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  • Harjola, Veli-Pekka; Parissis, John; Brunner-La Rocca, Hans-Peter; Celutkiene, Jelena; Chioncel, Ovidiu; Collins, Sean P.; De Backer, Daniel; Filippatos, Gerasimos S.; Gayat, Etienne; Hill, Loreena; Lainscak, Mitja; Lassus, Johan; Masip, Josep; Mebazaa, Alexandre; Miro, Oscar; Mortara, Andrea; Mueller, Christian; Mullens, Wilfried; Nieminen, Markku S.; Rudiger, Alain; Ruschitzka, Frank; Seferovic, Petar M.; Sionis, Alessandro; Vieillard-Baron, Antoine; Weinstein, Jean Marc; de Boer, Rudolf A.; Crespo-Leiro, Maria G.; Piepoli, Massimo; Riley, Jillian P. (2018)
    This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure.
  • Perner, Anders; Prowle, John; Joannidis, Michael; Young, Paul; Hjortrup, Peter B.; Pettilä, Ville (2017)
    Acute kidney injury (AKI) and fluids are closely linked through oliguria, which is a marker of the former and a trigger for administration of the latter. Recent progress in this field has challenged the physiological and clinical rational of using oliguria as a trigger for the administration of fluid and brought attention to the delicate balance between benefits and harms of different aspects of fluid management in critically ill patients, in particular those with AKI. This narrative review addresses various aspects of fluid management in AKI outlining physiological aspects, the effects of crystalloids and colloids on kidney function and the effect of various resuscitation and de-resuscitation strategies on the course and outcome of AKI.
  • Perner, Anders; Hjortrup, Peter B.; Pettilä, Ville (2018)
  • Kaskinen, Anu K.; Keski-Nisula, Juho; Martelius, Laura; Moilanen, Eeva; Hämäläinen, Mari; Rautiainen, Paula; Andersson, Sture; Pitkänen-Argillander, Olli M. (2021)
    Objectives: The present study was performed to determine whether lung injury manifests as lung edema in neonates after congenital cardiac surgery and whether a stress-dose corticosteroid (SDC) regimen attenuates postoperative lung injury in neonates after congenital cardiac surgery. Design: A supplementary report of a randomized, double-blinded, placebo-controlled clinical trial. Setting: A pediatric tertiary university hospital. Participants: Forty neonates (age Measurements and Main Results: The chest radiography lung edema score was lower in the SDC than in the placebo group on the first postoperative day (POD one) (p = 0.03) and on PODs two and three (p = 0.03). Furthermore, a modest increase in the edema score of 0.9 was noted in the placebo group, whereas the edema score remained at the preoperative level in the SDC group. Postoperative dynamic respiratory system compliance was higher in the SDC group until POD three (p < 0.01). However, postoperative oxygenation; length of mechanical ventilation; and tracheal aspirate biomarkers of inflammation and oxidative stress, namely interleukin-6, interleukin-8, resistin, and 8-isoprostane, showed no differences between the groups. Conclusions: The SDC regimen reduced the development of mild and likely clinically insignificant radiographic lung edema and improved postoperative dynamic respiratory system compliance without adverse events, but it failed to improve postoperative oxygenation and length of mechanical ventilation. (C) 2021 The Authors. Published by Elsevier Inc.
  • Robba, Chiara; Poole, Daniele; McNett, Molly; Asehnoune, Karim; Boesel, Julian; Bruder, Nicolas; Chieregato, Arturo; Cinotti, Raphael; Duranteau, Jacques; Einav, Sharon; Ercole, Ari; Ferguson, Niall; Guerin, Claude; Siempos, Ilias I.; Kurtz, Pedro; Juffermans, Nicole P.; Mancebo, Jordi; Mascia, Luciana; McCredie, Victoria; Nin, Nicolas; Oddo, Mauro; Pelosi, Paolo; Rabinstein, Alejandro A.; Neto, Ary Serpa; Seder, David B.; Skrifvars, Markus B.; Suarez, Jose I.; Taccone, Fabio Silvio; van der Jagt, Mathieu; Citerio, Giuseppe; Stevens, Robert D. (2020)
    Purpose To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI). Methods An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1-3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75-85%, and <75% of panellists, respectively, agreed with a statement. Results The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts. Conclusions This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches.
