Early Prediction of Intensive Care Unit-Acquired Weakness: A Multicenter External Validation Study.

OBJECTIVES: An early diagnosis of intensive care unit-acquired weakness (ICU-AW) is often not possible due to impaired consciousness. To avoid a diagnostic delay, we previously developed a prediction model, based on single-center data from 212 patients (development cohort), to predict ICU-AW at 2 days after ICU admission. The objective of this study was to investigate the external validity of the original prediction model in a new, multicenter cohort and, if necessary, to update the model. METHODS: Newly admitted ICU patients who were mechanically ventilated at 48 hours after ICU admission were included. Predictors were prospectively recorded, and the outcome ICU-AW was defined by an average Medical Research Council score <4. In the validation cohort, consisting of 349 patients, we analyzed performance of the original prediction model by assessment of calibration and discrimination. Additionally, we updated the model in this validation cohort. Finally, we evaluated a new prediction model based on all patients of the development and validation cohort. RESULTS: Of 349 analyzed patients in the validation cohort, 190 (54%) developed ICU-AW. Both model calibration and discrimination of the original model were poor in the validation cohort. The area under the receiver operating characteristics curve (AUC-ROC) was 0.60 (95% confidence interval [CI]: 0.54-0.66). Model updating methods improved calibration but not discrimination. The new prediction model, based on all patients of the development and validation cohort (total of 536 patients) had a fair discrimination, AUC-ROC: 0.70 (95% CI: 0.66-0.75). CONCLUSIONS: The previously developed prediction model for ICU-AW showed poor performance in a new independent multicenter validation cohort. Model updating methods improved calibration but not discrimination. The newly derived prediction model showed fair discrimination. This indicates that early prediction of ICU-AW is still challenging and needs further attention.

The ecological effects of selective decontamination of the digestive tract (SDD) on antimicrobial resistance: a 21-year longitudinal single-centre study.

BACKGROUND: The long-term ecological effects on the emergence of antimicrobial resistance at the ICU level during selective decontamination of the digestive tract (SDD) are unknown. We determined the incidence of newly acquired antimicrobial resistance of aerobic gram-negative potentially pathogenic bacteria (AGNB) during SDD. METHODS: In a single-centre observational cohort study over a 21-year period, all consecutive patients, treated with or without SDD, admitted to the ICU were included. The antibiotic regime was unchanged over the study period. Incidence rates for ICU-acquired AGNB's resistance for third-generation cephalosporins, colistin/polymyxin B, tobramycin/gentamicin or ciprofloxacin were calculated per year. Changes over time were tested by negative binomial regression in a generalized linear model. RESULTS: Eighty-six percent of 14,015 patients were treated with SDD. Most cultures were taken from the digestive tract (41.9%) and sputum (21.1%). A total of 20,593 isolates of AGNB were identified. The two most often found bacteria were Escherichia coli (N = 6409) and Pseudomonas (N = 5269). The incidence rate per 1000 patient-day for ICU-acquired resistance to cephalosporins was 2.03, for polymyxin B/colistin 0.51, for tobramycin 2.59 and for ciprofloxacin 2.2. The incidence rates for ICU-acquired resistant microbes per year ranged from 0 to 4.94 per 1000 patient-days, and no significant time-trend in incidence rates were found for any of the antimicrobials. The background prevalence rates of resistant strains measured on admission for cephalosporins, polymyxin B/colistin and ciprofloxacin rose over time with 7.9%, 3.5% and 8.0% respectively. CONCLUSIONS: During more than 21-year SDD, the incidence rates of resistant microbes at the ICU level did not significantly increase over time but the background resistance rates increased. An overall ecological effect of prolonged application of SDD by counting resistant microorganisms in the ICU was not shown in a country with relatively low rates of resistant microorganisms.

The association of intravenous insulin and glucose infusion with intensive care unit and hospital mortality: a retrospective study.

