Browsing by Subject "SEPTIC SHOCK"

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  • Petaja, Liisa; Vaara, Suvi; Liuhanen, Sasu; Suojaranta-Ylinen, Raili; Mildh, Leena; Nisula, Sara; Korhonen, Anna-Maija; Kaukonen, Kirsi-Maija; Salmenpera, Markku; Pettila, Ville (2017)
    Objectives: Acute kidney injury (AKI) occurs frequently after cardiac surgery and is associated with increased mortality. The Kidney Disease: Improving Global Outcomes (KDIGO) criteria for diagnosing AKI include creatinine and urine output values. However, the value of the latter is debated. The authors aimed to evaluate the incidence of AKI after cardiac surgery and the independent association of KDIGO criteria, especially the urine output criterion, and 2.5-year mortality. Design: Prospective, observational, cohort study. Setting: Single-center study in a university hospital. Participants: The study comprised 638 cardiac surgical patients from September 1, 2011, to June 20, 2012. Interventions: None. Measurements and Main Results: Hourly urine output, daily plasma creatinine, risk factors for AKI, and variables for EuroSCORE II were recorded. AKI occurred in 183 (28.7%) patients. Patients with AKI diagnosed using only urine output had higher 2.5-year mortality than did patients without AKI (9/53 [17.0%] v 23/455 [5.1%], p = 0.001). AKI was associated with mortality (hazard ratios [95% confidence intervals]: 3.3 [1.8-6.1] for KDIGO I; 5.8 [2.7-12.1] for KDIGO 2; and 7.9 [3.5-17.6]) for KDIGO 3. KDIGO stages and AKI diagnosed using urine output were associated with mortality even after adjusting for mortality risk assessed using EuroSCORE II and risk factors for AKI. Conclusions: AKI diagnosed using only the urine output criterion without fulfilling the creatinine criterion and all stages of AKI were associated with long-term mortality. Preoperatively assessed mortality risk using EuroSCORE II did not predict this AKI-associated mortality. (C) 2017 Elsevier Inc. All rights reserved.
  • Bellomo, Rinaldo; Kellum, John A.; Ronco, Claudio; Wald, Ron; Martensson, Johan; Maiden, Matthew; Bagshaw, Sean M.; Glassford, Neil J.; Lankadeva, Yugeesh; Vaara, Suvi; Schneider, Antoine (2017)
    Acute kidney injury (AKI) and sepsis carry consensus definitions. The simultaneous presence of both identifies septic AKI. Septic AKI is the most common AKI syndrome in ICU and accounts for approximately half of all such AKI. Its pathophysiology remains poorly understood, but animal models and lack of histological changes suggest that, at least initially, septic AKI may be a functional phenomenon with combined microvascular shunting and tubular cell stress. The diagnosis remains based on clinical assessment and measurement of urinary output and serum creatinine. However, multiple biomarkers and especially cell cycle arrest biomarkers are gaining acceptance. Prevention of septic AKI remains based on the treatment of sepsis and on early resuscitation. Such resuscitation relies on the judicious use of both fluids and vasoactive drugs. In particular, there is strong evidence that starch-containing fluids are nephrotoxic and decrease renal function and suggestive evidence that chloride-rich fluid may also adversely affect renal function. Vasoactive drugs have variable effects on renal function in septic AKI. At this time, norepinephrine is the dominant agent, but vasopressin may also have a role. Despite supportive therapies, renal function may be temporarily or completely lost. In such patients, renal replacement therapy (RRT) becomes necessary. The optimal intensity of this therapy has been established, while the timing of when to commence RRT is now a focus of investigation. If sepsis resolves, the majority of patients recover renal function. Yet, even a single episode of septic AKI is associated with increased subsequent risk of chronic kidney disease.
