| 1. |
- Al-Abani, K, et al.
(författare)
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Thrombosis and Bleeding After Implementation of an Intermediate-Dose Prophylactic Anticoagulation Protocol in ICU Patients With COVID-19: A Multicenter Screening Study
- 2022
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Ingår i: Journal of intensive care medicine. - : SAGE Publications. - 1525-1489 .- 0885-0666. ; 37:4, s. 480-490
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Tidskriftsartikel (refereegranskat)abstract
- Thrombosis and bleeding after implementation of an intermediate-dose prophylactic anticoagulation protocol in intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19): a multicenter screening study Background: Venous thromboembolism (VTE) is common among critically ill patients with COVID-19. Information regarding VTE prevalence and bleeding complications after implementation of intermediate-dose prophylactic anticoagulation in such patients is, however, limited. Methods: We performed a prospective, observational study in 6 ICUs in 2 university-affiliated teaching hospitals in Sweden. After implementation of an intermediate-dose prophylactic anticoagulation protocol, we performed ultrasound screening for proximal lower-extremity deep vein thrombosis (DVT) and collected routine computed tomography pulmonary angiography exam results. Results: A total of 100 COVID-19 patients were included from June 21, 2020, through February 18, 2021. During a median follow-up of 120 (IQR, 89-134) days, we found VTE in 37 patients with the majority (78.4%) being diagnosed after ICU arrival. Overall, 20 patients had proximal lower-extremity DVT with 95% being detected on ultrasound screening; 22 patients had pulmonary vascular thrombosis; and 4 patients had venous thrombosis at other sites. A total of 6 patients had both proximal lower-extremity DVT and pulmonary vascular thrombosis. On univariate logistic regression analysis of 14 baseline characteristics, only pre-existing heart failure was associated with VTE (OR 4.67, 95% CI 1.13-19.34). Major and non-major bleeding occurred in 10 and 18 patients, respectively. Conclusions: In our cohort of ICU patients with COVID-19, we observed a high prevalence of VTE and bleeding complications after implementation of intermediate-dose anticoagulation. In approximately half of patients, VTE was identified on screening ultrasound.
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| 2. |
- Flam, B, et al.
(författare)
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Authors' Response
- 2015
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Ingår i: Journal of intensive care medicine. - : SAGE Publications. - 1525-1489 .- 0885-0666. ; 52:1, s. 493-4
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
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| 3. |
- Flam, B, et al.
(författare)
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Pheochromocytoma-Induced Inverted Takotsubo-Like Cardiomyopathy Leading to Cardiogenic Shock Successfully Treated With Extracorporeal Membrane Oxygenation
- 2015
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Ingår i: Journal of intensive care medicine. - : SAGE Publications. - 1525-1489 .- 0885-0666. ; 30:6, s. 365-372
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Tidskriftsartikel (refereegranskat)abstract
- Pheochromocytoma classically displays a variety of rather benign symptoms, such as headache, palpitations, and sweating, although severe cardiac manifestations have been described. We report a case of pheochromocytoma-induced inverted takotsubo-like cardiomyopathy leading to shock and cardiac arrest successfully treated with extracorporeal membrane oxygenation (ECMO) as a bridge to pharmacological therapy and curative adrenalectomy. A previously healthy 46-year-old woman presented to the emergency department with abdominal pain, dyspnea, nausea, and vomiting. Clinical evaluation revealed cardiorespiratory failure with hypoxia and severe metabolic acidosis. Computed tomography (CT) scan showed pulmonary edema and a left adrenal mass. Transthoracic echocardiography (TTE) displayed severe left ventricular dysfunction with inverted takotsubo contractile pattern. Despite mechanical ventilation and inotropic and vasopressor support, asystolic cardiac arrest ensued. The patient was resuscitated using manual chest compressions followed by venoarterial ECMO. Repeated TTEs demonstrated resolution of the cardiomyopathy within a few days. Laboratory results indicated transient renal and hepatic dysfunction, and CT scan of the brain displayed occipital infarctions. Biochemical testing and radionuclide scintigraphy confirmed a pheochromocytoma. Pharmacological adrenergic blockade was instituted prior to delayed adrenalectomy after which the diagnosis was histopathologically verified. The patient recovered after rehabilitation. We conclude that pheochromocytoma should be considered in patients presenting with unexplained cardiovascular compromise, especially if they display (inverted) takotsubo contractile pattern. Timely, adequate management might involve ECMO as a bridge to pharmacological therapy and curative surgery.
