Heinz Steltzer

Impact of acute renal failure on antioxidant status in multiple organ failure

Background: Acute renal failure (ARF) can be triggered or aggravated by reactive oxygen species (ROS) but established ARF per se might also affect the antioxidant defence mechanisms of the organism. We evaluated a broad pattern of antioxidants in critically ill patients with multiple organ failure with (MOF‐ARF) and without acute renal failure (MOF) to identify any potential involvement of renal dysfunction in the depletion of the antioxidant system.

Prognostic performance and customization of the SAPS II: results of a multicenter Austrian study

Objectives: To evaluate the prognostic performance of the original Simplified Acute Physiology Score (SAPS) II in Austrian intensive care patients and to evaluate the impact of customization. Design: Analysis of the database of a multicenter study. Setting: Nine adult medical, surgical, and mixed intensive care units (ICUs) in Austria. Patients: A total of 1733 patients consecutively admitted to the ICUs. Measurements and results: The database included admission data, SAPS II, length of stay, and hospital mortality. The Hosmer–Lemeshow goodness-of-fit test for the SAPS II showed a lack of uniformity of fit (H = 89.1, 10 df, p < 0.0001; C = 91.8, 10 df, p < 0.0001). Subgroup analysis showed good performance in patients with cardiovascular (medical and surgical) diseases as the primary reasons for admission. A new predictive equation was derived by means of the logistic regression. Goodness-of-fit was excellent for the customized model (SAPS IIAM) (H = 11.2, 9 df, p = 0.33, C = 11.6, 9 df, p = 0.24). The mean standardized mortality ratio (SMR) changed from 0.81 ± 0.26 to 0.93 ± 0.29 with customization. Conclusions: SAPS II was not well calibrated when applied to all patients. However, it performed well for patients with cardiovascular diseases as the primary reason for admission and may thus be applied to these patients. Standardized mortality ratios that are calculated from scoring systems without known calibration must be viewed with skepticism.

Comparison of invasive and noninvasive measurement of plasma disappearance rate of indocyanine green in patients undergoing liver transplantation: A prospective investigator-blinded study

Plasma disappearance rate of indocyanine green (PDRICG) has been proposed for assessment of liver function in liver transplants donors and recipients, in patients with chronic liver failure, and as a prognostic factor in critically ill patients. The assessment of PDRICG using a newly developed noninvasive digital pulse densitometry method was simultaneously compared to invasive aortic fiber‐optic method in patients undergoing orthotopic liver transplantation (OLT). Fourteen consecutive liver transplant candidates (11 male, 3 female) were prospectively enrolled into the study. A 4F aortic catheter with an integrated fiber‐optic device and a thermistor was inserted via a femoral artery sheath for invasive aortic (INV) PDRICG assessment in all patients. The fiber‐optic device was connected to a computer system (COLD‐Z021, PULSION Medical Systems, Munich, Germany). A finger‐piece sensor was used for non‐invasive (NINV) pulse‐densitometric PDRICG assessment. For the PDRICG assessment .5 mg/kg of ICG in cooled saline (10‐15 mL) was injected through a central venous catheter. The assessments of PDRICG were performed after induction of anesthesia, after clamping of the hepatic artery, after clamping of the inferior vena cava, after reperfusion of the graft, and on the first postoperative day. During the PDRICG measurements, the investigators were blinded for the results of the noninvasive monitoring. Seventy‐one pairs of measurements were performed successfully. PDRICG ranged from 0%/min to 43.8 %/min (11.6%/min ± 9.6 %/min, mean ± SD) for invasive and from 2.6%/min to 36.1 %/min (10%/min ± 7.6 %/min, mean ± SD) for noninvasive assessment method. The linear regression analysis yielded the equation: PDRICGNINV = 1.493 ± 0.735 × PDRICGINV, with a correlation coefficient of r = 0.93 (P < .0001). The analysis according to Bland and Altman showed a good agreement between the PDRICGNINV and PDRICGINV with a mean bias 1.5 ± 3.8 for all measurements. In conclusion, according to these results, the noninvasive transcutaneous pulse‐densitometric method correlates well with the invasive aortic fiber‐optic method and thus can be used in patients undergoing liver transplantation. (Liver Transpl 2004;10:1060–1064.)

Evaluation of an interdisciplinary data set for national intensive care unit assessment

OBJECTIVES To evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care. DESIGN A prospective, multicentric study. SETTING Nine adult medical, surgical, and mixed ICUs in Austria. PATIENTS A total of 1234 patients consecutively admitted to the ICUs. INTERVENTIONS Collection of data for the ASDI data set. MEASUREMENTS AND MAIN RESULTS The overall mean SAPS II score was 33.1+/-2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2%+/-2.9%, whereas observed mortality was only 16.8%+/-2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6+/-1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4+/-0.9 vs. 25.7+/-0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2 = .23; p < .54) or standardized mortality ratio per unit (r2 = -.22; p < .56) was found. CONCLUSIONS Implementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28.