  • Linko, Rita Teresa; Hedger, Mark P.; Pettila, Ville; Ruokonen, Esko; Ala-Kokko, Tero; Ludlow, Helen; de Kretser, David M. (2014)
  • Biancari, Fausto; Mariscalco, Giovanni; Dalen, Magnus; Settembre, Nicla; Welp, Henryk; Perrotti, Andrea; Wiebe, Karsten; Leo, Enrico; Loforte, Antonio; Chocron, Sidney; Pacini, Davide; Juvonen, Tatu; Broman, L. Mikael; Di Perna, Dario; Yusuff, Hakeem; Harvey, Chris; Mongardon, Nicolas; Maureira, Juan P.; Levy, Bruno; Falk, Lars; Ruggieri, Vito G.; Zipfel, Svante; Folliguet, Thierry; Fiore, Antonio (2021)
    Objectives: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). Design: Multicenter retrospective, observational study. Setting: Ten tertiary referral university and community hospitals. Participants: Patients with confirmed severe COVID-19-related ARDS. Interventions: Venovenous or venoarterial ECMO. Measurements and Main Results: One hundred thirty-two patients (mean age 51.1 +/- 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 +/- 4.4, mean pH was 7.23 +/- 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 +/- 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 +/- 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. Conclusions: The present findings suggested that about half of adult patients with severe COVID-19 -related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. (C) 2021 The Authors. Published by Elsevier Inc.
  • Yokoyama, Yoshie; Jelenkovic, Aline; Sund, Reijo; Sung, Joohon; Hopper, John L.; Ooki, Syuichi; Heikkila, Kauko; Aaltonen, Sari; Tarnoki, Adam D.; Tarnoki, David L.; Willemsen, Gonneke; Bartels, Meike; van Beijsterveldt, Toos C. E. M.; Saudino, Kimberly J.; Cutler, Tessa L.; Nelson, Tracy L.; Whitfield, Keith E.; Wardle, Jane; Llewellyn, Clare H.; Fisher, Abigail; He, Mingguang; Ding, Xiaohu; Bjerregaard-Andersen, Morten; Beck-Nielsen, Henning; Sodemann, Morten; Song, Yun-Mi; Yang, Sarah; Lee, Kayoung; Jeong, Hoe-Uk; Knafo-Noam, Ariel; Mankuta, David; Abramson, Lior; Burt, S. Alexandra; Klump, Kelly L.; Ordonana, Juan R.; Sanhez-Romera, Juan F.; Colodro-Conde, Lucia; Harris, Jennifer R.; Brandt, Ingunn; Nilsen, Thomas Sevenius; Craig, Jeffrey M.; Saffery, Richard; Ji, Fuling; Ning, Feng; Pang, Zengchang; Dubois, Lise; Boivin, Michel; Brendgen, Mara; Dionne, Ginette; Vitaro, Frank; Martin, Nicholas G.; Medland, Sarah E.; Montgomery, Grant W.; Magnusson, Patrik K. E.; Pedersen, Nancy L.; Aslan, Anna K. Dahl; Tynelius, Per; Haworth, Claire M. A.; Plomin, Robert; Rebato, Esther; Rose, Richard J.; Goldberg, Jack H.; Rasmussen, Finn; Hur, Yoon-Mi; Sorensen, Thorkild I. A.; Boomsma, Dorret I.; Kaprio, Jaakko; Silventoinen, Karri (2016)
    We analyzed birth order differences in means and variances of height and body mass index (BMI) in monozygotic (MZ) and dizygotic (DZ) twins from infancy to old age. The data were derived from the international CODATwins database. The total number of height and BMI measures from 0.5 to 79.5 years of age was 397,466. As expected, first-born twins had greater birth weight than second-born twins. With respect to height, first-born twins were slightly taller than second-born twins in childhood. After adjusting the results for birth weight, the birth order differences decreased and were no longer statistically significant. First-born twins had greater BMI than the second-born twins over childhood and adolescence. After adjusting the results for birth weight, birth order was still associated with BMI until 12 years of age. No interaction effect between birth order and zygosity was found. Only limited evidence was found that birth order influenced variances of height or BMI. The results were similar among boys and girls and also in MZ and DZ twins. Overall, the differences in height and BMI between first-and second-born twins were modest even in early childhood, while adjustment for birth weight reduced the birth order differences but did not remove them for BMI.
