Severe myoglobinuric acute kidney injury in a kidney recipient: rapid recovery after hemodialysis with the super high-flux membrane Theralite®â€©.

Myoglobinuric acute kidney injury (AKI) is a severe condition requiring early therapeutic strategies. Early recognition and treatment are crucial to reduce morbidity and mortality rate. Here, we report a kidney recipient with severe rhabdomyolysis and AKI secondary to parvovirus B19 infection. Initiation of hemodialysis with the super high-flux filter Theralite® (Gambro, cut-off 45 kDa, 2.1 m2) resulted in the clearance of myoglobin from 61 to 71% after 3 hours. Elimination rates of IL-6 and ß2-microglobulin were ~ 30 - 64% and 55 - 71% after 3 hours, respectively. Renal graft function rapidly recovered. The place of this effective but expensive procedure still needs to be defined and validated in high-risk patients.
.

Manual versus Automated moNitoring Accuracy of GlucosE II (MANAGE II).

BACKGROUND: Intravascular continuous glucose monitoring (CGM) may facilitate glycemic control in the intensive care unit (ICU). We compared the accuracy of a CGM device (OptiScanner®) with a standard reference method. METHODS: Adult patients who had blood glucose (BG) levels >150 mg/dl and required insertion of an arterial and central venous catheter were included. The OptiScanner® was inserted into a multiple-lumen central venous catheter. Patients were treated using a dynamic-scale insulin algorithm to achieve BG values between 80 and 150 mg/dl. The BG values measured by the OptiScanner® were plotted against BG values measured using a reference analyzer. The correlation between the BG values measured using the two methods and the clinical relevance of any differences were assessed using the coefficient of determination (r 2) and the Clarke error grid, respectively; bias was assessed by the mean absolute relative difference (MARD). Three different standards of glucose monitoring were used to assess accuracy. Glycemic control was assessed using the time in range (TIR). Six indices of glycemic variability were calculated. RESULTS: The analysis included 929 paired samples from 88 patients, monitored for a total of 2584 hours. Reference BG values ranged between 60 and 484 mg/dl. The r 2 value was 0.89. The percentage of BG values within zones A and B of the Clarke error grid was 99.9%; the MARD was 7.7%. Using the ISO 15197 standard and Food and Drug Administration and consensus standards, respectively, 80.4% of measurements were within 15 mg/dl and 88.2% within 15% of reference values, 40% of measurements were within 7 mg/dl and 72.5% within 10% of reference values, and 65.2% of measurements were within 10 mg/dl and 82.7% within 12.5% of reference values. The TIR was slightly lower with the OptiScanner® than with the reference method. The J-index, standard deviation and maximal glucose change were the indices of glycemic variability least affected by the measurement device. CONCLUSIONS: Based on the MARD, the performance of the OptiScanner® is adequate for use in ICU patients. Because recent standards for accuracy were not met, the OptiScanner® should not be used as a sole monitor. The assessment of glycemic variability is influenced by the time interval between BG determinations. TRIAL REGISTRATION: Clinicaltrials.gov NCT01720381 . Registered 31 October 2012.

The Impact of Renal Failure and Renal Replacement Therapy on Outcome During Extracorporeal Membrane Oxygenation Therapy.

Acute kidney injury (AKI) is common in patients treated with veno-arterial (VA-) or veno-venous (VV-) extracorporeal membrane oxygenation (ECMO). In this setting, the use of continuous renal replacement therapy (CRRT) can help to optimize fluid status but may also negatively impact on patients' outcome. In contrast, the relationship between AKI, CRRT, and survival in critically ill adult patients receiving ECMO is not well defined. The institutional ECMO database (n = 162) from November 2008 to December 2013, excluding patients with ICU survival <24 hours was reviewed. Demographics, co-morbidities, and concomitant therapies for all patients were collected. AKI was defined according to the Acute Kidney Injury Network (AKIN) criteria. ICU mortality was noted. Data were retrieved for 135 patients (79 with VA-ECMO and 56 with VV-ECMO). Of these, 95 developed AKI, 63 (47%) of whom required CRRT; thus three groups of patients were identified: (a) no AKI; (b) AKI without CRRT (AKINOCRRT ); and (c) CRRT with AKI (AKICRRT ). AKINOCCRT patients were more likely to have preexisting heart disease, to be more severely ill, and to be treated with VA-ECMO than those without AKI. AKICRRT patients were also more likely to be treated with VA-ECMO, had more organ dysfunction at the time of ECMO insertion, and needed more transfusions and inotropic agents than patients without AKI. ICU mortality was 53% (72/135) and was similar in the three groups, even when different AKI stages or VA/VV-ECMO were analyzed separately. In this study, the use of CRRT was not associated with an increased mortality in an adult population of patients treated with ECMO, even after adjustment for confounders.

