Kashani, Kianoush

Abstract Early diagnosis of AKI and preventive measures can likely decrease the severity of the injury and improve patient outcomes. Current hemodynamic monitoring variables, including BP, heart and respiratory rates, temperature, and oxygenation status, have been used to identify patients at high risk for AKI. Despite the widespread use of such variables, their ability to accurately and timely detect patients who are high risk has been questioned. Therefore, there is a critical need to develop and validate tools that can measure new and more kidney-specific hemodynamic and laboratory variables, potentially assisting with AKI risk stratification, implementing appropriate and timely preventive measures, and hopefully improved outcomes. The new ultrasonography techniques provide novel insights into kidney hemodynamics and potential management and/or therapeutic targets. Contrast-enhanced ultrasonography; Doppler flow patterns of hepatic veins, portal vein, and intrakidney veins; and ultrasound elastography are among approaches that may provide such information, particularly related to vascular changes in AKI, venous volume excess or congestion, and fluid tolerance. This review summarizes the current state of these techniques and their relevance to kidney hemodynamic management.

Background: Post-arrest hypotension is common after out of hospital cardiac arrest (OHCA) and many patients resuscitated after OHCA will require vasopressors. We sought to determine the associations between echocardiographic parameters and vasopressor requirements in OHCA patients. Methods: We retrospectively analyzed adult patients with OHCA treated with targeted temperature management between December 2005 and September 2016 who underwent a transthoracic echocardiogram (TTE). Categorical variables were compared using 2-tailed Fisher’s exact and Pearson’s correlation coefficients and variance (r 2 ) values were used to assess relationships between continuous variables. Results: Among 217 included patients, the mean age was 62 ± 12 years, including 74% males. The arrest was witnessed in 90%, the initial rhythm was shockable in 88%, and 58% received bystander CPR. At the time of TTE, 41% of patients were receiving vasopressors; this group of patients was older, had greater severity of illness, higher inpatient mortality and left ventricular ejection fraction (LVEF) was modestly lower (36.8 ± 17.1% vs. 41.4 ± 16.4%, P = 0.04). Stroke volume, cardiac power output and left ventricular stroke work index correlated with number of vasopressors (Pearson r −0.24 to −0.34, all P < 0.002), but the correlation with LVEF was weak (Pearson r −0.13, P = 0.06). Conclusions: In patients after OHCA, left ventricular systolic dysfunction was associated with the need for vasopressors, and Doppler TTE hemodynamic parameters had higher correlation coefficients compared with vasopressor requirements than LVEF. This emphasizes the complex nature of shock after OHCA, including pathophysiologic processes not captured by TTE assessment alone.

ABSTRACT Introduction: The impact of albumin resuscitation on sepsis outcomes is debated, particularly in the initial phase of resuscitation. We aimed to investigate the association between albumin use in the initial 6 h of resuscitation and subsequent outcomes in adult septic patients. Methods: This single-center, retrospective, propensity score-matched cohort study included adult patients admitted to intensive care units (ICUs) with sepsis or septic shock from January 1, 2006, to May 4, 2018, at a tertiary referral hospital. We compared two groups based on albumin receipt within the initial six resuscitation hours (albumin group vs. non-albumin group). We performed a 1:2 propensity score matching to assess shock-free time in ICU as the primary outcome. Results: Of 2,732 patients with medical sepsis, 286 cases in the albumin group were matched with 549 individuals in the non-albumin group. Compared to the non-albumin group, the albumin group required more intravenous fluids and had higher net fluid balance, lower mean arterial pressure, and lower serum base excess level in the initial 6 and 24 h of resuscitation. Shock-free time, ICU and hospital length of stay, and 28-day mortality were not different between albumin and non-albumin groups (56 vs. 66 h, P = 0.18; 3.5 days vs. 3.7 days, P = 0.61; 9.1 days vs. 9.5 days, P = 0.27; 36% vs. 32%, P = 0.25, respectively). Conclusions: Using albumin during the initial 6 h of resuscitation was not associated with benefits in clinical outcomes of patients with medical sepsis.

