Publications (22) View all
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Article: Risk factors for development of acute kidney injury in critically ill patients: a systematic review and meta-analysis of observational studies.
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ABSTRACT: Background. Acute kidney injury (AKI) is a frequent complication of critically ill patients. The impact of different risk factors associated with this entity in the ICU setting is unknown. Objectives. The purpose of this research was to assess the risk factors associated with the development of AKI in critically ill patients by meta-analyses of observational studies. Data Extraction. Two reviewers independently and in duplicate used a standardized form to collect data from published reports. Authors were contacted for missing data. The Newcastle-Ottawa scale assessed study quality. Data Synthesis. Data from 31 diverse studies that enrolled 504,535 critically ill individuals from a wide variety of ICUs were included. Separate random-effects meta-analyses demonstrated a significantly increased risk of AKI with older age, diabetes, hypertension, higher baseline creatinine, heart failure, sepsis/systemic inflammatory response syndrome, use of nephrotoxic drugs, higher severity of disease scores, use of vasopressors/inotropes, high risk surgery, emergency surgery, use of intra-aortic balloon pump, and longer time in cardiopulmonary bypass pump. Conclusion. The best available evidence suggests an association of AKI with 13 different risk factors in subjects admitted to the ICU. Predictive models for identification of high risk individuals for developing AKI in all types of ICU are required.Critical care research and practice 01/2012; 2012:691013. -
Article: Lung ultrasound in critically ill patients: comparison with bedside chest radiography.
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ABSTRACT: To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard. Forty-two mechanically ventilated patients scheduled for CT were prospectively studied with a modified lung ultrasound protocol. Four pathologic entities were evaluated: consolidation, interstitial syndrome, pneumothorax, and pleural effusion. Each hemithorax was evaluated for the presence or absence of each abnormality. Eighty-four hemithoraces were evaluated by the three imaging techniques. The sensitivity, specificity, and diagnostic accuracy of CXR were 38, 89, and 49% for consolidation, 46, 80, and 58% for interstitial syndrome, 0, 99, and 89% for pneumothorax, and 65, 81, and 69% for pleural effusion, respectively. The corresponding values for lung ultrasound were 100, 78, and 95% for consolidation, 94, 93, and 94% for interstitial syndrome, 75, 93, and 92% for pneumothorax, and 100, 100, and 100% for pleural effusion, respectively. The relatively low sensitivity of lung ultrasound for pneumothorax could be due to small number of cases (n = 8) and/or suboptimal methodology. In our unselected general ICU population lung ultrasound has a considerably better diagnostic performance than CXR for the diagnosis of common pathologic conditions and may be used as an alternative to thoracic CT.European Journal of Intensive Care Medicine 09/2011; 37(9):1488-93. · 5.17 Impact Factor -
Article: Poloxamer 188 facilitates the repair of alveolus resident cells in ventilator-injured lungs.
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ABSTRACT: Rationale: Wounded alveolus resident cells are identified in human and experimental acute respiratory distress syndrome models. Poloxamer 188 (P188) is an amphiphilic macromolecule shown to have plasma membrane-sealing properties in various cell types. Objectives: To investigate whether P188 (1) protects alveolus resident cells from necrosis and (2) is associated with reduced ventilator-induced lung injury in live rats, isolated perfused rat lungs, and scratch and stretch-wounded alveolar epithelial cells. Methods: Seventy-four live rats and 18 isolated perfused rat lungs were ventilated with injurious or protective strategies while infused with P188 or control solution. Alveolar epithelial cell monolayers were subjected to scratch or stretch wounding in the presence or absence of P188. Measurements and Main Results: P188 was associated with fewer mortally wounded alveolar cells in live rats and isolated perfused lungs. In vitro, P188 reduced the number of injured and necrotic cells, suggesting that P188 promotes cell repair and renders plasma membranes more resilient to deforming stress. The enhanced cell survival was accompanied by improvement in conventional measures of lung injury (peak airway pressure, wet-to-dry weight ratio) only in the ex vivo-perfused lung preparation and not in the live animal model. Conclusions: P188 facilitates plasma membrane repair in alveolus resident cells, but has no salutary effects on lung mechanics or vascular barrier properties in live animals. This discordance may have pathophysiological significance for the interdependence of different injury mechanisms and therapeutic implications regarding the benefits of prolonging the life of stress-activated cells.American Journal of Respiratory and Critical Care Medicine 07/2011; 184(8):939-47. · 11.08 Impact Factor -
Article: Predictors of acute kidney injury in septic shock patients: an observational cohort study.
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ABSTRACT: Acute kidney injury (AKI) is a frequent complication in critically ill patients and sepsis is the most common contributing factor. We aimed to determine the risk factors associated with AKI development in patients with septic shock. Observational cohort study consisted of consecutive adults with septic shock admitted to a medical intensive care unit (ICU) of a tertiary care academic hospital from July 2005 to September 2007. AKI was defined according to RIFLE criteria (urine output and creatinine criteria). Demographic, clinical, and treatment variables were reviewed. Main outcomes measured were AKI occurrence, all-cause hospital mortality, and hospital and ICU length of stay. Three hundred ninety patients met inclusion criteria, of which 237 (61%) developed AKI. AKI development was independently associated with delay to initiation of adequate antibiotics, intra-abdominal sepsis, blood product transfusion, use of angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker, and body mass index (kg/m²). Higher baseline GFR and successful early goal directed resuscitation were associated with a decreased risk of AKI. Hospital mortality was significantly greater in patients who developed AKI (49 versus 34%). In a contemporary cohort of patients with septic shock, both patient and health care delivery risk factors seemed to be important for AKI development.Clinical Journal of the American Society of Nephrology 07/2011; 6(7):1744-51. · 5.23 Impact Factor -
Article: Should mechanical ventilation be guided by esophageal pressure measurements?
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ABSTRACT: Despite the well recognized role of mechanical ventilation in lung injury, appropriate surrogate markers to guide titration of ventilator settings remain elusive. One would like to strike a balance between protecting aerated units from overdistension while recruiting unstable units, thereby reducing tissue damage associated with their cyclic recruitment and derecruitment. To do so requires some estimate of the topographical distribution of parenchymal stress and strain. Recent studies have highlighted the importance of chest wall recoil and its effect on pleural pressure (Ppl) in determining lung stress. Although esophageal pressure (Pes) has traditionally been used to measure the average Ppl in normal upright patients, in recumbent acute lung injury/acute respiratory distress syndrome patients Pes-based estimates of Ppl are subject to untestable assumptions. Nevertheless, Pes measurements in recumbent patients with injured lungs strongly suggest that Ppl over dependent parts of the lung can exceed airway pressure by substantial amounts. Moreover, results of a pilot study in which Pes was used to titrate positive end-expiratory pressure (PEEP) suggest clinical benefit. Notwithstanding its theoretical limitations, esophageal manometry has shown promise in PEEP titration and deserves further evaluation in a larger trial on patients with injured lungs.Current opinion in critical care 02/2011; 17(3):275-80. · 2.67 Impact Factor
