[Show abstract][Hide abstract] ABSTRACT: Purpose:
In acute kidney injury patients, metabolic acidosis is common. Its severity, duration, and associated changes in mean arterial pressure (MAP) and vasopressor therapy may be affected by the intensity of continuous renal replacement therapy (CRRT). We aimed to compare key aspects of acidosis and MAP and vasopressor therapy in patients treated with two different CRRT intensities.
We studied a nested cohort of 115 patients from two tertiary intensive care units (ICUs) within a large multicenter randomized controlled trial treated with lower intensity (LI) or higher intensity (HI) CRRT.
Levels of metabolic acidosis at randomization were similar [base excess (BE) of -8 ± 8 vs. -8 ± 7 mEq/l; p = 0.76]. Speed of BE correction did not differ between the two groups. However, the HI group had a greater increase in MAP from baseline to 24 h (7 ± 3 vs. 0 ± 3 mmHg; p < 0.01) and a greater decrease in norepinephrine dose (from 12.5 to 3.5 vs. 5 to 2.5 μg/min; p < 0.05). The correlation (r) coefficients between absolute change in MAP and norepinephrine (NE) dose versus change in BE were 0.05 and -0.37, respectively.
Overall, LI and HI CRRT have similar acid-base effects in patients with acidosis. However, HI was associated with greater improvements in MAP and vasopressor requirements (clinical trial no. NCT00221013).
Intensive Care Medicine 01/2013; 39(3). DOI:10.1007/s00134-012-2800-0 · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To estimate the prognostic value of point-of-care measurement of biomarkers related to dyspnea in patients receiving a medical emergency team (MET) review.
Prospective observational study.
University affiliated hospital.
Cohort of 95 patients receiving MET review over a six month period.
We used a commercial multi-biomarker panel for shortness-of-breath (SOB panel) (Biosite Triage Profiler, Biosite Incorporated®), 9975 Summers Ridge Road, San Diego, CA 92121, USA) including Brain natriuretic peptide (BNP), D-dimer, myoglobin (Myo), creatine kinase MB isoenzyme (CK-MB) and troponin I (Tn-I). We recorded information about demographics, MET review triggers, and MET procedures and patient outcome.
Mean age was 70.5 (±15) years, 38 (41%) patients had a history of chronic heart failure (CHF) and 67 (70%) chronic kidney disease (CKD). At MET activation, 42 (44%) patients were dyspneic. The multi-biomarker panel was positive for at least one marker in 48 (51%) cases. BNP and D-dimer had a sensitivity of 0.79 and 0.93 for ICU admission with a negative predictive value (NPV) of 0.89 and 0.92 respectively. Thirty-five (37%) patients died. BNP was positive in 85% of such cases with sensitivity and NPV of 0.86 and 0.82, respectively. D-dimer was positive in 77% of non-survivors with a sensitivity and NPV of 0.94 and 0.88, respectively. BNP (area under the curve of receiver operating characteristic curve--AUC-ROC: 0.638) and D-dimer (AUC-ROC: 0.574) achieved poor discrimination of subsequent death. Similar findings applied to ICU admission. The combination of normal BNP and D-dimer levels completely ruled out ICU admission or death. The cardiac part of the panel was not useful in predicting ICU admission or mortality.
Although, BNP and D-dimer are poor discriminants of ICU admission and hospital mortality, normal BNP and D-dimer levels practically exclude subsequent need for ICU admission and hospital mortality.
[Show abstract][Hide abstract] ABSTRACT: To test the precision and limits of agreement of point-of-care testing (POCT)-based measurement of serum creatinine (Cr) in critically ill patients.
We studied 250 paired blood samples from 82 critically ill patients from a general intensive care unit by simultaneous POCT and central laboratory testing (Jaffé method). Correlation, precision, bias, and limits of agreement were assessed. Possible confounders for interference of noncreatinine chromogens were evaluated by multivariate linear regression analysis.