Introduction: Acute kidney injury (AKI) is a highly prevalent risk factor for mortality among patients with cardiogenic shock (CS). We sought to assess the incidence and prognostic relevance of AKI as a function of shock severity in unselected Cardiac Intensive Care Unit (CICU) patients, as measured by the Society for the Cardiovascular Angiography and Interventions (SCAI) shock stage. Methods: We retrospectively reviewed admissions to the Mayo Clinic from 2007 to 2015 and stratified patients by the SCAI shock stage. AKI was defined and staged based on changes in serum creatinine during hospitalization as per KDIGO guidelines. Predictors of in-hospital mortality were analyzed using Kaplan-Meier survival analysis, and one-year mortality was analyzed using Cox proportional-hazards analysis. Results: The final study population included 10,004 unique patients with a mean age of 67 years and 37% females. The percentage of patients with SCAI shock stages A, B, C, D, and E were 47%, 30%, 15%, 7%, and 1%, respectively. AKI of any severity occurred in 51% of patients during hospitalization, including severe (stage 2/3) AKI in 16%. The incidence of AKI and severe AKI increased with the SCAI shock stage. Hospital mortality occurred in 8% of patients and increased as a function of the AKI stage and SCAI shock stage. AKI was associated with increased hospital mortality after multivariable adjustment (adjusted OR per AKI stage 1.17, 95% CI 1.05-1.30, p=0.005). Twenty-one percent of patients died within one year of CICU admission, and worse AKI was associated with increased one-year mortality (adjusted HR per AKI stage 1.11, 95% CI 1.05-1.18, p=<0.001). Hospital survivors with AKI of any severity had higher mortality compared with patients who did not have AKI (p<0.001). Conclusions: AKI was increasingly common in CICU patients with higher shock severity. In-hospital and one-year mortality risk increased as a function of the severity of AKI and the SCAI shock stage. This analysis emphasizes the importance of AKI as a complication of shock and as a predictor of adverse outcomes in CICU patients.

Abstract Aims This study aims to evaluate the impact of the combination of cardiogenic shock (CS) and cardiac arrest (CA) complicating non-ST-segment elevation myocardial infarction (NSTEMI). Methods and results Adult (&gt;18 years) NSTEMI admissions using the National Inpatient Sample database (2000 to 2017) were stratified by the presence of CA and/or CS. Outcomes of interest included in-hospital mortality, early coronary angiography, hospitalization costs, and length of stay. Of the 7 302 447 hospitalizations due to NSTEMI, 147 795 (2.0%) had CS only, 155 522 (2.1%) had CA only, and 41 360 (0.6%) had both CS and CA. Compared with 2000, the adjusted odds ratios (ORs) and 95% confidence interval (CIs) for CS, CA, and both CS and CA in 2017 were 3.75 (3.58–3.92), 1.46 (1.42–1.50), and 4.52 (4.16–4.87), respectively (all P &lt; 0.001). The CS + CA (61.2%) cohort had higher multiorgan failure than CS (42.3%) and CA only (32.0%) cohorts, P &lt; 0.001. The CA only cohort had lower rates of overall (52% vs. 59–60%) and early (17% vs. 18–27%) angiography compared with the other groups (all P &lt; 0.001). CS + CA admissions had higher in-hospital mortality compared with those with CS alone (aOR 4.12 [95% CI 4.00–4.24]), CA alone (aOR 1.69 [95% CI 1.65–1.74]), or without CS/CA (aOR 22.66 [95% CI 22.06–23.27]). The presence of CS, either alone or with CA, was associated with higher hospitalization costs and longer hospital length of stay. Conclusions The combination of CS and CA is associated with higher rates of acute non-cardiac organ failure and in-hospital mortality in NSTEMI admissions as compared with those with either CS or CA alone.

AbstractBackgroundAcute kidney injury (AKI) is common among patients with cardiogenic shock (CS) and it is independently associated with mortality. We sought to assess the prevalence, severity, and prognosis of AKI as a function of cardiogenic shock severity in unselected Cardiac Intensive Care Unit (CICU) patients.MethodsWe retrospectively reviewed admissions to the Mayo Clinic between 2007 to 2015 and stratified patients by the AKI stage (based on modified Kidney Disease: Improving Global Outcomes criteria) and Society for cardiovascular angiography and interventions (SCAI) shock stage. The association with in‐hospital mortality was analyzed using multivariable logistic regression.ResultsWe included 9,311 unique patients with a mean age of 67 years and 37% females. SCAI shock stages A, B, C, D, and E were present in 47%, 30%, 15%, 7%, and 1% of patients. The incidence of AKI of any severity was 39% in the CICU and 51% during the hospitalization. Hospital mortality occurred in 8% of all patients, and the risk increased as a function of the rising AKI and SCAI shock stage. Worsening AKI stage was associated with increased adjusted hospital mortality (adjusted OR per AKI stage 1.22, 95% CI 1.10–1.36, p < .001). Higher AKI stages were associated with increased adjusted hospital mortality in SCAI stage A/B (p < .001), but not in SCAI stage C, D, or E (all p > .05).ConclusionsHigher AKI stages were independently associated with mortality in CICU patients after accounting for shock severity and may add incremental prognostic utility in patients with lower SCAI stages.

