The association between increasing fluid balance, acute kidney injury and mortality in patients with sepsis and septic shock: A retrospective single center audit.

PURPOSE: To determine whether a positive fluid balance is associated with AKI and mortality in sepsis and septic shock patients. METHODS: A retrospective chart review of 482 patients treated for sepsis or septic shock. Patients were stratified according to quartiles of cumulative fluid balance on days 1 and 3. Logistic models were built to explore the association between fluid balance, AKI, and ICU mortality. RESULTS: During the first days of ICU admission, fluid input did not differ between survivors and non-survivors, yet a significant difference in output resulted in a more positive fluid balance in non-survivors on day 1 (37.24 ± 31.98 ml/kg vs. 24.97 ± 23.76 ml/kg, p < 0.001) and day 3 (83.33 ± 70.86 ml/kg vs. 62.20 ± 45.90 ml/kg, P = 0.005). Using a logistic regression model, a positive fluid balance on day three was independently associated with higher ICU mortality (odds ratio 1.007 for every one ml/kg, P = 0038) and AKIN stage III (odds ratio 1.006 for every one ml/kg, p = 0.031). CONCLUSION: In patients with sepsis and septic shock, a more positive fluid balance is associated with an increased incidence of acute kidney injury and death after correction for possible confounders.

Stage, treatment and survival of low-grade serous ovarian carcinoma in the Netherlands: A nationwide study.

INTRODUCTION: Serous ovarian carcinomas constitute the largest group of epithelial ovarian cancer (60%-75%) and are further classified into high- and low-grade serous carcinoma. Low-grade serous carcinoma (LGSC) is a relatively rare subtype (approximately 5% of serous carcinomas) and epidemiologic studies of large cohorts are scarce. With the present study we aimed to report trends in stage, primary treatment and relative survival of LGSC of the ovary in a large cohort of patients in an effort to identify opportunities to improve clinical practice and outcome of this relatively rare disease. MATERIAL AND METHODS: Patients diagnosed with LGSC between 2000 and 2019 were identified from the Netherlands Cancer Registry (n = 855). Trends in FIGO stages and primary treatment were analyzed with the Cochran-Armitage trend test, and differences in and trends of 5-year relative survival were analyzed using multivariable Poisson regression. RESULTS: Over time, LGSC was increasingly diagnosed as stage III (39.9%-59.0%) and IV disease (5.7%-14.4%) and less often as stage I (34.6%-13.5%; p < 0.001). Primary debulking surgery was the most common strategy (76.2%), although interval debulking surgery was preferred more often over the years (10.6%-31.1%; p < 0.001). Following primary surgery, there was >1 cm residual disease in only 15/252 patients (6%), compared with 17/95 patients (17.9%) after interval surgery. Full cohort 5-year survival was 61% and survival after primary debulking surgery was superior to the outcome following interval debulking surgery (60% vs 34%). Survival following primary debulking surgery without macroscopic residual disease (73%) was better compared with ≤1 cm (47%) and >1 cm residual disease (22%). Survival following interval debulking surgery without macroscopic residual disease (51%) was significantly higher than after >1 cm residual disease (24%). Except FIGO stage II (85%-92%), survival did not change significantly over time. CONCLUSIONS: Over the years, LGSC has been diagnosed as FIGO stage III and stage IV disease more often and interval debulking surgery has been increasingly preferred over primary debulking in these patients. Relative survival did not change over time (except for stage II) and worse survival outcomes after interval debulking surgery were observed. The results support the common recommendation to perform primary debulking surgery in patients eligible for primary surgery.

New potential for an old kid on the block: Impact of premorbid metformin use on lactate kinetics, kidney injury and mortality in sepsis and septic shock, an observational study.