The mean difference in serum Cr measured by central laboratory and POCT was +9.6 μmol/L (95% limits of agreement: -11.2 to +30.4 μmol/L). The mean percentage difference between the two techniques was 8.7% (95% limits of agreement -7.8% to +25.1%). On multivariate regression, the difference in serum Cr was increased with greater hemoglobin and lactate levels but decreased with greater bilirubin, albumin, and calcium levels.
Compared with the central laboratory testing, POCT-based measurement of serum Cr in critically ill patients carried a small negative bias. This difference appeared affected by the blood levels of biochemical variables known to affect the Jaffé method. POCT-based Cr measurement appears sufficiently accurate for clinical use.
[Show abstract][Hide abstract] ABSTRACT: There is no information on the clinical features and outcome of patients receiving multiple Medical Emergency Team (MET) reviews. Accordingly, we studied the characteristics and outcome of patients receiving one MET call and compared them with those receiving multiple MET reviews.
Retrospective observational study using prospectively collected data.
Cohort of 1664 patients receiving 2237 MET reviews over a 2-year period.
We retrieved information about patient demographics, reasons for MET review, procedures performed by the MET and hospital outcome. We found that 1290 (77.5%) patients received a single MET review and 374 (22.5%) received multiple MET reviews (mean 2.5 reviews, median 2.0). Multiple MET reviews were more likely to be in surgical patients (p < 0.001) and to be due to arrhythmias (p = 0.016). Multiple MET review patients were more likely to be admitted for gastrointestinal diseases (p < 0.001), had a 50% longer hospital stay (p < 0.001) and a 34.6% increase in hospital mortality (p < 0.001) compared to single MET review patients. Their odds ratio (OR) for mortality was 2.14 (95% C.I.: 1.62-2.83; p < 0.001). After exclusion of patients with not for resuscitation (NFR) orders, the OR for mortality was 2.92 (95% C.I.: 2.10-4.06; p < 0.001). The in-hospital mortality of patients subject to multiple MET reviews who were not designated NFR was 34.1%, but only 9.7% of these deaths occurred within 48 h of the initial MET review.
In our hospital, one fifth of patients receiving MET calls are subject to multiple MET calls. Such patients have identifiable features and have an increased risk of morbidity and mortality. Within any rapid response system, such patients should be recognized as a higher risk group and receive specific additional attention.
[Show abstract][Hide abstract] ABSTRACT: Point of care technology makes it possible to measure blood and urine creatinine and electrolytes within the intensive care unit. We tested whether such point of care technology can accurately measure urine creatinine and electrolytes. We obtained urine from 28 patients for a total of 77 paired samples and measured creatinine and electrolytes using central laboratory technology and point of care technology. The mean difference in urine creatinine was 74 mcmol/L with 95% limits of agreement of -673 to 821 mcmol/L. The mean difference in urinary sodium was 0.282 mmol/L with 95% limits of agreement of -14 to 15 mmol/L. Significantly greater biases and wider limits of agreement were seen for potassium and chloride. We conclude that, despite the limited bias, due to wide limits of agreement, urinary creatinine and sodium cannot be estimated with point of care technology. Even greater inaccuracies make the estimation of potassium and chloride in urine by point of care technology not usable for clinical purposes.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the impact of Rapid Response System (RRS) maturation on delayed Medical Emergency Team (MET) activation and patient characteristics and outcomes.
Recent cohort of 200 patients receiving a MET review and early control cohort of 400 patients receiving a MET review five years earlier at the start of RRS implementation.