  • Hongisto, Mari; Lassus, Johan; Tarvasmäki, Tuukka; Sionis, Alessandro; Tolppanen, Heli; Lindholm, Matias Greve; Banaszewski, Marek; Parissis, John; Spinar, Jindrich; Silva-Cardoso, Jose; Carubelli, Valentina; Di Somma, Salvatore; Masip, Josep; Harjola, Veli-Pekka (2017)
    Background: Despite scarce data, invasive mechanical ventilation (MV) is widely recommended over noninvasive ventilation (NIV) for ventilatory support in cardiogenic shock (CS). We assessed the real-life use of different ventilation strategies in CS and their influence on outcome focusing on the use of NIV and MV. Methods: 219 CS patients were categorized by the maximum intensity of ventilatory support they needed during the first 24 h into MV (n= 137; 63%), NIV(n= 26; 12%), and supplementary oxygen (n= 56; 26%) groups. We compared the clinical characteristics and 90-day outcome between the MV and the NIV groups. Results: Mean age was 67 years, 74% were men. The MV and NIV groups did not differ in age, medical history, etiology of CS, PaO2/FiO(2) ratio, baseline hemodynamics or LVEF. MV patients predominantly presented with hypoperfusion, with more severe metabolic acidosis, higher lactate levels and greater need for vasoactive drugs, whereas NIV patients tended to be more often congestive. 90-day outcome was significantly worse in the MV group (50% vs. 27%), but after propensity score adjustment, mortality was equal in both groups. Confusion, prior CABG, ACS etiology, higher lactate level, and lower baseline PaO2 were independent predictors of mortality, where as ventilation strategy did not have any influence on outcome. Conclusions: Although MV is generally recommended mode of ventilatory support in CS, a fair number of patients were successfully treated with NIV. Moreover, ventilation strategy was not associated with outcome. Thus, NIV seems a safe option for properly chosen CS patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.
  • Borges, J. B.; Porra, L.; Pellegrini, M.; Tannoia, A.; Derosa, S.; Larsson, A.; Bayat, S.; Perchiazzi, G.; Hedenstierna, G. (2016)
    BackgroundIt is not well known what is the main mechanism causing lung heterogeneity in healthy lungs under mechanical ventilation. We aimed to investigate the mechanisms causing heterogeneity of regional ventilation and parenchymal densities in healthy lungs under anesthesia and mechanical ventilation. MethodsIn a small animal model, synchrotron imaging was used to measure lung aeration and regional-specific ventilation (sV.). Heterogeneity of ventilation was calculated as the coefficient of variation in sV. (CVsV.). The coefficient of variation in lung densities (CVD) was calculated for all lung tissue, and within hyperinflated, normally and poorly aerated areas. Three conditions were studied: zero end-expiratory pressure (ZEEP) and FIO2 0.21; ZEEP and FIO2 1.0; PEEP 12 cmH(2)O and F(I)O(2)1.0 (Open Lung-PEEP = OLP). ResultsThe mean tissue density at OLP was lower than ZEEP-1.0 and ZEEP-0.21. There were larger subregions with low sV. and poor aeration at ZEEP-0.21 than at OLP: 12.9 9.0 vs. 0.6 +/- 0.4% in the non-dependent level, and 17.5 +/- 8.2 vs. 0.4 +/- 0.1% in the dependent one (P = 0.041). The CVsV. of the total imaged lung at PEEP 12 cmH(2)O was significantly lower than on ZEEP, regardless of FIO2, indicating more heterogeneity of ventilation during ZEEP (0.23 +/- 0.03 vs. 0.54 +/- 0.37, P = 0.049). CVD changed over the different mechanical ventilation settings (P = 0.011); predominantly, CVD increased during ZEEP. The spatial distribution of the CVD calculated for the poorly aerated density category changed with the mechanical ventilation settings, increasing in the dependent level during ZEEP. ConclusionZEEP together with low FIO2 promoted heterogeneity of ventilation and lung tissue densities, fostering a greater amount of airway closure and ventilation inhomogeneities in poorly aerated regions.