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| 4. |
- Guilbault, Ryan W.R., et al.
(författare)
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External Validation of Two Classification and Regression Tree Models to Predict the Outcome of Inpatient Cardiopulmonary Resuscitation
- 2017
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Ingår i: Journal of Intensive Care Medicine. - : SAGE Publications. - 0885-0666 .- 1525-1489. ; 32:5, s. 333-338
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To prospectively validate a previously developed classification and regression tree (CART) model that predicts the likelihood of a good outcome among patients undergoing inpatient cardiopulmonary resuscitation. Design: Prospective validation of a clinical decision rule. Setting: Skåne University Hospital in Malmo, Sweden. Patients: All adult patients (N = 287) experiencing in-hospital cardiopulmonary arrest and undergoing cardiopulmonary resuscitation between 2007 and 2010. Interventions: Patients from Skåne University Hospital who underwent CPR (N = 287) were classified using the CART models to predict their likelihood of survival neurologically intact or with minimal deficits, based on a cerebral performance category score of 1. Discrimination and classification accuracy of the score in the Swedish population was compared to that in the original (derivation and internal validation) populations. Measurements and Main Results: For model 1, the area under the receiver-operating characteristic curve (AUROCC) was 0.77, compared with 0.76 and 0.73 in the original derivation and validation populations, respectively. Model 1 classified 71 (2.8%) of 287 patients as being at a very low risk of a good neurologic outcome compared with 157 (26.1%) of 287 patients predicted to be at an above average risk of a good neurologic outcome. Model 2 had a similar AUROCC as the original validation population of 0.71 but lower than the original derivation population. Model 2 performed similarly to Model 1 with regards to its ability to correctly classify patients as very low or higher than average likelihood of a good neurologic outcome. Conclusion: Two CART models validated well in a different population, displaying similar discrimination and classification accuracy compared to the original population. Although additional validation in larger populations is desirable before widespread adoption, these results are very encouraging.
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| 5. |
- Raasveld, SJ, et al.
(författare)
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Extracorporeal Membrane Oxygenation in Patients With COVID-19: An International Multicenter Cohort Study
- 2021
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Ingår i: Journal of intensive care medicine. - : SAGE Publications. - 1525-1489 .- 0885-0666. ; 36:8, s. 910-917
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Tidskriftsartikel (refereegranskat)abstract
- To report and compare the characteristics and outcomes of COVID-19 patients on extracorporeal membrane oxygenation (ECMO) to non-COVID-19 acute respiratory distress syndrome (ARDS) patients on ECMO. Methods: We performed an international retrospective study of COVID-19 patients on ECMO from 13 intensive care units from March 1 to April 30, 2020. Demographic data, ECMO characteristics and clinical outcomes were collected. The primary outcome was to assess the complication rate and 28-day mortality; the secondary outcome was to compare patient and ECMO characteristics between COVID-19 patients on ECMO and non-COVID-19 related ARDS patients on ECMO (non-COVID-19; January 1, 2018 until July 31, 2019). Results: During the study period 71 COVID-19 patients received ECMO, mostly veno-venous, for a median duration of 13 days (IQR 7-20). ECMO was initiated at 5 days (IQR 3-10) following invasive mechanical ventilation. Median PaO2/FiO2 ratio prior to initiation of ECMO was similar in COVID-19 patients (58 mmHg [IQR 46-76]) and non-COVID-19 patients (53 mmHg [IQR 44-66]), the latter consisting of 48 patients. 28-day mortality was 37% in COVID-19 patients and 27% in non-COVID-19 patients. However, Kaplan-Meier curves showed that after a 100-day follow-up this non-significant difference resolves. Non-surviving COVID-19 patients were more acidotic prior to initiation ECMO, had a shorter ECMO run and fewer received muscle paralysis compared to survivors. Conclusions: No significant differences in outcomes were found between COVID-19 patients on ECMO and non-COVID-19 ARDS patients on ECMO. This suggests that ECMO could be considered as a supportive therapy in case of refractory respiratory failure in COVID-19.
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| 6. |
- Seilitz, Jenny, 1978-, et al.