Molecular adsorbent recirculating system and hemostasis in patients at high risk of bleeding: an observational study

IntroductionLiver failure is associated with reduced synthesis of clotting factors, consumptive coagulopathy, and platelet dysfunction. The aim of the study was to evaluate the effects of liver support using a molecular adsorbent recirculating system (MARS) on the coagulation system in patients at high risk of bleeding.MethodsWe studied 61 MARS treatments in 33 patients with acute liver failure (n = 15), acute-on-chronic liver failure (n = 8), sepsis (n = 5), liver graft dysfunction (n = 3), and cholestasis (n = 2). Standard coagulation tests, standard thromboelastography (TEG), and heparinase-modified and abciximab-fab-modified TEG were performed immediately before and 30 minutes after commencement of MARS, and after the end of MARS treatment. Prostaglandin I2 was administered extracorporeally to all patients; 17 patients additionally received unfractioned heparin.ResultsThree moderate bleeding complications in three patients, requiring three to four units of packed red blood cells, were observed. All were sufficiently managed without interrupting MARS treatment. Although there was a significant decrease in platelet counts (median, 9 G/l; range, -40 to 145 G/l) and fibrinogen concentration (median, 15 mg/dl; range, -119 to 185 mg/dl) with a consecutive increase in thrombin time, the platelet function, as assessed by abciximab-fab-modified TEG, remained stable. MARS did not enhance fibrinolysis.ConclusionMARS treatment appears to be well tolerated during marked coagulopathy due to liver failure. Although MARS leads to a further decrease in platelet count and fibrinogen concentration, platelet function, measured as the contribution of the platelets to the clot firmness in TEG, remains stable. According to TEG-based results, MARS does not enhance fibrinolysis.

Effects of pentoxifylline on hemodynamics and oxygenation in septic and nonseptic patients

OBJECTIVE To evaluate the effects of pentoxifylline on hemodynamics and systemic oxygenation in septic and nonseptic critically ill patients. DESIGN Prospective clinical investigation. SETTING Intensive care unit (ICU) of a university hospital. PATIENTS Nineteen critically ill patients were included in the study 1 to 4 days after their admission to the ICU. A systemic inflammatory response syndrome was present in 12 patients, fulfilling at least two of the American College of Chest Physicians/ Society of Critical Care Medicine Consensus Conference criteria. The other seven patients did not fulfill these criteria and were classified as nonseptic. INTERVENTIONS All patients were mechanically ventilated. The dosage of catecholamines was kept constant during the entire study period and at least during 15 mins before the start of the study. In both study groups, pulmonary and radial artery catheters were inserted and 5 mg/kg of pentoxifylline (diluted in 300 mL of physiologic saline) was intravenously administered over a period of 180 mins at a rate of 100 mL/hr. MEASUREMENTS AND MAIN RESULTS Hemodynamic variables, oxygen transport (DO2), oxygen uptake (VO2), and oxygen extraction ratio were determined before pentoxifylline, after 2.5 mg/kg of pentoxifylline, after 5 mg/kg of pentoxifylline, and 60 mins after the termination of pentoxifylline. Repeated-measures analysis of variance and Mann-Whitney test were used for statistical analysis. At baseline, there were significant differences between the septic and the nonseptic groups in mean pulmonary arterial pressure (septic: 31 +/- 5 mm Hg; nonseptic: 26 +/- 7 mm Hg, p < .05), and pulmonary vascular resistance index (PVRI) (septic: 344 +/- 121 dyne.sec/ cm5.m2; nonseptic: 233 +/- 100 dyne.sec/cm5.m2, p < .05). In the septic group, significant increases in heart rate and cardiac index were observed. Systemic vascular resistance index and PVRI decreased. No significant changes in hemodynamic variables occurred in the nonseptic group. In both groups, DO2 and VO2 increased significantly, while oxygen extraction ratio remained unchanged. CONCLUSIONS The administration of pentoxifylline to septic patients results in a significant improvement in hemodynamic performance compared with critically ill nonseptic patients. The better hemodynamic state is accompanied by an increase in DO2 and VO2 with unchanged oxygen extraction ratio.

Extracorporeal albumin dialysis in patients with Amanita phalloides poisoning

Background: Ingestion of Amanita phalloides is the most common cause of lethal mushroom poisoning. The relative late onset of symptoms is a distinct diagnostic feature of Amanita intoxication and also the main reason of failure for extracorporeal removal of Amanita‐specific toxins from the gut and circulation.