  • Tolppanen, Heli; Rivas-Lasarte, Mercedes; Lassus, Johan; Sans-Rosello, Jordi; Hartmann, Oliver; Lindholm, Matias; Arrigo, Mattia; Tarvasmäki, Tuukka; Kober, Lars; Thiele, Holger; Pulkki, Kari; Spinar, Jindrich; Parissis, John; Banaszewski, Marek; Silva-Cardoso, Jose; Carubelli, Valentina; Sionis, Alessandro; Harjola, Veli-Pekka; Mebazaa, Alexandre (2017)
    Background: The clinical CardShock risk score, including baseline lactate levels, was recently shown to facilitate risk stratification in patients with cardiogenic shock (CS). As based on baseline parameters, however, it may not reflect the change in mortality risk in response to initial therapies. Adrenomedullin is a prognostic biomarker in several cardiovascular diseases and was recently shown to associate with hemodynamic instability in patients with septic shock. The aim of our study was to evaluate the prognostic value and association with hemodynamic parameters of bioactive adrenomedullin (bio-ADM) in patients with CS. Methods: CardShock was a prospective, observational, European multinational cohort study of CS. In this sub-analysis, serial plasma bio-ADM and arterial blood lactate measurements were collected from 178 patients during the first 10 days after detection of CS. Results: Both bio-ADM and lactate were higher in 90-day non-survivors compared to survivors at all time points (P <0.05 for all). Lactate showed good prognostic value during the initial 24 h (AUC 0.78 at admission and 0.76 at 24 h). Subsequently, lactate returned normal ( 55.7 pg/mL) at 48 h compared to those with low bio-ADM levels (49.1 vs. 22.6%, P = 0.001). High levels of bio-ADM were associated with impaired cardiac index, mean arterial pressure, central venous pressure, and systolic pulmonary artery pressure during the study period. Furthermore, high levels of bio-ADM at 48 to 96 h were related to persistently impaired cardiac and end-organ function. Conclusions: Bio-ADM is a valuable prognosticator and marker of impaired hemodynamics in CS patients. High levels of bio-ADM may show shock refractoriness and developing end-organ dysfunction and thus help to guide therapeutic approach in patients with CS.
  • Möller, Vidar; Östholm-Balkhed, Åse; Berild, Dag; Fredriksson, Mats; Gottfredsson, Magnus; Holmbom, Martin; Järvinen, Asko; Kristjansson, Mar; Rydell, Ulf; Sonksen, Ute Wolff; Kolmos, Hans Joern; Hanberger, Håkan (2021)
    Background The Nordic countries have comparable nationwide antibiotic resistance surveillance systems and individual antibiotic stewardship programmes. The aim of this study was to assess antibiotic resistance among major pathogens in relation to practice guidelines for hospital antibiotic treatment and antibiotic use in Nordic countries 2010-2018. Methods Antibiotic resistance among invasive isolates from 2010-2018 and aggregated antibiotic use were obtained from the European Centre for Disease Prevention and Control. Hospital practice guidelines were obtained from national or regional guidelines. Results Antibiotic resistance levels among Escherichia coli and Klebsiella pneumoniae were similar in all Nordic countries in 2018 and low compared to the European mean. Guidelines for acute pyelonephritis varied; 2nd generation cephalosporin (Finland), 3rd generation cephalosporins (Sweden, Norway), ampicillin with an aminoglycoside or aminoglycoside monotherapy (Denmark, Iceland and Norway). Corresponding guidelines for sepsis of unknown origin were 2nd (Finland) or 3rd (Sweden, Norway, Iceland) generation cephalosporins, carbapenems, (Sweden) combinations of penicillin with an aminoglycoside (Norway, Denmark), or piperacillin-tazobactam (all Nordic countries). Methicillin-resistant Staphylococcus aureus rates were 0-2% and empirical treatment with anti-MRSA antibiotics was not recommended in any country. Rates of penicillin non-susceptibility among Streptococcus pneumoniae were low (
  • FINNAKI Study Grp (2019)