AbstractContinuous renal replacement therapy (CRRT) is the preferred extracorporeal kidney support therapy employed to support critically ill patients with acute or chronic kidney dysfunction in intensive care units. Significant heterogeneity in CRRT practice exists in part due to variable logistics, resources, and scarcity of evidence‐based CRRT practices. Importantly, homogenization of practice patterns by developing substantial evidence and effective dissemination among providers is essential for optimizing CRRT practices. The emphasis on quality of CRRT delivery has prompted identification of potential quality indicators, development of multifaceted quality improvement initiatives, effective computer science utilization, and a surge of multidisciplinary quality assurance teams that advocate for “best” CRRT practices. This manuscript provides an overview of quality improvement methodologies and reviews candidate quality indicators of CRRT and the impact of quality improvement on enhancing CRRT delivery practices.

Purpose: To describe the epidemiology, outcomes, and temporal trends of respiratory failure in the cardiac intensive care unit (CICU). Materials and Methods: Retrospective cohort analysis of 2,986 unique Mayo Clinic CICU patients from 2007 to 2018 with respiratory failure. Temporal trends were analyzed, along with hospital and 1-year mortality. Multivariable logistic regression was used to determine adjusted hospital mortality trends. Results: The prevalence of respiratory failure in the CICU increased from 15% to 38% during the study period ( P < 0.001 for trend). Among patients with respiratory failure, the utilization of invasive ventilation decreased and noninvasive ventilation modalities increased over time. Hospital mortality and 1-year mortality were 24% and 54%, respectively, with variation according to the type of respiratory support (highest among patients receiving invasive ventilation alone: 35% and 46%, respectively). Hospital mortality was highest among patients with concomitant cardiac arrest and/or shock (52% for patients with both). Hospital mortality decreased in the overall population from 35% to 25% ( P < 0.001 for trend), but was unchanged among patients receiving positive-pressure ventilation. Conclusions: The prevalence of respiratory failure in CICU more than doubled during the last decade. The use of noninvasive respiratory support increased, while overall mortality declined over time. Cardiac arrest and shock accounted for the majority of deaths. Further research is needed to optimize the outcomes of high-risk CICU patients with respiratory failure.

ABSTRACT Background: Recent data suggests improved outcomes among cardiac intensive care unit (CICU) patients treated with norepinephrine, especially patients with severe shock. We aimed to describe the association between norepinephrine and mortality in CICU patients with severe shock, defined as those requiring high-dose vasopressors (HDV). Materials and Results: We retrospectively evaluated Mayo Clinic CICU patients treated with vasopressors from 2007 to 2015. HDV was defined as a peak Cumulative Vasopressor Index of four for any vasopressor. Peak norepinephrine equivalent (NEE) dose was used to compare vasopressor doses. Multivariable logistic regression was used to determine predictors of hospital mortality. Results: We included 2,090 patients with a median age of 69 years (IQR 59–78), including 35% females; 44% of patients received HDV. Hospital mortality was higher among patients receiving HDV (42% vs. 16%, unadjusted OR 3.87, 95% CI 3.16–4.75, P < 0.01). On multivariable analysis in HDV patients, hospital mortality increased with rising peak NEE (adjusted OR 1.02 per 0.01 mcg/kg/min, 95% CI 1.01–1.02, P < 0.01) and the use of NE was associated with lower hospital mortality (adjusted OR 0.46, 95% CI 0.31–0.72, P < 0.01). After adjustment for illness severity, peak NEE and norepinephrine use were not associated with mortality among patients who did not require HDV. Conclusions: Mortality is high among CICU patients requiring HDV, and rises with increasing vasopressor requirements. Use of NE was associated with lower mortality among patients requiring HDV, but not among those without HDV, implying that patients with more severe shock may benefit from preferential use of NE.