BACKGROUND: We assessed the association of intravenous insulin and glucose infusion with intensive care unit (ICU) and hospital mortality. METHODS: For this retrospective association study, we used data from all patients admitted to a medical-surgical ICU between January 2012 and September 2017. We excluded patients admitted < 24 h, patients with a diabetic ketoacidosis, patients with a therapy restriction upon ICU admission and readmissions. Using multivariate logistic regression, we examined the relation between intravenous insulin and glucose infusion and ICU and hospital mortality for all patients. Additionally, we used the same model to analyze the outcomes for patients admitted > 72 h. RESULTS: Of 9507 eligible patients, 3966 were included. After correction for potential confounders, intravenous insulin was associated with ICU and hospital mortality in patients admitted > 24 h (n = 3966) (odds ratio (OR) 1.09 [95% CI 1.05-1.13] and 1.09 [95% CI 1.06-1.13] per 0.1 IU/kg added, respectively). Likewise, intravenous glucose was associated with ICU mortality (OR 1.01 [95% CI 1.00-1.01]) but not with hospital mortality and (OR 1.00 [95% CI 1.00-1.01]) per g/day added, respectively. In patients admitted > 72 h (n = 1550), insulin dose was associated with both ICU and hospital mortality (p = 0.002 and p < 0.001, respectively), but glucose infusion was not (p = 0.08 and p = 0.2, respectively). CONCLUSIONS: Intravenous insulin administration is associated with an increased risk of ICU and hospital mortality, after correction for potential confounders. Parenteral glucose administration was limited in amount but was still associated with ICU mortality. However, based on these results, it is unknown whether this association is an epiphenomenon, or represents a true harm of insulin and glucose administration.

Validation of the Dutch version of the critical-care pain observation tool.

BACKGROUND: Systematic assessment of pain is necessary for adequate treatment of pain. Patient self-reported pain is a superior assessment but is of limited use for intubated patients in the intensive care unit. For these patients, the critical-care pain observation tool (CPOT) has been developed. AIM: To perform a validation of the Dutch CPOT. STUDY DESIGN: Cross-sectional observational study. METHODS: The Dutch translation of the CPOT was used. Clinimetric characteristics were analysed in a cross-sectional design. Internal consistency (Cronbach's alpha) was tested by collecting CPOT scores in patients at rest and during turning. Inter-rater reliability was tested by collecting CPOT scores simultaneously by two different nurses who were blinded to each other's scores. Criterion validity (area under the curve, sensitivity and specificity) of the Dutch CPOT (index test) was analysed using patient self-reported pain (reference test). RESULTS: Cronbach's alpha was 0.56. During rest, the inter-rater reliability was 0.38 (95% confidence interval (CI): 0.20-0.53). During turning, the inter-rater reliability was 0.56 (95% CI: 0.42-0.68; area under the curve = 0.65 [95% CI 0.57-0.73]). At a threshold CPOT score of 2, the sensitivity and specificity were 39% and 85%, respectively. CONCLUSION: The Dutch CPOT is available for pain assessment in intubated patients unable to self-report. Inter-rater reliability is moderate. At the threshold, a CPOT score of 2, the sensitivity was 39% and the specificity of 85%. RELEVANCE TO CLINICAL PRACTICE: The CPOT is easy to use for systematic assessment of pain. Additional information about the threshold is valuable for use in daily practice.

One-year mortality of patients admitted to the intensive care unit after in-hospital cardiac arrest: a retrospective study.

PURPOSE: Little is known about long-term survival after In-Hospital Cardiac Arrest (IHCA). The purpose of this study is to report the one-year survival of patients after IHCA and to identify predicting factors. METHODS: Single-center retrospective study of all adult in-hospital CPR attempts conducted between 2003 and 2014 in a tertiary teaching hospital. Demographic and clinical variables of patients were obtained at 24 h pre-arrest, during CPR and post-CPR. All patients were tracked one year after discharge from hospital. RESULTS: CPR was performed for IHCA on 417 patients. Return of spontaneous circulation (ROSC) was achieved in 283 (68%) patients, 234 were admitted to ICU. Overall, 95 (23%) patients survived one year after discharge, The survival rate of patients who were admitted to ICU after IHCA was 38% (89/234) at hospital discharge and 26% (61/234) at one year. Univariate analysis showed numerous variables are associated with one-year survival, for example comorbidity index and time to ROSC. DISCUSSION: One-year survival of patients admitted to the ICU after IHCA was 26%. Severity of disease pre-arrest and at ICU-admission could prove useful in prognostication. No multivariate model could be constructed and large prospective studies are needed to elicit the role of pre-arrest factors on survival.

