Daryl J. Kor

Incidence and transfusion risk factors for transfusion-associated circulatory overload among medical intensive care unit patients

BACKGROUND: Transfusion‐associated circulatory overload (TACO) is a frequent complication of blood transfusion. Investigations identifying risk factors for TACO in critically ill patients are lacking.

Predictors of Acute Kidney Injury in Septic Shock Patients: An Observational Cohort Study

BACKGROUND AND OBJECTIVES 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. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS 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. RESULTS 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%). CONCLUSIONS In a contemporary cohort of patients with septic shock, both patient and health care delivery risk factors seemed to be important for AKI development.

Fresh Red Blood Cell Transfusion and Short-Term Pulmonary, Immunologic, and Coagulation Status A Randomized Clinical Trial

RATIONALE Transfusion-related pulmonary complications are leading causes of morbidity and mortality attributed to transfusion. Observational studies suggest an important role for red blood cell (RBC) storage duration in these adverse outcomes. OBJECTIVES To evaluate the impact of RBC storage duration on short-term pulmonary function as well as immunologic and coagulation status in mechanically ventilated patients receiving RBC transfusion. METHODS This is a double-blind, randomized, clinical trial comparing fresh (≤5 d of storage) versus standard issue single-unit RBC transfusion in adult intubated and mechanically ventilated patients. The primary outcome is the change in pulmonary gas exchange as assessed by the partial pressure of arterial oxygen to fraction of inspired oxygen concentration ratio (ΔPa(O(2))/Fi(O(2))). Secondary outcomes include changes in immune and coagulation status. MEASUREMENTS AND MAIN RESULTS Fifty patients were randomized to receive fresh RBCs and an additional 50 patients to standard issue RBCs. Median storage age was 4.0 days (interquartile range, 3.0-5.0) and 26.5 days (interquartile range, 21.0-36.0) in the fresh RBC group and standard issue RBC group, respectively. No differences were noted in the primary outcome of ΔPa(O(2))/Fi(O(2)) (difference between the mean ΔPa(O(2))/Fi(O(2)) in the standard issue RBC group vs. the fresh RBC group, -11.5; 95% confidence interval, -35.3 to 12.3; P = 0.22). Similarly, no significant differences were noted in markers of immunologic or coagulation status. CONCLUSIONS In this randomized clinical trial, no differences were noted in early measures of pulmonary function or in immunologic or coagulation status when comparing fresh versus standard issue single-unit RBC transfusion. Clinical trial registered with ClinicalTrials.gov (NCT00751322).

Prehospitalization Antiplatelet Therapy Is Associated With a Reduced Incidence of Acute Lung Injury: A Population-Based Cohort Study

BACKGROUND Acute lung injury (ALI) is a potentially fatal lung disease with few treatment options. Platelet activation is a key component of ALI pathophysiology and may provide an opportunity for prevention strategies. We examined the association of prehospitalization antiplatelet therapy with development of ALI in critically ill patients. METHODS All Olmsted County, Minnesota, residents with a medical ICU admission in the year 2006 were evaluated. Patients with at least one major risk factor for ALI who did not meet criteria for ALI at the time of hospital admission were included in the analysis. Baseline characteristics, major risk factors for ALI, the presence of antiplatelet therapy at the time of hospitalization, and the propensity to receive this therapy were determined. The primary outcome was ALI or ARDS during the hospitalization. Secondary outcomes were ICU and hospital-free days and ICU and hospital mortality. RESULTS A total of 161 patients were evaluated. Seventy-nine (49%) were receiving antiplatelet therapy at hospital admission; 33 (21%) developed ALI/ARDS. Antiplatelet therapy was associated with a reduced incidence of ALI/ARDS (12.7% vs 28.0%; OR, 0.37; 95% CI, 0.16-0.84; P = .02). This association remained significant after adjusting for confounding variables. CONCLUSIONS Prehospitalization antiplatelet therapy was associated with a reduced incidence of ALI/ARDS. If confirmed in a more diverse patient population, these results would support the use of antiplatelet agents in an ALI prevention trial.