We obtained information including demographics, clinical triggers for and timing of MET activation in relation to the first documented MET review criterion (activation delay) and patient outcomes. We found that patients in the recent cohort were older, more likely to be surgical and to have Not For Resuscitation (NFR) orders before MET review. Furthermore, fewer patients (22.0% vs. 40.3%, p<0.001) had delayed MET activation. When delayed activation occurred, there was a non-significant difference in its duration (early cohort: 12.0 [IQR 23.0]h vs. recent cohort: 9.0 [IQR 20.5]h, p=0.554). Similarly, unplanned ICU admissions decreased from 31.3% to 17.3% (p<0.001). Delayed MET activation was independently associated with greater risk of unplanned ICU admission and hospital mortality (O.R. 1.79, 95% C.I. 1.33.-2.93, p=0.003 and O.R. 2.18, 95% C.I. 1.42-3.33, p<0.001, respectively). Being part of the recent cohort was independently associated with a decreased risk of delayed activation (O.R. 0.45, 95% C.I. 0.30-0.67, p<0.001) and unplanned ICU admission (O.R. 0.5, 95% C.I. 0.32-0.78, p=0.003).
Maturation of a RRS is associated with a decrease in the incidence of unplanned ICU admissions and MET activation delay. Assessment of a RRS early in the course of its implementation may underestimate its efficacy.
[Show abstract][Hide abstract] ABSTRACT: To identify factors that predict outcome in patients receiving a Medical Emergency Team review.
Prospective observational study.
Cohort of 228 patients receiving one or more Medical Emergency Team reviews during daytime hours over a 1-year-period. Control cohort of all patients (n = 900) receiving a Medical Emergency Team review in the same period.
We prospectively collected information from patients receiving a Medical Emergency Team review during daytime hours from Monday to Friday (audit group) including the clinical cause of deterioration and timing of call in relation to the first documented Medical Emergency Team call criterion (activation delay). We also collected information from the hospital Medical Emergency Team database regarding all patients visited by the Medical Emergency Team during the same period (complete cohort). Audit group patients had several similar characteristics to complete cohort patients but were less likely to be not-for-resuscitation before Medical Emergency Team review and more likely to receive a Medical Emergency Team review because of hypotension, change in neurological status and oliguria. Delayed Medical Emergency Team activation and not-for resuscitation orders were the only factors to show an independent statistical association with mortality (OR 2.53, 95% CI: 1.2-5.31, P = 0.01 and OR 5.63, 95% CI: 2.81-11.28, P < 0.01, respectively).
Delayed Medical Emergency Team activation and NFR orders are the strongest independent predictors of mortality in patients receiving a Medical Emergency Team review. Avoidance of delayed Medical Emergency Team activation should be a priority for hospitals operating rapid response systems.
Intensive Care Medicine 11/2008; 34(11):2112-6. DOI:10.1007/s00134-008-1229-y · 7.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Studies of hospital performance highlight the problem of 'failure to rescue' in acutely ill patients. This is a deficiency strongly associated with serious adverse events, cardiac arrest, or death. Rapid response systems (RRSs) and their efferent arm, the medical emergency team (MET), provide early specialist critical care to patients affected by the 'MET syndrome': unequivocal physiological instability or significant hospital staff concern for patients in a non-critical care environment. This intervention aims to prevent serious adverse events, cardiac arrests, and unexpected deaths. Though clinically logical and relatively simple, its adoption poses major challenges. Furthermore, research about the effectiveness of RRS is difficult to conduct. Sceptics argue that inadequate evidence exists to support its widespread application. Indeed, supportive evidence is based on before-and-after studies, observational investigations, and inductive reasoning. However, implementing a complex intervention like RRS poses enormous logistic, political, cultural, and financial challenges. In addition, double-blinded randomised controlled trials of RRS are simply not possible. Instead, as in the case of cardiac arrest and trauma teams, change in practice may be slow and progressive, even in the absence of level I evidence. It appears likely that the accumulation of evidence from different settings and situations, though methodologically imperfect, will increase the rationale and logic of RRS. A conclusive randomised controlled trial is unlikely to occur.
All truth passes through three stages.
First, it is ridiculed.
Second, it is violently opposed.
Third, it is accepted as being self-evident.
Arthur Schopenhauer (1788–1860), German philosopher