Glycemic Effects of a Low-Carbohydrate Enteral Formula Compared With an Enteral Formula of Standard Composition in Critically Ill Patients: An Open-Label Randomized Controlled Clinical Trial.

BACKGROUND: Enteral low-carbohydrate formulas (LCFs) could serve as a noninsulin alternative for the treatment of stress hyperglycemia in critically ill patients. We compared the glycemic effects of an LCF with a standard formula. METHODS: We conducted an open-label randomized trial in patients admitted to our intensive care unit between September 2015 and June 2016. Adult patients with an indication for enteral nutrition were randomized to an LCF (Glucerna 1.5 kcal) or a standard enteral formula (Fresubin Energy Fibre, with additional protein supplement). Primary outcome was glucose variability defined as mean absolute glucose (MAG) change (mmol/L/h). Secondary outcomes were mean glucose, time in target, hypoglycemic and hyperglycemic events, and insulin requirements. We assessed glycemic outcomes per blinded continuous glucose monitoring (CGM) system and compared outcomes with glucose measurements per blood gas analysis and point-of-care device. RESULTS: We randomized 107 patients (LCF: n = 53; standard: n = 54). Six patients had no CGM data, leaving 101 patients (n = 52; n = 49) for the intention-to-treat analysis. MAG change and time in target range were not different between groups. LCF gave a lower mean glucose measured per point-of-care device (7.8 ± 1.0 vs 8.4 ± 1.1 mmol/L, P = .007). LCF patients required significantly less insulin on the second study day (46.8 vs 68.0 IU, P = .036). CONCLUSION: LCF showed a trend toward a modestly reduced mean glucose and significantly lower insulin requirements as compared with standard feeding but had no effect on glucose variability or time in target range.

Pain Measurement in Mechanically Ventilated Patients After Cardiac Surgery: Comparison of the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT).

OBJECTIVES: The Behavioral Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT) are behavioral pain assessment tools for sedated and unconscious critically ill patients. The aim of this study was to compare the reliability, internal consistency, and discriminant validation of the BPS and the CPOT simultaneously in mechanically ventilated patients after cardiac surgery. DESIGN: A prospective, observational cohort study. SETTING: A 20-bed closed-format intensive care unit with mixed medical, surgical, and cardiac surgery patients in a teaching hospital in Amsterdam, The Netherlands. PARTICIPANTS: The study comprised 72 consecutive intubated and mechanically ventilated patients after cardiac surgery who were not able to self-report pain. MEASUREMENTS AND MAIN RESULTS: Two nurses assessed the BPS and CPOT simultaneously and independently at the following 4 moments: rest, a nonpainful procedure (oral care), rest, and a painful procedure (turning). Both scores showed a significant increase of 2 points between rest and turning. The median BPS score of nurse 1 showed a significant increase of 1 point between rest and the nonpainful procedure (oral care), whereas both median CPOT scores did not change. The interrater reliability of the BPS and CPOT showed fair-to-good agreement of 0.74 overall. During the periods of rest 1 and rest 2, values ranged from 0.24 to 0.46. Cronbach's alpha values for the BPS were 0.62 (nurse 1) and 0.59 (nurse 2) compared with 0.65 and 0.58, respectively, for the CPOT. CONCLUSIONS: The BPS and CPOT are reliable and valid pain assessment tools in a daily clinical setting. However, the discriminant validation of both scores seems less satisfactory in sedated or agitated patients and this topic requires further investigation.

The Clinical Benefits and Accuracy of Continuous Glucose Monitoring Systems in Critically Ill Patients-A Systematic Scoping Review.

