Adam S. Weltz

Epidemiology and outcomes of acute kidney injury in critically ill surgical patients

PURPOSE Acute kidney injury (AKI) is common in critically ill patients but is poorly defined in surgical patients. We studied AKI in a representative cohort of critically ill surgical patients. METHODS This was a retrospective 1-year cohort study of general surgical intensive care unit patients. Patients were identified from a prospective database, and clinical data were reviewed. Acute kidney injury events were defined by risk, injury, failure, loss, and end-stage renal classification criteria. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. Risk factors for AKI and outcomes were compared by univariate and multivariate analyses. RESULTS Of 624 patients, 296 (47%) developed AKI. Forty-two percent of events were present upon admission, whereas 36% occurred postoperatively. Risk, injury, failure, loss, and end-stage renal classification distributions by grade were as follows: risk, 152 (51%); injury, 69 (23%); and failure, 75 (25%). Comorbid diabetes, emergency admission, major surgery, sepsis, and illness severity were independently associated with renal dysfunction. Patients with AKI had significantly worse outcomes, including increased inpatient and 1-year mortality. Acute kidney injury starting before admission was associated with worse renal dysfunction and greater renal morbidity than de novo inpatient events. CONCLUSIONS Acute kidney injury is common in critically ill surgical patients and is associated with increased mortality, persisting renal impairment and greater resource use.

Acute Kidney Injury in Critically Ill Vascular Surgery Patients is Common and Associated with Increased Mortality.

Introduction: Vascular surgery patients have multiple risk factors for renal dysfunction, but acute kidney injury (AKI) is poorly studied in this group. The purpose of this study was to define the incidence, risk factors, and outcomes of AKI in high-risk vascular patients. Methods: Critically ill vascular surgery patients admitted during January–December 2012 were retrospectively analyzed with 1-year follow-up. The endpoint was AKI by established RIFLE creatinine criteria. The primary analysis was between patients with or without AKI, with secondary analysis of post-operative AKI. Outcomes were inpatient and 1-year mortality, inpatient lengths of stay, and discharge renal function. Results: One-hundred and thirty six vascular surgery patients were included, representing 27% of all vascular surgery admissions during the study period. Sixty-five (48%) developed AKI. Independent global risk factors for AKI were diabetes, increasing critical illness severity, and sepsis. While intraoperative blood loss and hypotension were associated with subsequent renal dysfunction, post-operative AKI rates were similar for patients undergoing aortic, carotid, endovascular, or peripheral vascular procedures. All RIFLE grades of AKI were associated with worse outcomes. Overall, patients with AKI had significantly increased short- and long-term mortality, longer inpatient lengths of stay, and worse discharge renal function. Conclusion: AKI is common among critically ill vascular surgery patients. Importantly, the type of surgical procedure appears to be less important than intra- and perioperative management in determining renal dysfunction. Regardless of its severity, AKI is a clinically significant complication that is associated with substantially worse patient outcomes.

The use of resuscitative endovascular balloon occlusion of the aorta to control hemorrhagic shock during video-assisted retroperitoneal debridement or infected necrotizing pancreatitis.

Highlights • We describe the use of resuscitative endovascular balloon occlusion of the aorta during a video assisted retroperitoneal debridement procedure.• We review the literature on resuscitative endovascular balloon occlusion of the aorta use in elective surgery, as well as trauma and vascular surgery.• We provide a comprehensive table outlining complications and mortality.• We provide support for the resurgence of this historical approach to hemorrhage control.

Acute Transverse Myelitis Associated with Salmonella Bacteremia: A Case Report

Patient: Female, 28 Final Diagnosis: Acute transverse myelitis Symptoms: Ascending paralysis Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare disease Background: Acute transverse myelitis (ATM) is an uncommon and often overlooked complication of certain bacterial and viral infections that can have a rapid onset and result in severe neurological deficits. Case Report: This case report describes a previously healthy 28-year-old woman who presented to the trauma center after developing acute paralysis and paresthesias of all four extremities within the span of hours. The initial presumptive diagnosis was spinal cord contusion due to a fall versus an unknown mechanism of trauma, but eventual laboratory studies revealed Salmonella bacteremia, indicating a probable diagnosis of parainfectious ATM. Conclusions: This case illustrates the importance of considering the diagnosis of parainfectious ATM in patients presenting with acute paralysis with incomplete or unobtainable medical histories.

Mechanisms of Immunosuppressive Drugs

Immunosuppressive regimens for organ transplantation are broadly divided into induction, maintenance, and rescue therapies. Induction immunosuppression is an intense perioperative treatment intended to suppress anti-donor responses and prevent acute rejection during the early postoperative period (Nashan, BioDrugs 19:39–46, 2005; Halloran, N Engl J Med 351:2715–2729, 2004). Maintenance immunosuppression is long-term therapy intended to prevent rejection for the life of the graft. Rescue therapies are similar to induction, both in efficacy and toxicity, but the primary purpose is to reverse established graft rejection. Only a limited number of immunosuppressive agents are available for induction and rejection therapy, including monoclonal antibodies (alemtuzumab, basiliximab, daclizumab, muromonab-CD3) and polyclonal antibodies (antithymocyte globulin [rabbit], antithymocyte globulin [equine]). These agents can also be classified depending on their ability to deplete T cells into depleting agents (alemtuzumab, antithymocyte globulins, muromonab-CD3) or nondepleting agents (basiliximab, daclizumab). Maintenance immunosuppression consists of a variety of glucocorticoids, antimetabolites, calcineurin inhibitors, and mTOR inhibitors. They are used in many different combinations, depending on programmatic philosophy and patient needs. This chapter will review the cellular and molecular mechanisms of these agents.