Derivation and Diagnostic Accuracy of the Surgical Lung Injury Prediction Model

Background:Acute lung injury (ALI) is a serious postoperative complication with limited treatment options. A preoperative risk-prediction model would assist clinicians and scientists interested in ALI. The objective of this investigation was to develop a surgical lung injury prediction (SLIP) model to predict risk of postoperative ALI based on readily available preoperative risk factors. Methods:Secondary analysis of a prospective cohort investigation including adult patients undergoing high-risk surgery. Preoperative risk factors for postoperative ALI were identified and evaluated for inclusion in the SLIP model. Multivariate logistic regression was used to develop the model. Model performance was assessed with the area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test. Results:Out of 4,366 patients, 113 (2.6%) developed early postoperative ALI. Predictors of postoperative ALI in multivariate analysis that were maintained in the final SLIP model included high-risk cardiac, vascular, or thoracic surgery, diabetes mellitus, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and alcohol abuse. The SLIP score distinguished patients who developed early postoperative ALI from those who did not with an area under the receiver operating characteristic curve (95% CI) of 0.82 (0.78–0.86). The model was well calibrated (Hosmer-Lemeshow, P = 0.55). Internal validation using 10-fold cross-validation noted minimal loss of diagnostic accuracy with a mean ± SD area under the receiver operating characteristic curve of 0.79 ± 0.08. Conclusions:Using readily available preoperative risk factors, we developed the SLIP scoring system to predict risk of early postoperative ALI.

Acute lung injury prediction score: derivation and validation in a population-based sample.

Early recognition of patients at high risk of acute lung injury (ALI) is critical for successful enrolment of patients in prevention strategies for this devastating syndrome. We aimed to develop and prospectively validate an ALI prediction score in a population-based sample of patients at risk. In a retrospective derivation cohort, predisposing conditions for ALI were identified at the time of hospital admission. The score was calculated based on the results of logistic regression analysis. Prospective validation was performed in an independent cohort of patients at risk identified at the time of hospital admission. In a derivation cohort of 409 patients with ALI risk factors, the lung injury prediction score discriminated patients who developed ALI from those who did not with an area under the curve (AUC) of 0.84 (95% CI 0.80–0.89; Hosmer–Lemeshow p = 0.60). The performance was similar in a prospective validation cohort of 463 patients at risk of ALI (AUC 0.84, 95% CI 0.77–0.91; Hosmer–Lemeshow p = 0.88). ALI prediction scores identify patients at high risk for ALI before intensive care unit admission. If externally validated, this model will serve to define the population of patients at high risk for ALI in whom future mechanistic studies and ALI prevention trials will be conducted.

Elevated Postoperative Blood Glucose and Preoperative Hemoglobin A1C Are Associated with Increased Wound Complications Following Total Joint Arthroplasty

BACKGROUND Diabetes is an established risk factor for complications following total joint arthroplasty. However, the correlation between postoperative blood glucose and preoperative hemoglobin A1C levels with complications following total joint arthroplasty is not well described. METHODS All patients undergoing elective primary total joint arthroplasty at our institution from 2004 through 2011 with both postoperative blood glucose and preoperative hemoglobin A1C levels were identified in a retrospective review. From among 1702 patients, those with wound complications within thirty days after the index arthroplasty were identified. A control group matched for exact age, sex, procedure, tourniquet use, surgical approach, and use of antibiotic cement was also created. Thirty patients met the study group inclusion criteria. The mean patient age was seventy-two years (range, fifty-three to eighty-nine years); the majority (53%) of patients were female. RESULTS The odds ratio for developing a wound complication was 3.75 (95% confidence interval, 1.25 to 11.22; p = 0.02) in patients with a mean postoperative glucose of >200 mg/dL, 3.0 (95% confidence interval, 0.97 to 9.30; p = 0.08) in patients with a maximum postoperative blood glucose of >260 mg/dL, and 9.0 (95% confidence interval, 1.14 to 71.20; p = 0.03) in patients with a preoperative hemoglobin A1C value of >6.7%. CONCLUSIONS Patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty. These results show that poor preoperative and postoperative glucose control is independently associated with wound complications.

Association of prehospitalization aspirin therapy and acute lung injury: results of a multicenter international observational study of at-risk patients.