Continuous Glucose Monitoring (CGM) systems could improve glycemic control in critically ill patients. We aimed to identify the evidence on the clinical benefits and accuracy of CGM systems in these patients. For this, we performed a systematic search in Ovid MEDLINE, from inception to 26 July 2016. Outcomes were efficacy, accuracy, safety, workload and costs. Our search retrieved 356 articles, of which 37 were included. Randomized controlled trials on efficacy were scarce (n = 5) and show methodological limitations. CGM with automated insulin infusion improved time in target and mean glucose in one trial and two trials showed a decrease in hypoglycemic episodes and time in hypoglycemia. Thirty-two articles assessed accuracy, which was overall moderate to good, the latter mainly with intravascular devices. Accuracy in critically ill children seemed lower than in adults. Adverse events were rare. One study investigated the effect on workload and cost, and showed a significant reduction in both. In conclusion, studies on the efficacy and accuracy were heterogeneous and difficult to compare. There was no consistent clinical benefit in the small number of studies available. Overall accuracy was moderate to good with some intravascular devices. CGM systems seemed however safe, and might positively affect workload and costs.

Readmission of ICU patients: A quality indicator?

PURPOSE: Readmission rate is frequently proposed as a quality indicator because it is related to both patient outcome and organizational efficiency. Currently available studies are not clear about modifiable factors as tools to reduce readmission rate. MATERIAL AND METHODS: In a 14year retrospective cohort study of 19,750 ICU admissions we identified 1378 readmissions (7%). A multivariate logistic regression analysis for determinants of readmission within 24h, 48h, 72h and any time during hospital admission was performed with adjustment for patients' characteristics and initial admission severity scores. RESULTS: In all models with different time points, patients with older age, a medical and emergency surgery initial admission and patients with higher SOFA score have a higher risk of readmission. Immunodeficiency was a predictor only in the at any time model. Confirmed infection was predicted in all models except the 24h model. Last day noradrenaline treatment was predicted in the 24 and 48h model. Mechanical ventilation on admission independently protected for readmission, which can be explained by the large number of cardiac surgery patients. All multivariate models had a moderate performance with the highest AUC of 0.70. CONCLUSIONS: Readmission can be predicted with moderate precision and independent variables associated with readmission are age, severity of disease, type of admission, infection, immunodeficiency and last day noradrenaline use. The latter factor is the only one that can be modified and therefore readmission rate does not meet the criteria to be used as a useful quality indicator.

The association between lactate, mean arterial pressure, central venous oxygen saturation and peripheral temperature and mortality in severe sepsis: a retrospective cohort analysis.

BACKGROUND: During resuscitation in severe sepsis and septic shock, several goals are set. However, usually not all goals are equally met. The aim of this study is to determine the relative importance of the different goals, such as mean arterial pressure (MAP), lactate, central venous oxygen saturation (ScvO2) and central to forefoot temperature (delta-T), and how they relate to intensive care unit (ICU) and hospital mortality. METHODS: In a retrospective cohort study in a 20-bed mixed medical and surgical ICU of a teaching hospital we studied consecutive critically ill patients who were admitted for confirmed infection and severe sepsis or septic shock between 2008 and 2014. All validated MAP, lactate levels, ScvO2 and delta-T for the first 24 hours of ICU treatment were extracted from a clinical database. Logistic regression analyses were performed on validated measurements in the first hour after admission and on mean values over 24 hours. Patients were categorized by MAP (24-hour mean below or above 65 mmHg) and lactate (24-hour mean below or above 2 mmol/l) for Cox regression analysis. RESULTS: From 837 patients, 821 were eligible for analysis. All had MAP and lactate measurements. The delta-T was available in 812 (99%) and ScvO2 was available for 193 out of these patients (23.5%). Admission lactate (p < 0.001) and admission MAP (p < 0.001) were independent predictors of ICU and hospital mortality. The 24-hour mean values for lactate, MAP and delta-T were all independent predictors of ICU mortality. Hospital mortality was independently predicted by the 24-hour mean lactate (odds ratio (OR) 1.34, 95% confidence interval (CI) 1.30-1.40, p = 0.001) mean MAP (OR 0.96, 95% CI 0.95-0.97, p = 0.001) and mean delta-T (OR 1.09, 95% CI 1.06-1.12, p = 0.001). Patients with a 24-hour mean lactate below 2 mmol/l and a 24-hour mean MAP above 65 mmHg had the best survival, followed by patients with a low lactate and a low MAP. CONCLUSIONS: Admission MAP and lactate independently predicted ICU and hospital mortality. The 24-hour mean lactate, mean MAP and mean delta-T independently predicted hospital mortality. A Cox regression analysis showed that 24-hour mean lactate above 2 mmol/l is the strongest predictor for ICU mortality.