    Background Injury to endothelium and glycocalyx predisposes to vascular leak, which may subsequently lead to increased fluid requirements and worse outcomes. In this post hoc study of the prospective multicenter observational Finnish Acute Kidney Injury (FINNAKI) cohort study conducted in 17 Finnish intensive care units, we studied the association of Syndecan-1 (SDC-1), Angiopoetin-2 (Ang-2), soluble thrombomodulin (sTM), vascular adhesion protein-1 (VAP-1) and interleukin-6 (IL-6) with fluid administration and balance among septic critical care patients and their association with development of acute kidney injury (AKI) and 90-day mortality. Results SDC-1, Ang-2, sTM, VAP-1 and IL-6 levels were measured at ICU admission from 619 patients with sepsis. VAP-1 decreased (p <0.001) and IL-6 increased (p <0.001) with increasing amounts of administered fluid, but other biomarkers did not show differences according to fluid administration. In linear regression models adjusted for IL-6, only VAP-1 was significantly associated with fluid administration on day 1 (p <0.001) and the cumulative fluid balance on day 5/ICU discharge (p = 0.001). Of 415 patients admitted without AKI, altogether 112 patients (27.0%) developed AKI > 12 h from ICU admission (AKI(>12 h)). They had higher sTM levels than patients without AKI, and after multivariable adjustment log, sTM level was associated with AKI(>12 h) with OR (95% CI) of 12.71 (2.96-54.67), p = 0.001). Ninety-day non-survivors (n = 180; 29.1%) had higher SDC-1 and sTM levels compared to survivors. After adjustment for known confounders, log SDC-1 (OR [95% CI] 2.13 [1.31-3.49], p = 0.002), log sTM (OR [95% CI] 7.35 [2.29-23.57], p <0.001), and log Ang-2 (OR [95% CI] 2.47 [1.44-4.14], p = 0.001) associated with an increased risk for 90-day mortality. Finally, patients who had high levels of all three markers, namely, SDC-1, Ang-2 and sTM, had an adjusted OR of 5.61 (95% CI 2.67-11.79; p <0.001) for 90-day mortality. Conclusions VAP-1 and IL-6 associated with fluid administration on the first ICU day. After adjusting for confounders, sTM was associated with development of AKI after 12 h from ICU admission. SDC-1, Ang-2 and sTM were independently associated with an increased risk for 90-day mortality.
  • Wiersema, Renske; Koeze, Jacqueline; Hiemstra, Bart; Pettilä, Ville; Perner, Anders; Keus, Frederik; van der Horst, Iwan C. C.; SICS-I Study Grp; Clement, R. P.; Dieperink, W.; Hilbink, D. H.; Klasen, M.; Klaver, M.; Kaufmann, T.; Schokking, L. J.; Sikkens, V. W. (2019)
    Acute kidney injury (AKI) occurs in up to 50% of all critically ill patients and hemodynamic abnormalities are assumed to contribute, but their nature and share is still unclear. We explored the associations between hemodynamic variables, including cardiac index and right ventricular function, and the occurrence of AKI in critically ill patients. In this prospective cohort study, we included all patients acutely admitted to an intensive care unit (ICU). Within 24 h after ICU admission clinical and hemodynamic variables were registered including ultrasonographic measurements of cardiac index and right ventricular function, assessed using tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic excursion (RV S'). Maximum AKI stage was assessed according to the KDIGO criteria during the first 72 h after admission. Multivariable logistic regression modeling was used including both known predictors and univariable significant predictors of AKI. Secondary outcomes were days alive outside ICU and 90-day mortality. A total of 622 patients were included, of which 338 patients (54%) had at least AKI stage 1 within 72 h after ICU admission. In the final multivariate model higher age (OR 1.01, 95% CI 1.00-1.03, for each year), higher weight (OR 1.03 CI 1.02-1.04, for each kg), higher APACHE IV score (OR 1.02, CI 1.01-1.03, per point), lower mean arterial pressure (OR 1.02, CI 1.01-1.03, for each mmHg decrease) and lower TAPSE (OR 1.05, CI 1.02-1.09 per millimeter decrease) were all independent predictors for AKI in the final multivariate logistic regression model. Sepsis, cardiac index, RV S' and use of vasopressors were not significantly associated with AKI in our data. AKI patients had fewer days alive outside of ICU, and their mortality rate was significantly higher than those without AKI. In our cohort of acutely admitted ICU patients, the incidence of AKI was 54%. Hemodynamic variables were significantly different between patients with and without AKI. A worse right ventricle function was associated with AKI in the final model, whereas cardiac index was not.
