Paulo Benigno Pena Batista

Prevention of Rhabdomyolysis in Bariatric Surgery

Background: Rhabdomyolysis (RML) is a clinical and biochemical syndrome caused by skeletal muscle necrosis that results in extravasation of toxic intracellular contents from the myocytes into the circulatory system. Postoperative RML in bariatric surgery occurs with various non-physiological surgical positions, with prolonged muscle compression. The potential consequences may lead to death. The purpose of this study is to review its pathophysiology and the best ways to prevent RML in bariatric surgery. Methods: We searched the literature and reviewed all relevant articles, by searching for the keywords: rhabdomyolysis, morbid obesity, prevention and bariatric surgery, giving a total of 39 articles. Results: Prevention may be enhanced by careful padding on the operative table at all pressure-points. Changing patient position, both intraoperatively and postoperatively, also reduces RML. A potential new solution to decrease the longer operative time and avoid RML is to perform the bariatric operation in two stages. Another way to limit the duration of surgery in high-risk patients is to alert surgeons not to select super-obese high-risk patients early in the learning curve. Conclusion: As RML is an important and potentially fatal complication of bariatric surgery, the best way to avoid it is effective prevention. More research on this subject is necessary.

Evaluation of Prognostic Indexes in Critical Acute Renal Failure Patients

Objective. To study different prognostic indexes in acute renal failure (ARF) patients admitted to an intensive care unit (ICU). Design. Prospective, cohort study. Individual Severity Score–Acute Tubular Necrosis (ISS‐ATN) obtained prospectively and retrospectively, Acute Physiologic and Chronic Health Evaluation (APACHE II) Score, APACHE II Risk, Lung Injury Score (LIS), and Number of Organ Failures (NOF) were calculated for each patient. The outcome analyzed was death in the ICU. Discrimination was evaluated by the area under the receiver operator characteristic curve (AUC). For calibration analysis, the chi‐square goodness‐of‐fit test was used to compare predicted mortality, calculated by ISS‐ATN (obtained prospectively or retrospectively) and APACHE II risk, with observed mortality. Setting. ICU, São Rafael Hospital, Salvador‐BA, Brazil. Patients. Seventy‐six ARF patients admitted to the ICU within 6 months. Interventions. Surgical and medical procedures. Measurements and Results. The observed AUC was 0.69 for LIS, 0.73 for prospective ISS‐ATN, 0.75 for retrospective ISS‐ATN, 0.76 for APACHE II Score, 0.78 for APACHE II Risk, and 0.88 for NOF. These areas were significantly different from 0.5 (p < .001). There was no difference between the observed and expected death rate calculated by ISS‐ATN. However, APACHE II underestimated the observed mortality (p < .001). Conclusion. The prognostic indexes studied showed good discriminative power. However, APACHE II was not well calibrated in contrast to the good calibration of ISS‐ATN.Objective. To study different prognostic indexes in acute renal failure (ARF) patients admitted to an intensive care unit (ICU). Design. Prospective, cohort study. Individual Severity Score–Acute Tubular Necrosis (ISS‐ATN) obtained prospectively and retrospectively, Acute Physiologic and Chronic Health Evaluation (APACHE II) Score, APACHE II Risk, Lung Injury Score (LIS), and Number of Organ Failures (NOF) were calculated for each patient. The outcome analyzed was death in the ICU. Discrimination was evaluated by the area under the receiver operator characteristic curve (AUC). For calibration analysis, the chi‐square goodness‐of‐fit test was used to compare predicted mortality, calculated by ISS‐ATN (obtained prospectively or retrospectively) and APACHE II risk, with observed mortality. Setting. ICU, Sao Rafael Hospital, Salvador‐BA, Brazil. Patients. Seventy‐six ARF patients admitted to the ICU within 6 months. Interventions. Surgical and medical procedures. Measurements and Results. The observed AUC was...

A clinical score to predict mortality in septic acute kidney injury patients requiring continuous renal replacement therapy: the HELENICC score

BackgroundThis study aimed to identify predictors of early (7-day) mortality in patients with septic acute kidney injury (AKI) who required continuous renal replacement therapy (CRRT).MethodsProspective cohort of 186 septic AKI patients undergoing CRRT at a tertiary hospital, from October 2005 to November 2010.ResultsAfter multivariate adjustment, five variables were associated to early mortality: norepinephrine utilization, liver failure, medical condition, lactate level, and pre-dialysis creatinine level. These variables were combined in a score, which demonstrated good discrimination, with a C-statistic of 0.82 (95% CI = 0.76–0.88), and good calibration (χ2 = 4.3; p = 0.83). SAPS 3, APACHE II and SOFA scores demonstrated poor performance in this population.ConclusionsThe HEpatic failure, LactatE, NorepInephrine, medical Condition, and Creatinine (HELENICC) score outperformed tested generic models. Future studies should further validate this score in different cohorts.