Validation of continuous QTc measurement in critically ill patients.

INTRODUCTION: Prolongation of the corrected QT interval (QTc) can lead to torsades de pointes. This study is designed to determine the validity of the continuous QTc (cQTc) measurement in critically ill patients. METHODS: In a retrospective cohort study, QTc analysis was performed with manual measurements on a single selected lead from a 12-lead ECG and cQTc measurement obtained at the same time. In addition, automated QTc measurement from the 12-lead ECG was also included in the study. Validation was performed by calculating intraclass correlation coefficient (ICC), Pearson's correlation and Bland-Altman plot. RESULTS: 119 patients with QRS<120 ms were included with a mean cQTc of 468 ms (standard deviation (SD) 37) and mean manually measured QTc of 449 ms (SD 41) (p<0.001). Pearson's correlation was 0.65 (p<0.01), ICC was 0.65 (95% CI: 0.53-0.74). Bland-Altman plot shows a mean difference of 19.5 ms (limits of agreement (LOA) -44.6 to 83.7). For cQTc compared to automated QTc from the 12-lead ECG the intraclass correlation coefficient was 0.77 (95% CI: 0.68-0.83, p<0.001) and the Bland-Altman plot shows a mean difference of 7.8 ms (LOA -40.2 to 55.8). CONCLUSION: cQTc measurement in critically ill patients with a QRS duration shorter than 120 ms shows an acceptable accuracy to be used in routine care.

Telemedicine in a Dutch intensive care unit: A descriptive study of the first results.

INTRODUCTION: Tele-intensive care (teleIC) can be used to increase the level of care in the intensive care unit (ICU) with the tele-intensivist being at a remote site. In this study we describe the implementation and outcomes, including patient and family satisfaction, of the first Dutch teleIC. METHODS: In a retrospective analysis the patient characteristics are described with a focus on patient outcomes and patient and family satisfaction. The teleIC started on 6 December 2010 in an ICU with three beds. Data for all admitted patients were collected from 1 January 2011 through 31 December 2013 from available systems. Severity of disease (APACHE IV) and standardized mortality ratios (SMR) were available over the complete calendar years 2012 and 2013. A prospective self-made survey of patient and family satisfaction was performed over a 14-month period after the implementation of teleIC. RESULTS: In 2012 and 2013, 556 patients were admitted. The number of operating room recovery patients in the ICU declined over time. One hundred and seven patients were transferred to a higher-level ICU (19%). The SMR for non-transferred patients was 0.73 (95% CI (confidence interval) 0.54-0.98) and 0.66 (95% CI (confidence interval) 0.40-1.02) for transferred patients. These numbers are in line with national data. Thirty-six percent of family and 38% of the patients responded to the survey and showed a positive response concerning communication within the tele IC setting. CONCLUSION: Implementation of teleIC in a Dutch situation was successful and showed favourable results in patient outcomes and the satisfaction of patients and family members.

Long-term treated intensive care patients outcomes: the one-year mortality rate, quality of life, health care use and long-term complications as reported by general practitioners.