INTRODUCTION: Sepsis and septic shock cause significant mortality worldwide, with no targeted molecular therapies available. Metformin has pleomorphic effects that may be beneficial in sepsis, but at present, the impact of metformin exposure on sepsis remains controversial. Metformin might alter lactate metabolism, but little is known about its influence on lactate kinetics. We therefore investigated the impact of preadmission metformin use on lactate kinetics, acute kidney injury (AKI) and mortality in sepsis. MATERIALS AND METHODS: We retrospectively analysed all ICU admissions with sepsis and septic shock between January 2013 and September 2020, identifying 77 users and 390 nonusers (subdivided in diabetics, n = 48 and nondiabetics, n = 342). RESULTS: (Sub)groups did not differ in illness severity or sepsis aetiology. Admission lactate levels were similar, but evolution in lactate over the first 24 h showed a larger decrease in users vs nonusers (median - 53% vs. -36%, p = .010). No difference in AKI or renal replacement therapy was found. Mortality was lower in users vs nonusers in case of septic shock (21.9% (n = 7) vs. 42.7% (n = 61) for 90d mortality, p = .029, OR 0.38 [95% CI: 0.15-0.93]), but showed no significant differences in the combined sepsis and septic shock population. CONCLUSIONS: In our data, preadmission metformin use is associated with a significantly larger decrease in lactate after admission with sepsis or septic shock and with reduced mortality in septic shock. This underscores the need for further studies investigating the interplay between metformin, lactate and sepsis, thereby exploring the potential use of metformin or its pathways in sepsis.

Borderline ovarian tumor frozen section diagnoses with features suspicious of invasive cancer: a retrospective study.

BACKGROUND: A frozen section diagnosis of a borderline ovarian tumor with suspicious features of invasive carcinoma ("at least borderline" or synonymous descriptions) presents us with the dilemma of whether or not to perform a full ovarian cancer staging procedure. Quantification of this dilemma may help us with the issue of this clinical decision. The present study assessed and compared both the prevalence of straightforward borderline and "at least borderline" frozen section diagnoses and the proportion of these women with a final histopathological diagnosis of invasive carcinoma, with a special interest in histologic subtypes. METHODS: A retrospective cohort study was performed in three hospitals in The Netherlands. All women that underwent ovarian surgery with perioperative frozen section evaluation in one of these hospitals between January 2007 and July 2018 were identified and included in case of a borderline or "at least borderline" frozen section diagnosis and a borderline ovarian tumor or invasive carcinoma as a final diagnosis. RESULTS: A total of 223 women were included, of which 41 women (18.4%) were diagnosed with "at least borderline" at frozen section. Thirteen of forty-one women (31.7%) following "at least borderline" frozen section diagnosis and 14 of 182 women (7.7%) following a straightforward borderline frozen section diagnosis were diagnosed with invasive carcinoma at paraffin section evaluation (p < 0.001). When compared to straightforward borderline frozen section diagnoses, the proportion of women diagnosed with invasive carcinoma increased from 3.1 to 35.7% for serous tumors (p = 0.001), 10.0 to 21.7% for mucinous tumors (p = 0.129) and 50.0 to 75.0% (p = 0.452) in case of other histologic subtypes following an "at least borderline" frozen section diagnosis. CONCLUSIONS: Overall, when compared to women with a decisive borderline frozen section diagnosis, women diagnosed with "at least borderline" frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis (7.7% vs 31.7%). Especially in the serous subtype, full staging during initial surgery might be considered after preoperative consent to prevent a second surgical procedure or chemotherapy in unstaged women. Further studies are needed to evaluate whether additional sampling in case of an "at least borderline" diagnosis may decrease the risk of surgical over-treatment.

Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil's dilemma for the surgeon: A systematic review and meta-analysis.

