Katarzyna Kotfis

Higher Fluid Balance Increases the Risk of Death From Sepsis: Results From a Large International Audit

Objectives: Excessive fluid therapy in patients with sepsis may be associated with risks that outweigh any benefit. We investigated the possible influence of early fluid balance on outcome in a large international database of ICU patients with sepsis. Design: Observational cohort study. Setting: Seven hundred and thirty ICUs in 84 countries. Patients: All adult patients admitted between May 8 and May 18, 2012, except admissions for routine postoperative surveillance. For this analysis, we included only the 1,808 patients with an admission diagnosis of sepsis. Patients were stratified according to quartiles of cumulative fluid balance 24 hours and 3 days after ICU admission. Measurements and Main Results: ICU and hospital mortality rates were 27.6% and 37.3%, respectively. The cumulative fluid balance increased from 1,217 mL (–90 to 2,783 mL) in the first 24 hours after ICU admission to 1,794 mL (–951 to 5,108 mL) on day 3 and decreased thereafter. The cumulative fluid intake was similar in survivors and nonsurvivors, but fluid balance was less positive in survivors because of higher fluid output in these patients. Fluid balances became negative after the third ICU day in survivors but remained positive in nonsurvivors. After adjustment for possible confounders in multivariable analysis, the 24-hour cumulative fluid balance was not associated with an increased hazard of 28-day in-hospital death. However, there was a stepwise increase in the hazard of death with higher quartiles of 3-day cumulative fluid balance in the whole population and after stratification according to the presence of septic shock. Conclusions: In this large cohort of patients with sepsis, higher cumulative fluid balance at day 3 but not in the first 24 hours after ICU admission was independently associated with an increase in the hazard of death.

Donor-recipient gender mismatch affects early graft loss after kidney transplantation.

BACKGROUND We sought to determine the risk factors influencing the occurrence of early graft loss among kidney transplant recipients. STUDY DESIGN One hundred forty-six potential donors and 230 kidney recipients were included in the study. Prior to organ procurement we collected demographic data as well as hemodynamic data of mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, systemic vascular resistance index acquired by means of a thermodilution method. The recipient data included age, gender, prior hemodialysis period, panel-reactive antibodies, cold ischemia time, renal insufficiency cause, and donor-recipient gender mismatch. We assessed the influence of the data on graft loss at 30 days after renal transplantation. To confirm the relationships, we performed statistical analyses using chi-square, Fisher exact, and V. Cramer tests. RESULTS There were no significant relationships between the analyzed parameters and early graft loss in the study group except for gender mismatch. The 71 female recipients of male kidneys showed the lowest graft survival: donor/recipient male/female 89%; donor/recipient female/male 97%; no mismatch 97% (P=.01). CONCLUSIONS Female recipients of male kidneys may experience a greater risk of early graft loss compared with all other gender combinations.

Worldwide Survey of the "Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment" (ABCDEF) Bundle.

Objectives: To assess the knowledge and use of the Assessment, prevention, and management of pain; spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle to implement the Pain, Agitation, Delirium guidelines. Design: Worldwide online survey. Setting: Intensive care. Intervention: A cross-sectional online survey using the Delphi method was administered to intensivists worldwide, to assess the knowledge and use of all aspects of the ABCDEF bundle. Measurement and Main Results: There were 1,521 respondents from 47 countries, 57% had implemented the ABCDEF bundle, with varying degrees of compliance across continents. Most of the respondents (83%) used a scale to evaluate pain. Spontaneous awakening trials and spontaneous breathing trials are performed in 66% and 67% of the responder ICUs, respectively. Sedation scale was used in 89% of ICUs. Delirium monitoring was implemented in 70% of ICUs, but only 42% used a validated delirium tool. Likewise, early mobilization was “prescribed” by most, but 69% had no mobility team and 79% used no formal mobility scale. Only 36% of the respondents assessed ICU-acquired weakness. Family members were actively involved in 67% of ICUs; however, only 33% used dedicated staff to support families and only 35% reported that their unit was open 24 hr/d for family visits. Conclusions: The current implementation of the ABCDEF bundle varies across individual components and regions. We identified specific targets for quality improvement and adoption of the ABCDEF bundle. Our data reflect a significant but incomplete shift toward patient- and family-centered ICU care in accordance with the Pain, Agitation, Delirium guidelines.