  • Kuusela, Pentti I; Saraswat, Mayank; Joenväärä, Sakari; Kaartinen, Johanna; Järvinen, Asko; Renkonen, Risto (2017)
    Blood culture is the primary diagnostic test performed in a suspicion of bloodstream infection to detect the presence of microorganisms and direct the treatment. However, blood culture is slow and time consuming method to detect blood stream infections or separate septic and/or bacteremic patients from others with less serious febrile disease. Plasma proteomics, despite its challenges, remains an important source for early biomarkers for systemic diseases and might show changes before direct evidence from bacteria can be obtained. We have performed a plasma proteomic analysis, simultaneously at the time of blood culture sampling from ten blood culture positive and ten blood culture negative patients, and quantified 172 proteins with two or more unique peptides. Principal components analysis, Orthogonal Projections to Latent Structures Discriminant Analysis (OPLS-DA) and ROC curve analysis were performed to select protein(s) features which can classify the two groups of samples. We propose a number of candidates which qualify as potential biomarkers to select the blood culture positive cases from negative ones. Pathway analysis by two methods revealed complement activation, phagocytosis pathway and alterations in lipid metabolism as enriched pathways which are relevant for the condition. Data are available via ProteomeXchange with identifier PXD005022.
  • Kirkpatrick, Andrew W.; Coccolini, Federico; Ansaloni, Luca; Roberts, Derek J.; Tolonen, Matti; McKee, Jessica L.; Leppaniemi, Ari; Faris, Peter; Doig, Christopher J.; Catena, Fausto; Fabian, Timothy; Jenne, Craig N.; Chiara, Osvaldo; Kubes, Paul; Manns, Braden; Kluger, Yoram; Fraga, Gustavo P.; Pereira, Bruno M.; Diaz, Jose J.; Sugrue, Michael; Moore, Ernest E.; Ren, Jianan; Ball, Chad G.; Coimbra, Raul; Balogh, Zsolt J.; Abu-Zidan, Fikri M.; Dixon, Elijah; Biffl, Walter; MacLean, Anthony; Ball, Ian; Drover, John; McBeth, Paul B.; Posadas-Calleja, Juan G.; Parry, Neil G.; Di Saverio, Salomone; Ordonez, Carlos A.; Xiao, Jimmy; Sartelli, Massimo (2018)
    Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and selfperpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. Methods: The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score >= 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score >= 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources. Discussion: Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only.
  • Perner, Anders; Haase, Nicolai; Wetterslev, Jorn; Aneman, Anders; Tenhunen, Jyrki; Guttormsen, Anne Berit; Klemenzson, Gudmundur; Pott, Frank; Bodker, Karen Doris; Badstolokken, Per Martin; Bendtsen, Asger; Soe-Jensen, Peter; Tousi, Hamid; Bestle, Morten; Pawlowicz, Malgorzata; Winding, Robert; Bulow, Hans-Henrik; Kancir, Claude; Steensen, Morten; Nielsen, Jonas; Fogh, Bjarne; Madsen, Kristian R.; Larsen, Nils H.; Carlsson, Marcela; Wiis, Jorgen; Petersen, John Asger; Iversen, Susanne; Schoidt, Ole; Leivdal, Siv; Berezowicz, Pawel; Pettilä, Ville; Ruokonen, Esko; Klepstad, Pal; Karlsson, Sari; Kaukonen, Maija; Rutanen, Juha; Karason, Sigurbergur; Kjaelgaard, Anne Lene; Holst, Lars Brokso; Wernerman, Jan; Scandinavian Critical Care Trials (2011)
  • Sartelli, Massimo; Catena, Fausto; Di Saverio, Salomone; Ansaloni, Luca; Malangoni, Mark; Moore, Ernest E.; Moore, Frederick A.; Ivatury, Rao; Coimbra, Raul; Leppaniemi, Ari; Biffl, Walter; Kluger, Yoram; Fraga, Gustavo P.; Ordonez, Carlos A.; Marwah, Sanjay; Gerych, Igor; Lee, Jae Gil; Trana, Cristian; Coccolini, Federico; Corradetti, Francesco; Kirkby-Bott, James (2014)
  • Glassford, Neil J.; Martensson, Johan; Eastwood, Glenn M.; Jones, Sarah L.; Tanaka, Aiko; Wilkman, Erica; Bailey, Michael; Bellomo, Rinaldo; Arabi, Yaseen; Bagshaw, Sean M.; Bannard-Smith, Jonathan; Bin, Du; Dubin, Arnaldo; Duranteau, Jacques; Echeverri, Jorge; Hoste, Eric; Joannidis, Michael; Kashani, Kianoush; Kellum, John; Kulkarni, Atul P.; Landoni, Giovanni; Candal, Christina Lluch; Matejovic, Martin; Yunos, Norazim Modh; Anaes, M.; Nichol, Alistair; Oudemans van Straaten, Heleen; Perner, Anders; Pettila, Ville; Phua, Jason; Hernandez, Glenn; Puxty, Alex; Reinhart, Konrad; Richards, Guy; Schneider, Antoine; Tsuji, Isabella; Uchino, Shigehiko; GLobal OBservational Evaluations I (2016)