Objective:To evaluate the association between prehospitalization aspirin therapy and incident acute lung injury in a heterogeneous cohort of at-risk medical patients. Design:This is a secondary analysis of a prospective multicenter international cohort investigation. Setting:Multicenter observational study including 20 US hospitals and two hospitals in Turkey. Patients:Consecutive, adult, nonsurgical patients admitted to the hospital with at least one major risk factor for acute lung injury. Interventions:None. Measurements and Main Results:Baseline characteristics and acute lung injury risk factors/modifiers were identified. The presence of aspirin therapy and the propensity to receive this therapy were determined. The primary outcome was acute lung injury during hospitalization. Secondary outcomes included intensive care unit and hospital mortality and intensive care unit and hospital length of stay. Twenty-two hospitals enrolled 3855 at-risk patients over a 6-month period. Nine hundred seventy-six (25.3%) were receiving aspirin at the time of hospitalization. Two hundred forty (6.2%) patients developed acute lung injury. Univariate analysis noted a reduced incidence of acute lung injury in those receiving aspirin therapy (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.46–0.90; p = .010). This association was attenuated in a stratified analysis based on deciles of aspirin propensity scores (Cochran-Mantel-Haenszel pooled OR, 0.70; 95% CI, 0.48–1.03; p = .072). Conclusions:After adjusting for the propensity to receive aspirin therapy, no statistically significant associations between prehospitalization aspirin therapy and acute lung injury were identified; however, a prospective clinical trial to further evaluate this association appears warranted.

Transfusion from male-only versus female donors in critically ill recipients of high plasma volume components

Objective:To reduce the incidence of transfusion-related acute lung injury (ALI), the American Association of Blood Banks recently recommended rapid implementation of strategies to minimize transfusion of high plasma volume components, fresh frozen plasma and apheresis platelets, from potentially alloimmunized donors, especially females. The objective of this study was to evaluate the effect of transfusing components from male-only vs. female donors on development of ALI, gas exchange, and outcome in critically ill patients. Design:In this retrospective case-control study, we identified patients who received high plasma volume components from male-only donors and compared them with patients matched by severity of illness, postoperative state, and number of transfusions but who received high plasma volume components from female donors. Setting:Four intensive care units at a tertiary medical center. Patients:Critically ill patients who received >2 units of fresh frozen plasma or apheresis platelets. Interventions:None. Measurements and Main Results:From a database of 3,567 patients who received a total of 46,101 units of fresh frozen plasma and 6,251 units of apheresis platelets, we identified 112 patients who received three or more male-only donor components and 112 matched controls. Baseline characteristics, ALI risk factors, and development of ALI were similar between the two groups. Arterial oxygenation (Pao2/Fio2) worsened after the female (mean difference −52, 95% confidence interval −14 to −91, p = .008) but not after male-only donor product transfusion (mean difference 22, 95% confidence interval −23 to 67, p = .325). Male-only component recipients had more ventilator-free days (median 28 vs. 27, p = .006) and a trend toward lower hospital mortality rates (14% vs. 24%, p = .054). Conclusions:In critically ill recipients of high plasma volume components, gas exchange worsened significantly after transfusion of female but not male donor components. Prospective studies are needed to evaluate the effect of recommendations by the American Association of Blood Banks on outcome of transfused critically ill patients.

Derivation and Validation of Automated Electronic Search Strategies to Identify Pertinent Risk Factors for Postoperative Acute Lung Injury

OBJECTIVE To develop and validate time-efficient automated electronic search strategies for identifying preoperative risk factors for postoperative acute lung injury. PATIENTS AND METHODS This secondary analysis of a prospective cohort study included 249 patients undergoing high-risk surgery between November 1, 2005, and August 31, 2006. Two independent data-extraction strategies were compared. The first strategy used a manual review of medical records and the second a Web-based query-building tool. Web-based searches were derived and refined in a derivation cohort of 83 patients and subsequently validated in an independent cohort of 166 patients. Agreement between the 2 search strategies was assessed with percent agreement and Cohen κ statistics. RESULTS Cohen κ statistics ranged from 0.34 (95% confidence interval, 0.00-0.86) for amiodarone to 0.85 for cirrhosis (95% confidence interval, 0.57-1.00). Agreement between manual and automated electronic data extraction was almost complete for 3 variables (diabetes mellitus, cirrhosis, H(2)-receptor antagonists), substantial for 3 (chronic obstructive pulmonary disease, proton pump inhibitors, statins), moderate for gastroesophageal reflux disease, and fair for 2 variables (restrictive lung disease and amiodarone). Automated electronic queries outperformed manual data collection in terms of sensitivities (median, 100% [range, 77%-100%] vs median, 87% [range, 0%-100%]). The specificities were uniformly high (≥ 96%) for both search strategies. CONCLUSION Automated electronic query building is an iterative process that ultimately results in accurate, highly efficient data extraction. These strategies may be useful for both clinicians and researchers when determining the risk of time-sensitive conditions such as postoperative acute lung injury.