Peripheral Blood Lymphocyte Subsets (CD4+, CD8+ T Cells, NK Cells) in Patients with Cardiovascular and Neurological Complications after Carotid Endarterectomy

Background: The aim of the study was to evaluate the differences in the circulating immune cells’ subgroups after the atherosclerotic plaque removal in patients presenting with postoperative complications as compared to the patients without complications after carotid endarterectomy (CEA). Methods: Patients with significant carotid atherosclerosis (n = 124, age range: 44 to 87 years) who underwent CEA were enrolled in a prospective study. The immunology study using flow cytometry was performed to determine the percentages of peripheral blood T cells (CD4+, CD8+, Treg—CD4+/CD25+) and NK (natural killer) cells before and after the procedure. The data were expressed as the percentage of total lymphocytes ± the standard error of mean. Results: The mean percentage of lymphocytes (61.54% ± 17.50% vs. 71.82% ± 9.68%, p = 0.030) and CD4 T lymphocytes (T helper, 38.13% ± 13.78% vs. 48.39% ± 10.24%, p = 0.027) was significantly lower six hours after CEA in patients with postoperative 30-day cardiovascular and neurological complications as compared to the group without complications. On the other hand the mean NK level in the group with complications was significantly higher (21.61% ± 9.00% vs. 15.80% ± 9.31%, p = 0.048). Conclusions: The results of this study suggest that after carotid endarterectomy the percentages of circulating immune cells subsets differ in patients with and without postoperative complications.

Graft Infection in Kidney Recipients and Its Relation to Transplanted Kidney Function

INTRODUCTION Following kidney transplantation, septic complications are the leading causes of therapeutic failure including recipient death or graft removal. The serum creatinine level is one of the earliest metrics of kidney metabolic function. We examined the influence of graft infection on serum creatinine levels in kidney recipients. STUDY DESIGN We analyzed the function of 220 kidneys transplanted in nine centers in Poland. The kidneys were recovered from 146 multiorgan donors. Donor urea and creatinine levels were within the normal range. We investigated the influence of perioperative graft infection incidence on recipient creatinine levels at 1, 2, 3, 7, 14, 30, 90, and 180 days after kidney transplantation. The association of the serum creatinine level with categorical variables was assessed using either Student t test analysis of variance and multivariate techniques. In all analyses P<.05 indicated statistical significance. RESULTS There were 25 graft infections revealing a significant relationship with increased recipient serum creatinine level after kidney transplantation (P=.003). Multivariate analysis confirmed the impact of infection. CONCLUSION Perioperative kidney graft infection influenced graft funtion in the early and late periods post-transplantation.

Risk Factors for Septic Complications in Kidney Transplant Recipients

INTRODUCTION Septic complications following kidney transplantation are a leading cause of therapeutic failure. An early diagnosis may protect the recipient from the severe consequences of sepsis. We sought to determine the risk factors influencing the occurrence of septic complications among kidney transplant recipients. MATERIALS AND METHODS The 146 potential donors included in the study were evaluated for brain stem death criteria. Supportive management included mechanical ventilation to normocapnia, rewarming, as well as fluid and electrolyte replacement. Dopamine infusions and desaminovasopressin were titrated to predetermined mean arterial pressure (MAP). Central venous pressure (CVP) was maintained at 8 to 11 mm Hg. Hemodynamic data were acquired by the thermodilution method prior to organ procurement: MAP, CVP, pulmonary capillary wedge pressure (PCWP), and systemic vascular resistance index (SVRI). Recipient data included age, gender, period of prior hemodialysis, panel reactive antibodies, cold ischemia time, and cause of renal insufficiency. The 232 kidney recipients were examined for occurrence of septic complications including septicemia, pneumonia, peritonitis, or graft infection. RESULTS Kidney transplants from donors with MAP < 70 mm Hg and SVRI < 1200 dyne x s/cm(5) x m(2) showed a significantly higher occurrence of septic complications in recipients (P < .05) where mortality rate was also significantly greater (P < .01). CONCLUSIONS MAP < 70 mm Hg and SVRI < 1200 dyne x s/cm(5) x m(2) among organ donors predicted greater occurrence of septic complications and increased mortality among kidney transplant recipients.

Methods of pain assessment in adult intensive care unit patients — Polish version of the CPOT (Critical Care Pain Observation Tool) and BPS (Behavioral Pain Scale)

Many patients treated in the intensive care unit (ICU) experience pain that is a source of suffering and leaves a longterm imprint (chronic pain, post-traumatic stress disorder). Nearly 30% of patients experience pain at rest, while the percentage increases to 50% during nursing procedures. Pain in ICU patients can be divided into four categories: continuous ICU treatment-related pain/discomfort, acute illness-related pain, intermittent procedural pain and pre-existing chronic pain present before ICU admission. As daily nursing procedures and interventions performed in the ICU may be a potential source of pain, it is crucial to use simple pain monitoring tools. The assessment of pain intensity in ICU patients remains an everyday challenge for clinicians, especially in sedated, intubated and mechanically ventilated patients. Regular assessment of pain intensity leads to improved outcome and better quality of life of patients in the ICU and after discharge from ICU. The gold standard in pain evaluation is patient self-reporting, which is not always possible. Current research shows that the two tools best validated for patients unable to self-report pain are the Behavioral Pain Scale (BPS) and the Critical Care Pain Observation Tool (CPOT). Although international guidelines recommend the use of validated tools for pain evaluation, they underline the need for translation into a given language. The authors of this publication obtained an official agreement from the authors of the two behavioral scales - CPOT and BPS - for translation into Polish. Validation of these tools in the Polish population will aid their wider use in pain assessment in ICUs in Poland.