    Purpose: The purpose of the study is to understand what clinicians believe defines fluid bolus therapy (FBT) and the expected response to such intervention. Methods: We asked intensive care specialists in 30 countries to participate in an electronic questionnaire of their practice, definition, and expectations of FBT. Results: We obtained 3138 responses. Despite much variation, more than 80% of respondents felt that more than 250 mL of either colloid or crystalloid fluid given over less than 30 minutes defined FBT, with crystalloids most acceptable. The most acceptable crystalloid and colloid for use as FBT were 0.9% saline and 4% albumin solution, respectively. Most respondents believed that one or more of the following physiological changes indicates a response to FBT: a mean arterial pressure increase greater than 10 mm Hg, a heart rate decrease greater than 10 beats per minute, an increase in urinary output by more than 10 mL/h, an increase in central venous oxygen saturation greater than 4%, or a lactate decrease greater than 1 mmol/L. Conclusions: Despite wide variability between individuals and countries, clear majority views emerged to describe practice, define FBT, and identify a response to it. Further investigation is now required to describe actual FBT practice and to identify the magnitude and duration of the physiological response to FBT and its relationship to patient-centered outcomes. (C) 2016 Elsevier Inc. All rights reserved.
  • Levy, Bruno; Clere-Jehl, Raphael; Legras, Annick; Morichau-Beauchant, Tristan; Leone, Marc; Frederique, Ganster; Quenot, Jean-Pierre; Kimmoun, Antoine; Cariou, Alain; Lassus, Johan; Harjola, Veli-Pekka; Meziani, Ferhat; Louis, Guillaume; Rossignol, Patrick; Duarte, Kevin; Girerd, Nicolas; Mebazaa, Alexandre; Vignon, Philippe (2018)
    BACKGROUND Vasopressor agents could have certain specific effects in patients with cardiogenic shock (CS) after myocardial infarction, which may influence outcome. Although norepinephrine and epinephrine are currently the most commonly used agents, no randomized trial has compared their effects, and intervention data are lacking. OBJECTIVES The goal of this paper was to compare in a prospective, double-blind, multicenter, randomized study, the efficacy and safety of epinephrine and norepinephrine in patients with CS after acute myocardial infarction. METHODS The primary efficacy outcome was cardiac index evolution, and the primary safety outcome was the occurrence of refractory CS. Refractory CS was defined as CS with sustained hypotension, end-organ hypoperfusion and hyperlactatemia, and high inotrope and vasopressor doses. RESULTS Fifty-seven patients were randomized into 2 study arms, epinephrine and norepinephrine. For the primary efficacy endpoint, cardiac index evolution was similar between the 2 groups (p = 0.43) from baseline (H0) to H72. For the main safety endpoint, the observed higher incidence of refractory shock in the epinephrine group (10 of 27 [37%] vs. norepinephrine 2 of 30 [7%]; p = 0.008) led to early termination of the study. Heart rate increased significantly with epinephrine from H2 to H24 while remaining unchanged with norepinephrine (p <0.0001). Several metabolic changes were unfavorable to epinephrine compared with norepinephrine, including an increase in cardiac double product (p = 0.0002) and lactic acidosis from H2 to H24 (p <0.0001). CONCLUSIONS In patients with CS secondary to acute myocardial infarction, the use of epinephrine compared with norepinephrine was associated with similar effects on arterial pressure and cardiac index and a higher incidence of refractory shock. (Study Comparing the Efficacy and Tolerability of Epinephrine and Norepinephrine in Cardiogenic Shock [OptimaCC]; NCT01367743) (J AmColl Cardiol 2018; 72: 173-82) (C) 2018 by the American College of Cardiology Foundation.