INTRODUCTION: Frozen section diagnoses of borderline ovarian tumors are not always straightforward and a borderline frozen section diagnosis with suspicious features of invasive carcinoma (reported as "at least borderline" or synonymous descriptions) presents us with the dilemma of whether or not to perform a full surgical staging procedure. By performing a systematic review and meta-analysis, the prevalence of straightforward borderline and "at least borderline" frozen section diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma in these cases, were assessed and compared, as quantification of this dilemma may help us with the issue of this clinical decision. MATERIAL AND METHODS: PubMed, EMBASE and Cochrane library databases were searched and studies discussing "at least borderline" frozen section diagnoses were included in the review. Numbers of specific frozen section diagnoses and subsequent final histological diagnoses were extracted and pooled analysis was performed to compare the proportion of patients diagnosed with invasive carcinoma following borderline and "at least borderline" frozen section diagnoses, presented as risk ratio and risk difference with 95% confidence intervals (95% CI). RESULTS: Of 4940 screened records, eight studies were considered eligible for quantitative analysis. A total of 921 women was identified and 230 (25.0%) of these women were diagnosed with "at least borderline" ovarian tumor at the time of frozen section. Final histological diagnoses were reported in five studies, including 61 women with an "at least borderline" diagnosis and 290 women with a straightforward borderline frozen section diagnosis. Twenty-five of 61 women (41.0%) of the "at least borderline" group had invasive cancer at final diagnosis, compared with 28 of 290 women (9.7%) of the straightforward borderline frozen section group (risk difference -0.34, 95% CI -0.53 to -0.15; relative risk 0.25, 95% CI 0.13-0.50). CONCLUSIONS: Women diagnosed with "at least borderline" frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis when compared with women with a straightforward borderline frozen section diagnosis (41.0% vs 9.7%). Especially in the serous subtype, and after preoperative consent, full staging during initial surgery might be considered in these cases to prevent a second surgical procedure.

Target-Controlled Infusion of Cefepime in Critically Ill Patients.

Attainment of appropriate pharmacokinetic-pharmacodynamic (PK-PD) targets for antimicrobial treatment is challenging in critically ill patients, particularly for cefepime, which exhibits a relative narrow therapeutic-toxic window compared to other beta-lactam antibiotics. Target-controlled infusion (TCI) systems, which deliver drugs to achieve specific target drug concentrations, have successfully been implemented for improved dosing of sedatives and analgesics in anesthesia. We conducted a clinical trial in an intensive care unit (ICU) to investigate the performance of TCI for adequate target attainment of cefepime. Twenty-one patients treated with cefepime according to the standard of care were included. Cefepime was administered through continuous infusion using TCI for a median duration of 4.5 days. TCI was based on a previously developed population PK model incorporating the estimated creatinine clearance based on the Cockcroft-Gault formula as the input variable to calculate cefepime clearance. A cefepime blood concentration of 16 mg/liter was targeted. To evaluate the measured versus predicted plasma concentrations, blood samples were taken (median of 10 samples per patient), and total cefepime concentrations were measured using ultraperformance liquid chromatography-tandem mass spectrometry. The performance of the TCI system was evaluated using Varvel criteria. Half (50.3%) of the measured cefepime concentrations were within ±30% around the target value of 16 mg liter-1 The wobble was 11.4%, the median performance error (MdPE) was 21.1%, the median absolute performance error (MdAPE) was 32.0%, and the divergence was -3.72% h-1 Based on these results, we conclude that TCI is useful for dose optimization of cefepime in ICU patients. (This study has been registered at ClinicalTrials.gov under identifier NCT02688582.).

Borderline tumours of the ovary: Common practice in the Netherlands.

OBJECTIVES: Discordance between frozen section diagnosis and the definite histopathological diagnosis and the fact that the frozen section result is not always unambiguous, may contribute to differences in clinical practice regarding perioperative treatment and follow-up of borderline ovarian tumours (BOTs) patients amongst gynaecologic oncologists, which may lead to over- and undertreatment. The aim of the study was to map the Dutch gynaecologists' preferred treatment and follow-up strategy in case of BOTs. METHODS: A questionnaire was sent to all Dutch gynaecologists involved in ovarian surgery with perioperative frozen section analysis, and the outcomes were assessed using descriptive statistics. RESULTS: Nearly half of the respondents (41.0%) would not perform a staging procedure in case of a BOT. In case of an ambiguous frozen section diagnosis, tending towards invasive carcinoma, a considerable number (sBOT 56.4%; mBOT 30.8%) would perform a lymph node sampling as part of the staging procedure. A relaparotomy/relaparoscopy, to perform a lymph node sampling in case of a serous or mucinous carcinoma after a BOT frozen section diagnosis, would be performed by 97.4% and 48.7% of the respondents, respectively. CONCLUSIONS: A considerable number of gynaecologists would perform a staging procedure that is recommended for ovarian cancer in case of an ambiguous BOT frozen section diagnosis, especially for serous tumours. In addition, nearly all gynaecologists would perform a second procedure including a lymph node sampling in case of a serous invasive carcinoma after a BOT frozen section diagnosis, which applies to half of the gynaecologists in case of a mucinous carcinoma.