Influence of Selected Factors on Long-Term Kidney Graft Survival—A Multivariable Analysis

BACKGROUND Long-term function of transplanted kidney is the factor determining quality of life for transplant recipients. The aim of this study was to evaluate the effect of selected factors on time of graft function after renal transplantation within 15 years of observation. METHODS Preoperative and intraoperative factors were analyzed in 232 kidney recipients within a 15-year observation period. Analysis included age, sex, cause of recipients renal failure, length of hemodialyses before transplantation, peak panel reactive antibodies test, human leukocyte antigen compatibility, cold ischemia time, delayed graft function occurrence, length and time of hemodialyses after transplantation, early graft rejection, creatinine level at days 1, 3, 7, 30, 90, and 180 after transplantation, and influence of these factors on the time of graft function. Statistical analysis was performed with the use of univariate and multivariate Kaplan-Meier test and Cox regression proportional hazards model, with P < .05 considered to be significant. RESULTS Univariate analysis showed significantly shorter renal graft function in the group of recipients with higher creatinine levels in all of the analyzed time periods and in patients experiencing delayed graft function. Length of time of hemodialyses after transplantation and number of dialyses had significant impact on worsening of late transplant results. Multivariate analysis reported that early graft rejection in the postoperative period is an independent factor improving late graft function: P = .002; hazard ratio (HR), 0.49 (95% confidence interval [CI], 0.31-0.78). Higher creatinine level at day 90 after kidney transplantation is a predictive factor of late graft dysfunction: P = .002; HR, 1.68 (95% CI 1.2-2.35). CONCLUSIONS Creatinine level at day 90 after renal transplantation is the prognostic factor of long-term kidney function. Early transplant rejection leads to introduction of more aggressive immunosuppression protocol, which improves long-term transplant results.

Association of the A1936G (rs203462) of A-Kinase Anchoring Protein 10 Polymorphisms With QT Interval Prolongation During Kidney Transplantation

INTRODUCTION The purpose of this study was to investigate whether the polymorphism in the kinase-binding domain of A-kinase anchoring protein 10 (AKAP10) was related to the risk of occurrence of potentially dangerous arrhythmias during kidney transplant. METHODS We performed this prospective observational study with additional patient monitoring during the kidney transplant procedure and in the postoperative period with continuous electrocardiogram (ECG) - (digital holter; ECG monitor type 300-7 Suprima system; Oxford, UK). After manual trace analysis, we performed classification of arrhythmias by interval measurement (including QT correction according to Bazetts formula: Qtc = QT/RR1/2), ST segment analysis within all channels, and analysis of heart rate variability (HRV) parameters (time analysis: SDNN as total rate variability measure, SDANN as long-term variability measure, SDNNindex, rMSSD and pNN50 as short-term variability measure) as well as frequency measure of power width parameters in the spectrum between 0.0033 Hz and 0.4 Hz. Subsequently applying polymerase chain reaction restriction fragment length polymorphism methods, we investigated A1936G (rs203462) AKAP10 polymorphism among 54 kidney recipients. RESULTS Analysis of variance showed that prolongation of the QTc interval associated with the variant genotypes (GG + AG) was significantly greater compared with the AA genotype among kidney recipients (P = .04). We did not observe a relationship between the AKAP10 polymorphism and other arrhythmias, or clinical or environmental factors. CONCLUSIONS Our data suggested that the AKAP10 (rs203462) GG + AG variation was associated with an increased risk of severe arrhythmias during kidney transplantation.

Cause of Death in Multiorgan Donors and Its Relation to the Function of Transplanted Kidneys

BACKGROUND Brain death is an important variable contributing to donor-specific kidney damage. Poor kidney performance posttransplantation may be related to the cause of death of the donor. OBJECTIVE To assess the influence of cause of death in multiorgan donors on the function of transplanted kidneys. MATERIAL AND METHODS Standard criteria for the brain stem death protocol were applied in 146 potential heart donors included in the study. Conventional supportive management consisted of mechanical ventilation to achieve normocapnia, rewarming, and fluid and electrolyte replacement. Dopamine infusion not exceeding 10 microg/kg/min and desaminovasopressin were titrated to predetermined mean arterial pressure (MAP). In renal allograft recipients (n = 232), kidney function was monitored using serial serum creatinine concentrations on days 1, 2, 3, 7, 14, 30, and 90 posttransplantation. The relation between donor cause of death (injury, bleeding, or other cause) and recipient serum creatinine concentration was analyzed in the postoperative period. RESULTS Significantly greater serum creatinine concentrations were observed up to 14 days posttransplantation in recipients of a kidney from a donor who died of any cause other than injury. Recipients of a kidney from a donor who died of bleeding exhibited significantly greater serum creatinine concentrations at 30 days posttransplantation. CONCLUSIONS A cause of death other than injury or bleeding in a multiorgan donor is predictive of worse kidney graft function in the first 14 days posttransplantation. Intracranial bleeding in a multiorgan donor is predictive of worse kidney graft function in the early period posttransplantation.