  • Closed Open Laparotomy COOL Sou; Doig, Christopher J.; Page, Stacey A.; McKee, Jessica L.; Tolonen, Matti; Kirkpatrick, Andrew W. (2019)
    Background Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study () will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS. Main body Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity. Conclusions A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.
  • 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.; Pettila, Ville (2017)
  • Rannikko, Juha; Holmberg, Ville; Karppelin, Matti; Arvola, Pertti; Huttunen, Reetta; Mattila, Eero; Kerttula, Niina; Puhto, Teija; Tamm, Ulle; Koivula, Irma; Vuento, Risto; Syrjänen, Jaana; Hohenthal, Ulla (2021)
    Because of widespread use of probiotics, their safety must be guaranteed. We assessed use of Saccharomyces boulardii probiotic yeast from medical records for patients who had Saccharomyces fungemia or other clinical Saccharomyces culture findings. We evaluated all Saccharomyces sp. findings at 5 university hospitals in Finland during 2009-2018. We found 46 patients who had Saccharomyces fungemia; at least 20 (43%) were using S. boulardii probiotic. Compared with a control group that had bacteremia or candidemia, the odds ratio for use of an S. boulardii probiotic was 14 (95% CI 4-44). Of 1,153 nonblood culture findings, the history for 125 patients was checked; at least 24 (19%) were using the probiotic (odds ratio 10, 95% CI 3-32). This study adds to published fungemia cases linked to use of S. boulardii probiotic and sheds light on the scale of nonblood Saccharomyces culture findings that are also linked to use of this probiotic.
  • Gaddnas, Fiia P.; Sutinen, Meeri M.; Koskela, Marjo; Tervahartiala, Taina; Sorsa, Timo; Salo, Tuula A.; Laurila, Jouko J.; Koivukangas, Vesa; Ala-Kokko, Tero I.; Oikarinen, Aarne (2010)
  • Laurikkala, Johanna; Wilkman, Erika; Pettila, Ville; Kurola, Jouni; Reinikainen, Matti; Hoppu, Sanna; Ala-Kokko, Tero; Tallgren, Minna; Tiainen, Marjaana; Vaahersalo, Jukka; Varpula, Tero M; Skrifvars, Markus; FINNRESUSCI Study Grp (2016)
    The aim of the study: There are limited data on blood pressure targets and vasopressor use following cardiac arrest. We hypothesized that hypotension and high vasopressor load are associated with poor neurological outcome following out-of-hospital cardiac arrest (OHCA). Methods: We included 412 patients with OHCA included in FINNRESUSCI study conducted between 2010 and 2011. Hemodynamic data and vasopressor doses were collected electronically in one, two or five minute intervals. We evaluated thresholds for time-weighted (TW) mean arterial pressure (MAP) and outcome by receiver operating characteristic (ROC) curve analysis, and used multivariable analysis adjusting for co-morbidities, factors at resuscitation, an illness severity score, TW MAP and total vasopressor load (VL) to test associations with one-year neurologic outcome, dichotomized into either good (1-2) or poor (3-5) according to the cerebral performance category scale. Results: Of 412 patients, 169 patients had good and 243 patients had poor one-year outcomes. The lowest MAP during the first six hours was 58 (inter-quartile range [IQR] 56-61) mmHg in those with a poor outcome and 61 (59-63) mmHg in those with a good outcome (p <0.01), and lowest MAP was independently associated with poor outcome (OR 1.02 per mmHg, 95% CI 1.00-1.04, p = 0.03). During the first 48h the median (IQR) of the 1W mean MAP was 80 (78-82) mmHg in patients with poor, and 82 (81-83) mmHg in those with good outcomes (p=0.03) but in multivariable analysis TWA MAP was not associated with outcome. Vasopressor load did not predict one-year neurologic outcome. Conclusions: Hypotension occurring during the first six hours after cardiac arrest is an independent predictor of poor one-year neurologic outcome. High vasopressor load was not associated with poor outcome and further randomized trials are needed to define optimal MAP targets in OHCA patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.