Effects of fluid administration on renal perfusion in critically ill patients.

INTRODUCTION: Fluid administration is a first-line therapy for acute kidney injury associated with circulatory failure. Although aimed at increasing renal perfusion in these patients, this intervention may improve systemic hemodynamics without necessarily ameliorating intrarenal flow distribution or urine output. We used Doppler techniques to investigate the effects of fluid administration on intrarenal hemodynamics and the relationship between changes in renal hemodynamics and urine output. We hypothesized that, compared to systemic hemodynamic variables, changes in renal hemodynamics would better predict increase in urine output after fluid therapy. METHODS: We measured systemic hemodynamic variables and performed renal interlobar artery Doppler on both kidneys before and after volume expansion in 49 adult patients with acute circulatory failure. We measured systolic and diastolic velocities and computed the resistivity index (RI). We recorded urine output for 3 h before and after the fluid challenge. RESULTS: Fluid administration resulted in a small but consistent decrease in RI (from 0.73 ± 0.09 to 0.71 ± 0.09, p < 0.01). There was a concomitant increase in mean arterial pressure (from 75 ± 15 to 80 ± 14 mmHg, p < 0.01), pulse pressure (49 ± 19 to 55 ± 19 mmHg, p < 0.01) and urine output (55 ± 76 to 81 ± 87 ml/hour, p < 0.01). Changes in RI were negatively correlated with changes in urine output and mean arterial pressure but not in pulse pressure. The increase in urine output was predicted by changes in RI but not by changes in systemic hemodynamics. CONCLUSIONS: Changes in renal hemodynamics during a fluid challenge can be observed by Doppler ultrasonography before urine output increases. Moreover, these changes are better predictors of an increase in urine output than are mean arterial pressure and pulse pressure.

Evaluation of endothelial damage in sepsis-related ARDS using circulating endothelial cells.

PURPOSE: Endothelial cell activation and dysfunction are involved in the pathophysiology of ARDS. Circulating endothelial cells (CECs) may be a useful marker of endothelial dysfunction and damage but have been poorly studied in ARDS. We hypothesized that the CEC count may be elevated in patients with sepsis-related ARDS compared to those with sepsis without ARDS. METHODS: ARDS was defined according to the Berlin consensus definition. The study population included 17 patients with moderate or severe ARDS, 9 with mild ARDS, 13 with sepsis and no ARDS, 13 non-septic patients, and 12 healthy volunteers. Demographic, hemodynamic, and prognostic variables, including PaO(2)/FiO(2) ratio, 28-day survival, blood lactate, APACHE II, and SOFA score, were recorded. CECs were counted in arterial blood samples using the reference CD146 antibody-based immunomagnetic isolation and UEA1-FITC staining method. Measurements were performed 12-24 h after diagnosis of ARDS and repeated daily for 3 days. RESULTS: The median day-1 CEC count was significantly higher in patients with moderate or severe ARDS than in mild ARDS or septic-control patients [27.2 (18.3-49.4) vs. 17.4 (11-24.5) cells/ml (p < 0.034), and 18.4 (9.1-31) cells/ml (p < 0.035), respectively]. All septic patients (with or without ARDS) had higher day-1 CEC counts than the non-septic patients [19.6 (14.2-30.6) vs. 10.8 (5.7-13.2) cells/ml, p = 0.002]. CONCLUSION: The day-1 CEC count was significantly higher in ARDS patients than in other critically ill patients, and in moderate or severe ARDS patients compared to those with milder disease, making it a potentially useful marker of ARDS severity.

Combination of veno-arterial extracorporeal membrane oxygenation and hypothermia for out-of-hospital cardiac arrest due to Taxus intoxication.

A young woman presented with cardiac arrest following ingestion of yew tree leaves of the Taxus baccata species. The toxin in yew tree leaves has negative inotropic and dromotropic effects. The patient had a cardiac rhythm that alternated between pulseless electrical activity with a prolonged QRS interval and ventricular fibrillation. When standard resuscitation therapy including digoxin immune Fab was ineffective, a combination of extracorporeal membrane oxygenation (ECMO) and hypothermia was initiated. The total duration of low flow/no flow was 82 minutes prior to the initiation of ECMO. After 36 hours of ECMO (including 12 hours of electrical asystole), the patient's electrocardiogram had normalized and the left ventricular ejection fraction was 50%. At this time, dobutamine and the ECMO were stopped. The patient had a full neurologic recovery and was discharged from the intensive care unit after 5 days and from the hospital 1 week later.

Extracorporeal cardiopulmonary resuscitation.

