those who can undergo a combined liver and kidney transplantation.

PMID: 22385933 [PubMed - as supplied by publisher]

Fluid management and risk factors for renal dysfunction in patients with severe sepsis and/or septic shock.

Crit Care. 2012 Feb 29;16(1):R34

Authors: Muller L, Jaber S, Molinari N, Favier L, Larche J, Motte G, Lazarovici S, Jacques L, Alonso S, Leone M, Constantin JM, Allaouchiche B, Suehs C, Lefrant JY, Group A

Abstract
ABSTRACT: INTRODUCTION: The causative role of new HydroxyEthyl starch (HES 130/0.4) towards renal dysfunction frequency (a > 50% increase in serum creatinine or need of Renal Replacement Therapy (RRT)) remains debated. Using the database of a multicentre study focusing on patients with severe sepsis and septic shock, the present study aimed at identifying factors associated with the occurrence of renal dysfunction. METHODS: Among the 435 patients including in a multicenter study, patients with severe sepsis and septic shock in 15 Southern French ICUs, 388 surviving patients after 24 hour of evolution, without history of renal failure were included. Factors associated with renal dysfunction and RRT were isolated using a multivariate analysis with logistic regression. RESULTS: Renal dysfunction was reported in 117 (33%) patients. 90 patients required RRT. Among study participants, 379 (98%) were administered fluids in the first 24 hours of management: HES 130/0.4 only (n = 39), crystalloids only (n = 63), or both HES 130/0.4 and crystalloids (n = 276). RRT was independently associated with the need for vasopressors and the baseline value of serum creatinine in the first 24 hours. Multivariate analysis indicated that male gender, SAPS II score, a surgical patient, lack of decrease in SOFA score during the first 24 hours, and the interventional period of the study were independently associated with renal dysfunction. Mortality increased in the presence of renal dysfunction (48 versus 24%, p < 0.01). CONCLUSIONS: Despite being used in more than 80% of patients with severe sepsis and/or septic shock, the administration of HES 130/0.4 in the first 24 hours of management was not associated with the occurrence of renal dysfunction.

PMID: 22377234 [PubMed - as supplied by publisher]