Agitated Saline Bubble−Enhanced Ultrasound for Assessing Appropriate Position of Hemodialysis Central Venous Catheter in Critically Ill Patients

APACHE, Acute Physiology and Chronic Health Evaluation; ICU, intensive care unit; SOFA, Sequential Organ Failure Assessment. To the Editor: Renal replacement therapy is recommended to be initiated immediately in patients with life-threatening acute kidney injury (AKI) related symptoms. Ultrasound-guided insertion of hemodialysis catheter is recommended for vascular access. Agitated saline bubble enhanced ultrasound is efficient and rapid to ensure the correct positioning of central venous cateter in critically ill patients. Delayed appearance of microbubbles in the right atrium indicates inadequate positioning. A recent retrospective study performed in 202 patients admitted in a dialysis center and undergoing internal jugular catheterization for hemodialysis or medication administration reported that 2 catheter malpositions were detected immediately by agitated saline bubble enhanced ultrasound. The primary aim of this prospective study, which was performed in ventilated, critically ill patients with AKI, was to compare agitated saline bubble enhanced ultrasound with bedside chest radiography for the confirmation of appropriate positioning of hemodialysis catheter. The secondary aim was to compare agitated saline bubble enhanced ultrasound and bedside chest radiography completion times.

Lactate clearance is associated with mortality in septic patients with acute kidney injury requiring continuous renal replacement therapy: A cohort study.

AbstractThe aim of the study was to assess the clinical utility of lactate measured at different time points to predict mortality at 48 hours and 28 days in septic patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).Consecutive critically ill patients with septic AKI requiring CRRT were prospectively studied. Variables were collected at initiation of CRRT and 24 hours later.In total, 186 patients were analyzed. Overall mortality at 48 hours was 28% and at 28 days was 69%. Initial lactate, lactate at 24 hours and the proportion of patients with a lactate clearance superior to 10% were different between survivors at 28 days [2.0 mmol/L, 1.95 mmol/L and 18/45 (40%)] and nonsurvivors [3.46 mmol, 4.66 mmol, and 18/94 (19%)]. Multivariate analysis demonstrated that lactate at 24 hours and lactate clearance, but not initial lactate, were independently associated to mortality. Area under the ROC curves for 28-day mortality was 0.635 for initial lactate; 0.828 for lactate at 24 hours and 0.701 for lactate clearance.Lactate clearance and lactate after 24 hours of CRRT, but not initial lactate, were independently associated with mortality in septic AKI patients undergoing CRRT. Serial lactate measurements may be useful prognostic markers than initial lactate in these patients.

Agitated saline bubble–enhanced ultrasound for the positioning of cuffed, tunneled dialysis catheters in patients with end-stage renal disease

Background: In patients with end-stage renal disease, the use of cuffed, tunneled dialysis catheters for hemodialysis has become integral to treatment plans. Fluoroscopy is a widely accepted method for the insertion and positioning of cuffed dialysis catheters, because it is easy to use, accurate and reliable, and has a relatively low incidence of complications. The purpose of our study was to evaluate the feasibility of tunneled hemodialysis catheter placement without the use of fluoroscopy but with a dynamic ultrasound-imaging-based guided technique. Methods: From January 2015 to December 2017, we performed an observational prospective cohort study of 56 patients with end-stage renal disease who required tunneled dialysis catheter placement. Results: The overall success rate for ultrasound-guided central access was 100%, with a mean number of 1.16 (±0.4) attempts per patient. There were no incidences of guide wire coiling/kinking, carotid puncture, pneumothorax, or catheter malfunction. Catheter flow during dialysis was 286 (±38) mL/min. The total number of catheter days was 7451, with a mean of 133 days and a range of 46–322 days. Life table analysis revealed primary patency rates of 100%, 96%, and 53% at 30, 60, and 120 days, respectively. Conclusion: Dynamic ultrasound-based visualization of microbubbles in the right atrium is a highly accurate method to detect percutaneous implantation of large-lumen, tunneled, central venous catheters without the need for fluoroscopic guidance technology. Future research should further develop and confirm these initial findings.