PURPOSE OF REVIEW: To discuss the role of extracorporeal membrane oxygenation (ECMO) in patients with cardiac arrest. RECENT FINDINGS: Return to spontaneous circulation dramatically decreases with the duration of cardiopulmonary resuscitation (CPR). In this context, it has been proposed to implement venoarterial ECMO in order to assist CPR (ECPR) both in inhospital cardiac arrest (IHCA) and in out-of-hospital cardiac arrest (OHCA). SUMMARY: This review highlights that ECPR is feasible for both IHCA and OHCA. In the recent series, the outcome of ECPR in IHCA is satisfactory, with survival rates good with neurologic outcome reaching the 40-50% range. All series converge in highlighting that time from cardiac arrest to ECMO flow is a critical determinant of outcome, with survival rates of 50% when initiated within 30 min of IHCA, 30% between 30 and 60 min, and 18% after 60 min. Results of ECPR in OHCA are more challenging. Recent series suggest that good outcome can be obtained in 15-20% of the patients, provided that time from arrest to ECMO is shorter than 60 min. Duration of cardiac arrest seems to be more important than location of cardiac arrest. ECPR thus seems to be a valuable option in selected cases.

Trombo aortico intraluminal e hematoma intramural apos manobra de ressuscitacao cardiopulmonar / Aortic luminal thrombus and intramural hematoma after cardiopulmonary resuscitation

Descrevemos o caso de um paciente com hematoma intramural e trombo flutuante após ressuscitação cardiopulmonar. Esse homem, de 92 anos de idade, teve uma parada cardíaca causada por fibrilação atrial e testemunhas iniciaram imediatamente manobras manuais de ressuscitação cardiopulmonar. Ao ser admitido no hospital, o paciente apresentava-se em choque cardiogênico, sendo, então, imediatamente submetido a ecocardiografia transesofágica. Além de uma parede anterior acinética, o exame da aorta torácica descendente mostrou um hematoma intramural e um trombo intra-aórtico flutuante a uma distância de 40cm do arco dental. Não havia dissecção da aorta. O trombo foi atribuído à compressão aórtica durante a ressuscitação cardiopulmonar. Embora o trombo aórtico e o hematoma intramural não tenham se associado a qualquer complicação nesse paciente, a inserção de um balão intra-aórtico poderia ter levado a uma ruptura da aorta ou a eventos embólicos. Recomenda-se a realização de ecocardiografia transesofágica, quando disponível, antes da inserção de um balão intra-aórtico de contrapulsação em pacientes submetidos à ressuscitação cardiopulmonar.

We describe the case of a patient with an intramural hematoma and floating thrombus after cardiopulmonary resuscitation. The 92-year old man had a cardiac arrest due to ventricular fibrillation and witnesses immediately initiated manual cardiopulmonary resuscitation. Transesophageal echocardiography was performed immediately on hospital admission because the patient was in cardiogenic shock. In addition to an akinetic anterior wall, examination of the descending thoracic aorta demonstrated an intramural hematoma and a floating intra-aortic thrombus at a distance of 40cm from the dental arch. There was no aortic dissection. The thrombus was attributed to aortic compression during cardiopulmonary resuscitation. Although the aortic thrombus and intramural hematoma were not associated with any complications in this patient, insertion of an intra-aortic balloon may have led to aortic rupture or embolic events. Transesophageal echocardiography should be performed, when available, prior to insertion of an intra-aortic balloon for counterpulsation in patients who have undergone cardiopulmonary resuscitation.

Extracorporeal life support associated with hypothermia and normoxemia in refractory cardiac arrest.

AIM: We describe a 1-year experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) associated with intra-arrest hypothermia and normoxemia. METHODS: Since January 1st 2012, ECPR has been applied in our hospital to all patients less than 65 years of age and without major co-morbidities who develop refractory cardiac arrest (CA) with bystander CPR. Over a 1-year period of observation, we recorded 28-day survival with intact neurological outcome and the rate of organ donation. RESULTS: During the observational period, 24 patients were treated with ECPR, with a median age of 48 years. Ten patients had IHCA. Acute coronary syndrome and/or major arrhythmias were the main cause of arrest. Intra-arrest cooling was used in 17 patients; temperature on ECMO initiation in these patients was 32.9 °C [32-34]. The time from collapse to ECPR was 58 min [45-70] and was shorter in survivors than in non-survivors (41 min [39-58] vs. 60 min [55-77], p=0.059). Non-survivors were more likely to have coagulopathy and received more blood transfusions. Six patients (25%) survived with good neurological outcome at day 28. Four patients with irreversible brain damage had organ function suitable for donation. CONCLUSION: ECPR provided satisfactory survival rates with good neurologic recovery in refractory CA for both IHCA and OHCA. ECMO may help rapidly stabilise systemic haemodynamic status and restore organ function.