Evaluation of the logistic organ dysfunction system for the assessment of organ dysfunction and mortality in critically ill patients

Abstract. Objectives: To evaluate the performance of the logistic organ dysfunction (LOD) system for the assessment of morbidity and mortality in multiple organ dysfunction/failure (MOD/F) in an independent database and to evaluate the use of sequential LOD measurements for the prediction of outcome. Design and setting: Prospective, multicentric cohort study in 13 adult medical, surgical, and mixed intensive care units (ICUs) in Austria. Patients: A total of 2893 consecutive admissions to the ICUs. Measurements and main results: Patient vital status at ICU and hospital discharge was recorded. Univariate analysis showed that the LOD was able to distinguish between survivors and nonsurvivors (2 vs. 6 median score). Within organ systems, higher levels of the severity of organ dysfunction were consistently associated with higher mortality. For the prediction of hospital mortality, the original prognostic LOD model did not perform well in our patients, as indicated by the goodness-of-fit Ĉ statistic. Using multiple logistic regression we developed a prognostic model with a satisfactory fit in our patients. The integration of further measurements during the ICU stay increased discrimination but not calibration. Conclusions: The LOD system is well correlated well with the numbers and levels of organ dysfunctions and discriminates well between survivors and nonsurvivors. It can thus be used to quantify the baseline severity of organ dysfunction. Moreover, after customization of the predictive equation the LOD predicted hospital mortality in our patients with high precision. It thus provides a combined measure of morbidity and mortality for critically ill patients with MOD/F.

Molecular adsorbent recirculating system in patients with early allograft dysfunction after liver transplantation: A pilot study

Early allograft dysfunction (EAD) after orthotopic liver transplantation (OLT) causes marked morbidity and mortality. We conducted a prospective pilot study to assess the safety and efficacy of molecular adsorbent recirculating system (MARS) in treatment of EAD after OLT. Twelve consecutive adult liver allograft recipients with a median age of 48 years, 9 of whom were male, were prospectively included and supported with MARS. EAD was defined as the presence of at least 2 of the following: serum bilirubin >10 mg/dL, prothrombin time <40%, aspartate aminotransferase or alanine transferase >1,000 U/L, and plasma disappearance rate of indocyanine green (PDRICG) <10% per minute within 72 hours after reperfusion. One‐year patient and graft survival was 66%. There was a significant decrease in serum bilirubin (P = 0.002), serum creatinine (P = 0.006), and aspartate aminotransferase (P = 0.005) and a significant increase in PDRICG (P = 0.007) after MARS treatment. Prothrombin time, albumin level, and platelet count remained stable. Sustained improvement of renal and neurological function and of mean arterial pressure were observed. No MARS‐related adverse effects occurred. MARS treatment provides a safe approach to the treatment of EAD after OLT. On the basis of this pilot study, a multicenter randomized clinical trial that uses MARS treatment in EAD after OLT has been initiated. Liver Transpl 12:1357‐1364, 2006.

Septic shock secondary to β-hemolytic streptococcus-induced necrotizing fasciitis treated with a novel cytokine adsorption therapy.

Introduction Numerous animal studies and preliminary data from a clinical trial in septic patients demonstrated that a decrease in blood cytokine levels using an extracorporeal cytokine filter (CytoSorb™) can effectively attenuate the inflammatory response during sepsis and possibly improve outcomes. Methods A 60-year-old female was admitted to hospital due to a forearm fracture. After surgical wound care by osteosynthesis the patient developed surgical wound infection which progressed to necrotizing fasciitis. All diagnostic criteria for SIRS were evident with additional proven infection from β-hemolytic streptococcus. On admission to the ICU, the patient presented a full picture of multiple organ dysfunction syndrome due to septic shock including kidney failure, lung failure as well as thrombocytopenia, metabolic acidosis, and arterial hypotension. Results After one day on mechanical ventilation and an IL-6 level of 70 000 pg/ml the patient was treated with CytoSorb therapy over a period of four days, resulting in a significant reduction of IL-6 to 66 pg/ml and an overall improvement of the patients condition. Despite the necessity of enucleation, the patient was successfully stabilized until control of the surgical infectious source was achieved. Importantly, treatment was safe and well-tolerated, without any adverse events. Conclusions This is the first report of the clinical application of CytoSorb hemoadsorption in combination with a CRRT in a patient with septic shock. CytoSorb as described was able to significantly reduce IL-6 plasma levels and decrease vasopressor need while no adverse and device-related events occurred. CytoSorb seems to be an interesting and safe extracorporeal therapy to stabilize and bridge septic patients to surgery or recovery.