Prognostic ability of quick-SOFA across different age groups of patients with suspected infection outside the intensive care unit: A cohort study.

Objectives: Sepsis identification in older patients is challenging. We evaluated the performance of qSOFA across different age groups of patients with suspected infection outside the intensive care unit (ICU). Methods: Retrospective cohort in a tertiary hospital in Brazil, from January 2016 to December 2016. Outcomes were hospital mortality, ICU admission and bacteremia. Performance of qSOFA was compared over three age groups: (1) reference: ≤65 years, (2) old: 65 to 79 years and (3) very old: ≥80 years. Results: There were 420 patients in the study, of which 259 (61.7%) were ≤65 years, 80 (19%) were 65 to 79 years and 81 (19.3%) were ≥80 years. Old and very old patients had higher qSOFA scores and lower SIRS scores. Overall, qSOFA ≥2 was associated to hospital mortality [OR (95% CI) = 5.8 (3.3–10.4), p < 0.001], ICU admission [OR (95% CI) = 2.7 (1.6–4.6), p < 0.001] and bacteremia [OR (95% CI) = 3.1 (1.7–5.8), p < 0.001]. Those associations were stronger in old and very old patients. qSOFA and SIRS demonstrated overall AUROCs for hospital mortality of 0.72 and 0.50, respectively. Conclusion: qSOFA demonstrated good overall accuracy and was more strongly associated to outcomes in old and very old patients, when compared to younger patients. HighlightsqSOFA demonstrated good overall accuracy and was more strongly associated to outcomes in older age groups.SIRS criteria were not predictive of outcomes in this population.There were different vital signs alterations in each age group.Older age was associated with worse outcomes.

Inclusion and definition of acute renal dysfunction in critically ill patients in randomized controlled trials: a systematic review

BackgroundIn evidence-based medicine, multicenter, prospective, randomized controlled trials (RCTs) are the gold standard for evaluating treatment benefits and ensuring the effectiveness of interventions. Patient-centered outcomes, such as mortality, are most often the preferred evaluated outcomes. While there is currently agreement on how to classify renal dysfunction in critically ill patients , the application frequency of this new classification system in RCTs has not previously been evaluated. In this study, we aim to assess the definition of renal dysfunction in multicenter RCTs involving critically ill patients that included mortality as a primary endpoint.MethodsA comprehensive search was conducted for publications reporting multicenter randomized controlled trials (RCTs) involving adult patients in intensive care units (ICUs) that included mortality as a primary outcome. MEDLINE and PUBMED were queried for relevant articles in core clinical journals published between May 2004 and December 2017.ResultsOf 418 articles reviewed, 46 multicenter RCTs with a primary endpoint related to mortality were included. Thirty-six (78.3%) of the trial reports provided information on renal function in the participants. Only seven articles (15.2%) included mean or median serum creatinine levels, mean creatinine clearance or estimated glomerular filtration rates. Sequential organ failure assessment (SOFA) score was the most commonly used definition of renal dysfunction (20 studies; 43.5%). Risk, Injury, Failure, Loss, End-stage renal disease (RIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) criteria were used in five (10.9%) trials. In thirteen trials (28.3%), no renal dysfunction criteria were reported. Only one trial excluded patients with renal dysfunction, and it used urinary output or need for renal replacement therapy (RRT) as criteria for this diagnosis.ConclusionThe presence of renal dysfunction was included as a baseline patient characteristic in most RCTs. The RIFLE, AKIN and KDIGO classification systems were infrequently used; renal dysfunction was generally defined using the SOFA score.

Prognostication in urgent intensive care unit referrals: a cohort study

Objectives Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician’s prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. Methods Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians’ prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. Results There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians’ prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. Conclusions Physician’s prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.

Fluid removal in critically ill patients during hemodialysis: is there a role for functional hemodynamic monitoring?

Renal replacement therapy is frequently required in critically ill patients with acute kidney injury. With intermittent hemodialysis, large volumes of fluid need to be removed over a relatively short period of time, jeopardizing hemodynamic stability in already hemodynamically compromised patients. Established methods of dry weight estimation are not practical in critical care and the estimation of excess body fluid removable by hemodialysis constitutes a particular change in these patients. Dynamic parameters of fluid responsiveness are increasingly being used to guide fluid therapy in critical care, but their suitability to monitor fluid removal with hemodialysis is not known.