BACKGROUND: The purpose of this study was to determine the one-year mortality rate and its predictors regarding long-term intensive care-treated patients together with their health-related quality of life (HRQL), place of living, healthcare use and long-term complication characteristics after intensive care unit (ICU) discharge. METHODS: A retrospective cohort study was performed in a 20-bed mixed ICU. The patients that were treated for more than 72 h between 2007 and 2012 were included in this study. The one-year mortality rate was calculated, and the characteristics of the ICU survivors that died within one year after ICU discharge were further analysed. For all patients, the Dutch version of the SF-36 questionnaire was used to assess their current HRQL. The results were compared with a normal population. Additionally, patients were questioned about their place of living, and their general practitioners (GPs) were questioned about the patients' possible long-term complications. RESULTS: Seven hundred and forty patients were included in this study, and their one-year mortality rate was 28 %, of which half died within the first week after ICU discharge. The one-year mortality rate predictors included age at the time of ICU admission, APACHE IV-predicted mortality score, number of comorbidities and ICU re-admissions. The ICU survivor HRQL was significantly lower compared with the normal population. Half of the patients did not return to their pre-hospital place of living, and numerous possible long-term complications were reported, particularly decreased tolerance, chronic fatigue and processing problems of relatives. CONCLUSIONS: One-year mortality rate of long-term ICU-treated patient was 28 %, and this was predicted by age, disease severity, comorbidities and ICU re-admissions. The ICU survivors reported a lower HRQL, and a minority of these patients returned home directly after hospital discharge; however, GPs reported numerous possible long-term complications.

Insulin treatment guided by subcutaneous continuous glucose monitoring compared to frequent point-of-care measurement in critically ill patients: a randomized controlled trial.

INTRODUCTION: Glucose measurement in intensive care medicine is performed intermittently with the risk of undetected hypoglycemia. The workload for the ICU nursing staff is substantial. Subcutaneous continuous glucose monitoring (CGM) systems are available and may be able to solve some of these issues in critically ill patients. METHODS: In a randomized controlled design in a mixed ICU in a teaching hospital we compared the use of subcutaneous CGM with frequent point of care (POC) to guide insulin treatment. Adult critically ill patients with an expected stay of more than 24 hours and in need of insulin therapy were included. All patients received subcutaneous CGM. CGM data were blinded in the control group, whereas in the intervention group these data were used to feed a computerized glucose regulation algorithm. The same algorithm was used in the control group fed by intermittent POC glucose measurements. Safety was assessed with the incidence of severe hypoglycemia (<2.2 mmol/L), efficacy with the percentage time in target range (5.0 to 9.0 mmol/L). In addition, we assessed nursing workload and costs. RESULTS: In this study, 87 patients were randomized to the intervention and 90 to the control group. CGM device failure resulted in 78 and 78 patients for analysis. The incidence of severe glycemia and percentage of time within target range was similar in both groups. A significant reduction in daily nursing workload for glucose control was found in the intervention group (17 versus 36 minutes; P <0.001). Mean daily costs per patient were significantly reduced with EUR 12 (95% CI -32 to -18, P = 0.02) in the intervention group. CONCLUSIONS: Subcutaneous CGM to guide insulin treatment in critically ill patients is as safe and effective as intermittent point-of-care measurements and reduces nursing workload and daily costs. A new algorithm designed for frequent measurements may lead to improved performance and should precede clinical implementation. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01526044. Registered 1 February 2012.

Corrected QT-interval prolongation and variability in intensive care patients.

PURPOSE: Critically ill patients are at risk for prolongation of the interval between the Q wave and the T wave in the electrocardiogram (corrected QT [QTc]). Corrected QT prolongation is probably a dynamic process. It is unknown how many patients have a QTc prolongation during their intensive care stay and how variable QTc prolongation is. MATERIALS AND METHODS: In a prospective cohort study, continuous 5-minute QTc measurements of 50 consecutive patients were collected. A prolonged QTc interval was more than 500 milliseconds for at least 15 minutes. The QT variance and variability index was used to evaluate QTc variation. RESULTS: Fifty-two percent of included patients had a prolonged QTc interval. In a single patient, 0.2% to 91.3% of the QTc intervals over time were prolonged. The use of erythromycin and amiodarone was associated with the mean QTc (P = .02 and P = .006, respectively). The Acute Physiology and Chronic Health Evaluation IV and Sequential Organ Failure Assessment scores were significantly higher in patients with a prolonged QTc interval (30.8 vs 8.6 and 7 vs 5.5, respectively). Eighty-four percent of all patients received at least 1 QTc-prolonging drug. The QT variance and QTc variance were significantly higher in patients with a prolonged QTc (P = .019 and P = .001, respectively). CONCLUSION: Continuous QTc monitoring showed a prolonged QTc interval in 52% of intensive care patients. Severity of illness and QT and QTc variances are higher in these patients.