Myocardial dysfunction during H1N1 influenza infection.

PURPOSE: The purpose of the study is to evaluate the incidence and hemodynamic consequences of right ventricular (RV) and left ventricular (LV) dysfunction in critically ill patients with H1N1 infection. PATIENTS AND METHODS: This is a retrospective analysis of all patients admitted to the intensive care unit of an academic hospital between October 2009 and March 2011 with severe H1N1 infection. Hemodynamic measurements and respiratory conditions were noted daily during the intensive care unit stay. RESULTS: Forty-six patients were admitted with severe H1N1 infection. Echocardiography was obtained in 39 patients on admission: 28 (72%) had abnormal ventricular function, of whom 13 (46%) had isolated LV abnormalities, 11 (39%) had isolated RV dysfunction, and 4 (14%) had biventricular dysfunction. Echocardiography was repeated in 19 of the 39 patients during their hospitalization: RV function tended to worsen with time, but LV function tended to normalize. The ventricular abnormalities were not associated with history, severity of the respiratory failure, or hemodynamic status. However, patients with ventricular dysfunction needed more aggressive therapy, including more frequent use of vasopressor and inotropic agents and of rescue ventilatory strategies, such as inhaled nitric oxide, prone positioning, and extracorporeal membrane oxygenation. CONCLUSIONS: These observations emphasize the high incidence of cardiac dysfunction in patients with H1N1 influenza infections.

The role of invasive techniques in cardiopulmonary evaluation.

PURPOSE OF REVIEW: To discuss the role of the invasive monitoring techniques pulmonary artery catheter (PAC) and transpulmonary thermodilution (TPD) for cardiopulmonary monitoring in the critically ill patient. RECENT FINDINGS: Characterization of the nature of hemodynamic alterations and hemodynamic optimization can be achieved both with PAC and TPD. Some recent trials suggest that volumetric measurements may be preferred in conditions with preserved left ventricular systolic function, whereas pressure measurements should be preferred in patients with altered left ventricular systolic function. Extravascular lung water is strongly associated with outcome and may be used to reflect the impact of fluid management strategies. The time response of this measurement needs still to be better defined. SUMMARY: This review highlights that PAC and TPD have an important role in cardiopulmonary monitoring of critically ill patients. Both techniques can be used efficiently to diagnose the nature of circulatory or respiratory failure and to monitor the effects of therapies. The choice of the technique should be guided by the patient's condition and the need for additional measurements rather than based on physician's preferences.

Aortic luminal thrombus and intramural hematoma after cardiopulmonary resuscitation.

We describe the case of a patient with an intramural hematoma and floating thrombus after cardiopulmonary resuscitation. The 92-year old man had a cardiac arrest due to ventricular fibrillation and witnesses immediately initiated manual cardiopulmonary resuscitation. Transesophageal echocardiography was performed immediately on hospital admission because the patient was in cardiogenic shock. In addition to an akinetic anterior wall, examination of the descending thoracic aorta demonstrated an intramural hematoma and a floating intra-aortic thrombus at a distance of 40cm from the dental arch. There was no aortic dissection. The thrombus was attributed to aortic compression during cardiopulmonary resuscitation. Although the aortic thrombus and intramural hematoma were not associated with any complications in this patient, insertion of an intra-aortic balloon may have led to aortic rupture or embolic events. Transesophageal echocardiography should be performed, when available, prior to insertion of an intra-aortic balloon for counterpulsation in patients who have undergone cardiopulmonary resuscitation.

Cardiac output measurements using the bioreactance technique in critically ill patients.

Measurement of cardiac output (CO) using minimally invasive devices has gained popularity. In 11 patients we compared CO values obtained using the bioreactance technique--a new continuous, totally non-invasive CO monitor--with those obtained by semi-continuous thermodilution using a pulmonary artery catheter. We obtained CO measurements at study inclusion and after any relevant change in hemodynamic status (spontaneous or during fluid challenge, inotrope or vasopressor infusions). There was a poor correlation between the two techniques (r = 0.145). These data suggest that caution should be applied when using bioreactance devices in critically ill patients.

Pocket ultrasound devices for focused echocardiography.

Pocket ultrasound devices have recently been developed and may be particularly useful for emergency assessment. These devices can be stored in a pocket but share only some technical features with conventional echocardiographic machines. Two-dimensional imaging and color flow mode are available, with possible adjustments of global gain and depth, but Doppler features are lacking. These devices are particularly fitted for focused echocardiography. In this issue, a trial compares a pocket ultrasound device with a conventional echocardiographic machine for focused echocardiography in patients admitted to the emergency department. This commentary will put these findings into perspective.