(författare)
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Early Onset of Postoperative Gastrointestinal Dysfunction Is Associated With Unfavorable Outcome in Cardiac Surgery : A Prospective Observational Study
- 2021
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Ingår i: Journal of Intensive Care Medicine. - : Sage Publications. - 0885-0666 .- 1525-1489. ; 36:11, s. 1264-1271
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: The distribution of postoperative gastrointestinal (GI) dysfunction and its association with outcome were investigated in cardiac surgery patients. Gastrointestinal function was evaluated using the Acute Gastrointestinal Injury (AGI) grade proposed by the European Society of Intensive Care Medicine.DESIGN: Prospective observational study at a single center.SETTING: University hospital.PATIENTS: Consecutive patients presenting for elective cardiac surgery with extracorporeal circulation (ECC).INTERVENTIONS: None.RESULTS: Daily assessment using the AGI grade was performed on the first 3 postoperative days in addition to standard care. For analysis, 3 groups were formed based on the maximum AGI grade: AGI 0, AGI 1, and AGI ≥2. Five hundred and one patients completed the study; 32.7%, 65.1%, and 2.2% of the patients scored a maximum AGI 0, AGI 1, and AGI ≥2, respectively. Patients with AGI grade ≥2 had more frequently undergone thoracic aortic surgery and had longer surgery duration and time on ECC. Patients with AGI grade ≥2 had statistically significant higher frequency of GI complications within 30 days (63.6% vs 1.2% and 5.5% in patients with AGI 0 and AGI 1) and higher 30-day mortality (9.1% vs 0.0% and 1.8% in patients with AGI 0 and AGI 1).CONCLUSIONS: Early GI dysfunction following cardiac surgery was associated with an unfavorable outcome. Increased attention to GI dysfunction in cardiac surgery patients is warranted and the AGI grade could be a helpful adjunct to a structured approach.
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| 7. |
- Svedung Wettervik, Teodor, et al.
(författare)
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Arterial Oxygenation in Traumatic Brain Injury : Relation to Cerebral Energy Metabolism, Autoregulation, and Clinical Outcome
- 2021
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Ingår i: Journal of Intensive Care Medicine. - : SAGE Publications. - 0885-0666 .- 1525-1489. ; 36:9, s. 1075-1083
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Tidskriftsartikel (refereegranskat)abstract
- Background:Ischemic and hypoxic secondary brain insults are common and detrimental in traumatic brain injury (TBI). Treatment aims to maintain an adequate cerebral blood flow with sufficient arterial oxygen content. It has been suggested that arterial hyperoxia may be beneficial to the injured brain to compensate for cerebral ischemia, overcome diffusion barriers, and improve mitochondrial function. In this study, we investigated the relation between arterial oxygen levels and cerebral energy metabolism, pressure autoregulation, and clinical outcome.Methods:This retrospective study was based on 115 patients with severe TBI treated in the neurointensive care unit, Uppsala university hospital, Sweden, 2008 to 2018. Data from cerebral microdialysis (MD), arterial blood gases, hemodynamics, and intracranial pressure were analyzed the first 10 days post-injury. The first day post-injury was studied in particular.Results:Arterial oxygen levels were higher and with greater variability on the first day post-injury, whereas it was more stable the following 9 days. Normal-to-high mean pO2 was significantly associated with better pressure autoregulation/lower pressure reactivity index (P = .02) and lower cerebral MD-lactate (P = .04) on day 1. Patients with limited cerebral energy metabolic substrate supply (MD-pyruvate below 120 µM) and metabolic disturbances with MD-lactate-/pyruvate ratio (LPR) above 25 had significantly lower arterial oxygen levels than those with limited MD-pyruvate supply and normal MD-LPR (P = .001) this day. Arterial oxygenation was not associated with clinical outcome.Conclusions:Maintaining a pO2 above 12 kPa and higher may improve oxidative cerebral energy metabolism and pressure autoregulation, particularly in cases of limited energy substrate supply in the early phase of TBI. Evaluating the cerebral energy metabolic profile could yield a better patient selection for hyperoxic treatment in future trials.
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| 8. |
- Svedung-Wettervik, Teodor, et al.