  • Rakkolainen, Ilmari; Elmasry, Moustafa; Steinvall, Ingrid; Vuola, Jyrki (2018)
    B-type natriuretic peptide has shown promising results as a biomarker for acute kidney injury in general intensive care patients. It may also indirectly reflect fluid balance of the circulation. Among burn patients, it has been observed to indicate excessive fluid resuscitation and organ dysfunction, although its clinical use to indicate acute kidney injury or guide fluid resuscitation has not been validated. The aim of this study was to evaluate whether the N-terminal pro-brain natriuretic peptide values are related to the amount of fluids given after severe burn injury and whether it can act as a novel biomarker for acute kidney injury in these patients. Nineteen consecutive burn patients were included. Plasma N-terminal pro-brain natriuretic peptide was measured daily during 1 week from admission. Other variables such as laboratory values and intravenous infusions were also recorded. The association between acute kidney injury and N-terminal pro-brain natriuretic peptide values was analyzed with a multivariable panel regression model, adjusted for burned total body surface area, age, body mass index, and laboratory values. N-terminal pro-brain natriuretic peptide values varied between single patients, and even more between the patients who developed acute kidney injury. Older age, lower body mass index, and cumulative infusions were independently associated with higher N-terminal pro-brain natriuretic peptide values, whereas acute kidney injury was not. N-terminal pro-brain natriuretic peptide values correlated with cumulative infusions given during the first week. The authors could not validate the role of N-terminal probrain natriuretic peptide as a biomarker for acute kidney injury in burns.
  • Vaara, Suvi T.; Ostermann, Marlies; Selander, Tuomas; Bitker, Laurent; Schneider, Antoine; Poli, Elettra; Hoste, Eric; Joannidis, Michael; Zarbock, Alexander; van Haren, Frank; Prowle, John; Pettilä, Ville; Bellomo, Rinaldo (2020)
    Abstract Background Fluid accumulation frequently coexists with acute kidney injury (AKI) and is associated with increased risk for AKI progression and mortality. Among septic shock patients, restricted use of resuscitation fluid has been reported to reduce the risk of worsening of AKI. Restrictive fluid therapy, however, has not been studied in the setting of established AKI. Here, we present the protocol and statistical analysis plan of the REstricted fluid therapy VERsus Standard trEatment in Acute Kidney Injury - the REVERSE-AKI trial that compares a restrictive fluid therapy regimen to standard therapy in critically ill patients with AKI. Methods REVERSE-AKI is an investigator-initiated, multinational, open-label, randomized, controlled, feasibility pilot trial conducted in 7 ICUs in 5 countries. We aim to randomize 100 critically ill patients with AKI to a restrictive fluid treatment regimen versus standard management. In the restrictive fluid therapy regimen, the daily fluid balance target is neutral or negative. The primary outcome is the cumulative fluid balance assessed after 72 hrs from randomization. Secondary outcomes include safety, feasibility, duration and severity of AKI, and outcome at 90 days (mortality and dialysis dependence). Conclusions This is the first multinational trial investigating the feasibility and safety of a restrictive fluid therapy regimen in critically ill patients with AKI.