Impact of a VAP bundle in Belgian intensive care units.

BACKGROUND: In order to decrease the incidence of ventilator-associated pneumonia (VAP) in Belgium, a national campaign for implementing a VAP bundle involving assessment of sedation, cuff pressure control, oral care with chlorhexidine and semirecumbent position, was launched in 2011-2012. This report will document the impact of this campaign. METHODS: On 1 day, once a year from 2010 till 2016, except in 2012, Belgian ICUs were questioned about their ventilated patients. For each of these, data about the application of the bundle and the possible treatment for VAP were recorded. RESULTS: Between 36.6 and 54.8% of the 120 Belgian ICUs participated in the successive surveys. While the characteristics of ventilated patients remained similar throughout the years, the percentage of ventilated patients and especially the duration of ventilation significantly decreased before and after the national VAP bundle campaign. Ventilator care also profoundly changed: Controlling cuff pressure, head positioning above 30° were obtained in more than 90% of cases. Oral care was more frequently performed within a day, using more concentrated solutions of chlorhexidine. Subglottic suctioning also was used but in only 24.7% of the cases in the last years. Regarding the prevalence of VAP, it significantly decreased from 28% of ventilated patients in 2010 to 10.1% in 2016 (p ≤ 0.0001). CONCLUSION: Although a causal relationship cannot be inferred from these data, the successive surveys revealed a potential impact of the VAP bundle campaign on both the respiratory care of ventilated patients and the prevalence of VAP in Belgian ICUs encouraging them to follow the guidelines.

Staging procedures in patients with mucinous borderline tumors of the ovary do not reveal peritoneal or omental disease.

OBJECTIVES: Staging in case of a borderline tumor of the ovary (BOT) is a controversial issue. Upstaging is not uncommon, but this occurs especially with presumed stage I serous borderline tumors. There are only a few documented cases of BOTs of non-serous histology that were not confined to the ovary. The aim of this study was to assess the incidence of non-invasive and invasive implants in the omentum and other (extra)pelvic peritoneal surfaces in patients with a mucinous BOT (mBOT). METHODS: A retrospective cohort study was performed in three hospitals in the Netherlands. All patients with a histopathological diagnosis of mBOT diagnosed from January 1st 1990 to December 1st 2015 were identified and included when the inclusion criteria were met. RESULTS: In total, 74 patients were included. Of these 74 patients, 46 (62.2%) underwent a staging procedure. In 12 (26.1%) patients, only omental tissue was obtained, in 32 (69.6%) patients, omental tissue and peritoneal biopsies were obtained and in two (4.3%) patients, only peritoneal biopsies were obtained. No implants were seen upon microscopic examination in any of the patients. Two patients (3%) developed a recurrence. CONCLUSIONS: Because no extra-ovarian disease was found, staging procedures in the case of an mBOT may be omitted. However, the actual perioperative decision for staging or not should be taken in the context of a frozen section diagnosis, which is not always accurate and straightforward. Recurrence with malignant disease is rare after mBOT. The value of post-treatment surveillance seems limited after bilateral salpingo-oophorectomy.

Accuracy of a feasibility version of an intravenous continuous glucose monitor in volunteers with diabetes and hospitalized patients.