(författare)
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Association of Arterial Metabolic Content with Cerebral Blood Flow Regulation and Cerebral Energy Metabolism-A Multimodality Analysis in Aneurysmal Subarachnoid Hemorrhage
- 2022
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Ingår i: Journal of Intensive Care Medicine. - : Sage Publications. - 0885-0666 .- 1525-1489. ; 37:11, s. 1442-1450
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Tidskriftsartikel (refereegranskat)abstract
- Background In this study, the association of the arterial content of oxygen, carbon dioxide, glucose, and lactate with cerebral pressure reactivity, energy metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH) was investigated.Methods In this retrospective study, 60 patients with aSAH, treated at the neurointensive care (NIC), Uppsala University Hospital, Sweden, between 2016 and 2021 with arterial blood gas (ABG), intracranial pressure, and cerebral microdialysis (MD) monitoring were included. The first 10 days were divided into an early phase (day 1 to 3) and a vasospasm phase (day 4 to 10).Results Higher arterial lactate was independently associated with higher/worse pressure reactivity index (PRx) in the early phase (beta = 0.32, P = .02), whereas higher pO(2) had the opposite association in the vasospasm phase (beta = -0.30, P = .04). Arterial glucose and pCO(2) were not associated with PRx. Higher arterial lactate (beta = 0.29, P = .05) was independently associated with higher MD-glucose in the vasospasm phase, whereas higher pO(2) had the opposite association in the vasospasm phase (beta = -0.33, P = .03). Arterial glucose and pCO(2) were not associated with MD-glucose. Higher pCO(2) in the early phase, lower arterial glucose in both phases, and lower arterial lactate in the vasospasm phase were associated (P < .05) with better clinical outcome.Conclusions Arterial variables associated with more vasoconstriction (higher pO(2) and lower arterial lactate) were associated with better cerebral pressure reactivity, but worse energy metabolism. In severe aSAH, when cerebral large-vessel vasospasm with exhausted distal vasodilation is common, more vasoconstriction could increase distal vasodilatory reserve and pressure reactivity, but also reduce cerebral blood flow and metabolic supply. The MD may be useful to monitor the net effects on cerebral metabolism in PRx-targeted NIC.
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| 9. |
- Zeiler, FA, et al.
(författare)
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Burst Suppression for ICP Control
- 2017
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Ingår i: Journal of intensive care medicine. - : SAGE Publications. - 1525-1489 .- 0885-0666. ; 32:2, s. 130-139
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Tidskriftsartikel (refereegranskat)abstract
- The goal of our study was to perform a systematic review of the literature to determine the effect that burst suppression has on intracranial pressure (ICP) control. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to January 2015), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and the Grading of Recommendation Assessment Development and Education (GRADE) methodology. Results: Seven articles were considered for review. A total of 108 patients were studied, all receiving burst suppression therapy. Two studies failed to document a decrease in ICP with burst suppression therapy. There were reports of severe hypotension and increased infection rates with barbiturate-based therapy. Etomidate-based suppressive therapy was linked to severe renal dysfunction. Conclusions: There currently exists both Oxford level 2b and GRADE C evidence to support that achieving burst suppression reduces ICP, and also has no effect on ICP, in severe traumatic brain injury. The literature suggests burst suppression therapy may be useful for ICP reduction in certain cases, although these situations are currently unclear. In addition, the impact on patient functional outcome is unclear. Further prospective study is warranted.
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| 10. |
- Hultgren, Malin, et al.
(författare)
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Prolonged Fatigue and Mental Health Challenges in Critical COVID-19 Survivors
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Ingår i: Journal of Intensive Care Medicine. - 0885-0666.
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Tidskriftsartikel (refereegranskat)abstract
- Background: The aim of this study was to investigate the development of fatigue and mental illness between 3 and 12 months after critical COVID-19 and explore risk factors for long-lasting symptoms. Study Design and Methods: A prospective, multicenter COVID-19 study in southern Sweden, including adult patients (≥18 years) with rtPCR-confirmed COVID-19 requiring intensive care. Survivors were invited to a follow-up at 3 and 12 months, where patient-reported symptoms were assessed using the Modified Fatigue Impact Scale (MFIS), the Hospital Anxiety and Depression Scale (HADS) and the Posttraumatic Stress Disorder Checklist version 5 (PCL-5). The development between 3 and 12 months was described by changes in relation to statistical significance and suggested values for a minimally important difference (MID). Potential risk factors for long-lasting symptoms were analyzed by multivariable logistic regression. Results: At the 3-month follow-up, 262 survivors (87%) participated, 215 (72%) returned at 12 months. Fatigue was reported by 50% versus 40%, with a significant improvement at 12 months (MFIS; median 38 vs. 33, P < .001, MID ≥4). There were no significant differences in symptoms of mental illness between 3 and 12 months, with anxiety present in 33% versus 28%, depression in 30% versus 22%, and posttraumatic stress disorder in 17% versus 13%. A worse functional outcome and less sleep compared to before COVID-19 were risk factors for fatigue and mental illness at 12 months. Conclusions: Fatigue improved between 3 and 12 months but was still common. Symptoms of mental illness remained unchanged with anxiety being the most reported. A worse functional outcome and less sleep compared to before COVID-19 were identified as risk factors for reporting long-lasting symptoms.
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