Can serum L-lactate, D-lactate, creatine kinase and I-FABP be used as diagnostic markers in critically ill patients suspected for bowel ischemia.

BACKGROUND: The prognostic value of biochemical tests in critically ill patients with multiple organ failure and suspected bowel ischemia is unknown. METHODS: In a prospective observational cohort study intensive care patients were included when the attending intensivist considered intestinal ischemia in the diagnostic workup at any time during intensive care stay. Patients were only included once. When enrolment was ended each patient was classified as 'proven intestinal ischemia', 'ischemia likely', 'ischemia unlikely' or 'no intestinal ischemia'. Proven intestinal ischemia was defined as the gross disturbance of blood flow in the bowel, regardless of extent and grade. Classification was based on reports from the operating surgeon, pathology department, endoscopy reports and CT-scan. Lactate dehydrogenase (LDH), creatine kinase (CK), alanine aminotransferase (ALAT), L-lactate were available for the attending physician. D-lactate and intestinal fatty acid binding protein (I-FABP) were analysed later in a batch. I-FABP was only measured in patients with proven ischemia or no ischemia. RESULTS: For 44 of the 120 included patients definite diagnostic studies were available. 23/44 patients (52%) had proven intestinal ischemia as confirmed by surgery, colonoscopy, autopsy and/or histopathological findings. LDH in these patients was 285 U/l (217-785) vs 287 U/l (189-836) in no-ischemia; p = 0.72. CK was 226 U/l in patients with proven ischemia (126-2145) vs 347 U/l (50-1427), p = 0.88. ALAT was 53 U/l (18-300) vs 34 U/l (14-34), p-0,56. D-lactate 0.41 mmol/l (0.11-0.75) vs 0.56 mmol/l (0.27-0.77), p = 0.46. L-lactate 3.5 mmol/l (2.2-8.4) vs 2.6 mmol/l (1.7-3.9), p = 0.09. I-FABP 2872 pg/ml (229-4340) vs 1020 pg/ml (239-5324), p = 0.98. Patient groups proven and likely ischemia together compared to unlikely and no-ischemia together showed significant higher L-lactate (p = 0.001) and higher D-lactate (p = 0.003). CONCLUSIONS: Measurement of LDH, CK, and ALAT did not discriminate critically ill patients with proven intestinal ischemia from those with definite diagnosis no-ischemia. However, L-lactate and D-lactate levels were higher in patients with proven or likely ischemia and need further study just as I-FABP.

Integration of 3D reconstruction in the SELection criteria for Excessive Crossing Times for Magnetically Supported Percutaneous Coronary Intervention. SELECT-MP.

AIMS: To develop a clinical prediction rule based on 3D reconstruction of coronary arteries that would prospectively identify lesions that are difficult to cross and could benefit from magnetic navigation. METHODS AND RESULTS: The coronary anatomy of a cohort of 120 lesions that had undergone percutaneous coronary intervention (derivation set) was analysed using 3D reconstruction for vessel and lesion characteristics. The crossing time was the total clock time to reach a satisfactory distal position after leaving the guiding catheter. Multivariable logistic regression and linear shrinkage with bootstrapping were used to develop a clinical prediction rule that dichotomised cases into easy or difficult (prolonged crossing time). A value of 6 was the best cut-off value. This clinical prediction rule was applied to a second independent cohort of patients (validation set) where crossing time was measured. The bootstrapped c-statistic of the model was 0.82 indicating excellent discrimination. CONCLUSIONS: 3D reconstruction helped to develop a simple, accurate clinical prediction rule to identify difficult cases for conventional wires and in whom magnetic navigation may be preferable.