BACKGROUND: A feasibility version of the GlucoClear™ continuous glucose monitoring system (Edwards Lifesciences, Irvine, CA), the intravenous blood glucose (IVBG) system, developed to facilitate glycemic management, was evaluated. MATERIALS AND METHODS: Two pilot studies were conducted. Ten volunteers with diabetes (1,725 matched pairs) and 10 patients scheduled for intensive care unit (ICU) admission following surgery (1,393 matched pairs) were studied. The patients' blood glucose concentrations were monitored by the IVBG system every 5 min for up to 72 h. The accuracy of the IVBG system was calculated and compared with the Yellow Springs Instrument (YSI) (Yellows Springs, OH) and Radiometer (Copenhagen, Denmark) measurements to determine the percentage of matched pairs that met 15/20%, 10/15%, 12/12.5%, and 10/10% assessment criteria. Performance was calculated as the percentage of the total measurements that would have been displayed in an unblinded study. Adverse events were monitored. RESULTS: The accuracy of the IVBG system met the International Organization for Standardization ISO 15197 15/20% criterion (99.07% in volunteers, 99.43% in the ICU, and both vs. YSI) and the stricter 10/15% criterion (96.17% in volunteers, 96.77% in the ICU, and both vs. YSI) over the 72-h period and across a broad range of blood glucose concentrations. Performance was 89.97% in the ICU study. The adverse device effects included induration of the peripheral vein, mild bruising, and mild hematoma. In the volunteers, there were patency problems with six catheters. CONCLUSIONS: The IVBG system is safe, accurate, and reliable. This minimally invasive system was not affected by potentially interfering medications. Real-time measurements, alarms, and trends provided by the IVBG system might support glycemic control protocols and prevent glycemic events in critically ill patients.

Analytical performance evaluation of four cartridge-type blood gas analyzers.

BACKGROUND: The immediate impact of blood gas test results on patient care favors the use of blood gas analyzers as point-of-care-testing (POCT) devices. We performed an analytical performance evaluation of four cartridge-type blood gas analyzers for the determination of pH, partial carbon dioxide pressure (pCO2), partial oxygen pressure (pO2), ionized calcium (iCa2+), potassium (K+), glucose, lactate and total hemoglobin (tHb), in comparison with a traditional blood gas analyzer. METHODS: The analyzers included in the study are: RP405, GEM Premier 4000, ABL90 FLEX and Cobas b 123. The ABL700 served as comparator. For each instrument the imprecision was estimated according to the CLSI EP5-A2. Based on the CLSI EP9-A2 evaluation protocol, a method comparison was performed using patient samples. Obtained data were compared against preset quality specifications, based on ABL700 performance and biological variation. RESULTS: The precision of the RP405 and ABL90 FLEX was remarkably better than the preset criteria based on ABL700 performance. The GEM appears to have the worst precision. The RP405 yielded the best overall performance, with exception for tHb and iCa2+. Noteworthy is the very good performance of the glucose determination on RP405. The ABL90 FLEX showed the best performance for pH, K+ and iCa2+ measurements. For tHb determination the Cobas b123 revealed the best results. Regarding practicability, all instruments were found to be user friendly. CONCLUSIONS: Globally, all four cartridge-type blood gas analyzers produced clinically acceptable results. The analytical performance, together with the ease of use and low maintenance time of the instruments, demonstrate that these analyzers are perfectly suitable for both POCT and laboratory use.

Fatal intoxication due to tramadol alone: case report and review of the literature.

Poisoning may also lead to both coma and multiple organ failure, also in youngsters without a known major medical history. As not all toxic agents are routinely screened when a poisoning is suspected, it is useful to consider less frequently encountered poisons in certain cases. We describe the occurrence of asystole and multiple organ failure which occurred in a young man after a suspected tramadol overdose. The tramadol concentration on admission in the ICU was indeed 8 microg/ml (mg/l), far above the therapeutic range. Subsequently, the patient developed severe acute liver failure, finally leading to death. Post-mortem toxicology did not reveal any other poison responsible for this unfavourable course as only very high serum and tissue tramadol and desmethyltramadol concentrations were found. Only a few fatal poisonings attributable to tramadol alone, as observed in our case, have been reported. An overview of these cases is presented.

Successful use of posaconazole in a pediatric case of fungal necrotizing fasciitis.

OBJECTIVE: To report a pediatric case of posttraumatic fungal fasciitis treated successfully with a combination including posaconazole. DESIGN: Case report. SETTING: Pediatric critical care unit at Antwerp University Hospital. PATIENT: A 12-yr-old female polytrauma patient, suffering from extensive skin and muscle injuries, developed fasciitis. Two fungi (Mucor and Trichosporon species) were isolated. The necrotic tissues were aggressively excised, hyperbaric oxygen therapy was applied, and oral posaconazole was added to the initial amphotericin B treatment. The patient made an excellent recovery. CONCLUSIONS: A combination of a high index of suspicion, early aggressive surgery, hyperbaric oxygen, and the association of amphotericin B and posaconazole led to a successful outcome in a case of fungal necrotizing fasciitis. After decades of disappointing amphotericin B treatment in spite of acceptable in vitro activity, the combination with the new triazole posaconazole seems promising.

Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for volume expansion in cardiac surgery patients: the effects on perioperative bleeding and transfusion needs.

In this prospective, randomized, open controlled study we compared the effects on net red blood cell loss of 6% hydroxyethyl starch 130/0.4 (HES: n = 64) and 3% modified fluid gelatin (GEL: n = 68) administered for intravascular volume management in patients undergoing coronary surgery. Blood losses were calculated from determination of circulating blood volume and measurement of preoperative and postoperative hematocrit. Amount of colloids that could be administered was limited to 50 mL/kg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Both groups were similar with regard to demographic and intraoperative variables. Total study drug was 48.9 +/- 17.2 mL/kg in the HES group and 48.9 +/- 14.6 mL/kg in the GEL group. Total red blood cell loss was 544 +/- 305 mL in the HES group and 504 +/- 327 mL the GEL group. Measured blood losses were also similar in both groups (HES, 19.4 +/- 12.3 mL/kg; GEL, 19.2 +/- 14.5 mL/kg). Exposure to allogeneic blood product was comparable in both groups. In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery.

Fomepizole as a therapeutic strategy in paediatric methanol poisoning. A case report and review of the literature.

UNLABELLED: Methanol poisoning is not frequently observed in children; however, without treatment, serious intoxication can be complicated by visual impairment, coma, metabolic acidosis, respiratory and circulatory insufficiency and death. Treatment in a paediatric intensive care is therefore compulsory. Methanol is metabolised in the liver by alcohol dehydrogenase to the toxic metabolites formaldehyde and formic acid. Classically, ethanol is given as a competitive inhibitor in order to avoid the formation of these compounds. We report on the use of fomepizole (4-methylpyrazole),a new and potent inhibitor of alcohol dehydrogenase, in a 3-year-old boy after the intake of a toxic amount of methanol. The course was uneventful and the use of fomepizole was not accompanied by any side-effects. An overview is given of all cases of paediatric poisoning in which fomepizole was used. CONCLUSION: Fomepizole seems to be a safe and valid alternative to ethanol in cases of paediatric methanol poisoning.

Basilar artery thrombosis in a trauma patient. Case report and review of the literature.

Thrombotic disease of the vertebrobasilar circulation is associated with a poor prognosis. It may occur in trauma patients, especially those with neck injuries and even several months after the initial insult. We report on the case of a young polytrauma patient, victim of a traffic accident, with associated cervical and thoracic spinal injuries resulting in paraplegia. Consciousness was not impaired initially, but during transfer to our hospital he became suddenly unconscious. An occluded basilar artery was found on angiography, but unfortunately we were unable to reopen the vessel with thrombolytic therapy. This case again proves that lesions of the vertebro-basilar system must always be suspected in neck injuries. Even after minor whiplash injuries, fatal basilar thrombosis may occur. A review of all reported cases of traumatic basilar artery thrombosis is given and the use of thrombolytic therapy is discussed.

Cardiac complications after noncardiac thoracic surgery: an evidence-based current review.

Despite advances in perioperative management, thoracic surgery remains a high-risk procedure for many patients. A systematic review of cardiac complications after thoracic surgery is presented. Most reviews about noncardiac thoracic surgery discuss postoperative analgesic regimens and pulmonary complications. In the present review, we also discuss atrial fibrillation as the most frequently encountered cardiac side effect. An evidence-based approach to other complications, such as myocardial ischemia, pulmonary edema, embolism, and shunt, is described. Furthermore, we offer recommendations for daily practice.