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Regulation of endogenous glucose production (EGP) is essential for glucose homeostasis. It includes gluconeogenesis (GNG) from non-carbohydrate substrates and hepatic glycogenolysis. Both these pathways are dysregulated in acute stress, but the magnitude of this deregulation cannot be assessed in clinical practice. The study aims at identifying clinically available variables predictive of EGP and GNG magnitude by modeling routinely available data. This exploratory study is based on the data from the Supplemental Parenteral Nutrition study 2 (SPN2), which measured EGP and GNG at days 4 and 10 in 23 critically ill patients. The correlation between EGP and GNG and 83 potential clinical indicators were explored, using single-stage and multivariate analysis. On single-stage analysis, the strongest correlations were noradrenaline dose at day 4 with GNG (R = 0.71; P = 0.0004) and Nutrition risk screening score (NRS) with EGP (R = 0.42; P = 0.05). At day 10, VO 2 (R = 0.59, P = 0.04) was correlated with GNG and VCO 2 with EGP (R = 0.85, P = 0.00003). Cumulated insulin dose between days 5 and 9 was correlated to EGP at day 10 (R = 0.55, P = 0.03). Our multivariate model could predict EGP at day 4 (VCO 2 , glucose and energy intake) with an error coefficient (e.c.) between 7.8% and 23.4% (minimal and maximal error), and GNG at day 10 (age, mean and basal blood glucose), with an e.c. of 18.5% and 29.9%. GNG at day 4 and EGP at day 10 could not be predicted with an e.c. < 40%. This preliminary exploratory study shows that GNG and EGP have different predictors on days 4 and 10; EGP is more correlated with the metabolic level, while GNG is dependent on external factors. Nevertheless, a bundle of variables could be identified to empirically assess the magnitude of both values. Our results suggest that a robust model might be built, but requires a prospective study including a larger number of patients. [ABSTRACT FROM AUTHOR]

Sepsis is the primary cause of acute kidney injury in critically ill patients. During the past decades, several extracorporeal blood purification techniques have been developed for sepsis and sepsis-induced acute kidney injury management. These therapies could act on both the infectious agent itself and the host immune response. In this article, we review the available literature discussing the different extracorporeal blood purification techniques, including high-volume hemofiltration, cascade hemofiltration, hemoperfusion, coupled plasma filtration adsorption, plasma exchange, and specific optimized renal replacement therapy membranes. [ABSTRACT FROM AUTHOR]

Résumé L’instabilité du genou est un motif très fréquent de consultation en orthopédie, séquellaire le plus souvent d’un traumatisme rapporté par le patient. L’interrogatoire ainsi qu’un examen clinique minutieux ont une place prépondérante dans la démarche diagnostique. Les antécédents du patient, le type de traumatisme, la notion de craquement sont tout aussi importants que l’hémarthrose initiale, les testings ligamentaires, la course rotulienne. Les examens complémentaires sont indispensables pour une définition précise des lésions et la planification opératoire, que ce soit les examens réalisés en consultation pour objectiver les symptômes, ou le bilan radiographique standard, puis en stress, l’imagerie par résonance magnétique et le scanner tridimensionnel. Ce même symptôme fait en réalité appel à de nombreuses étiologies. L’instabilité peut siéger dans le plan frontal ou sagittal et être surtout d’origine ligamentaire, allant de la simple entorse du ligament latéral interne à la rupture du ligament croisé antérieur voire jusqu’à la luxation du genou. Le terme instabilité inclut aussi les luxations de rotule, stade le plus grave de l’instabilité fémoro-patellaire, autant que les lésions tendineuses et méniscales. Une fois le type d’instabilité défini et les lésions anatomiques identifiées, le traitement sera alors adapté à chaque patient ; il sera alors fonctionnel, orthopédique ou chirurgical, selon les lésions, l’âge, l’activité physique, la motivation et la gêne ressentie. Il est important d’avoir connaissance de l’évolution naturelle de ces instabilités afin de prévenir les lésions qui en découlent, principalement arthrosiques. Chronic knee instability is a very common reason for consultation in orthopaedics, most often after injury reported by the patient. Physical examination has an important place for the diagnostic approach. Previous patient history, type of trauma are also important as well as initial hemarthrosis, ligament testing and patellar tracking. Further investigations (X-rays and MRI) enable to confirm clinical diagnosis and to analyse associated lesions (meniscus, cartilage). Instability as the main symptom may cover numerous etiologies. Knee instability may be observed in the frontal or sagittal plan or both. There are several grades of severity from the common medial collateral ligament sprain to the complete tear of the anterior cruciate ligament or even knee dislocation. The term instability also includes the patellar dislocations, the most serious stage of the femoropatellar instability. Once the type of instability defined and the anatomical lesions identified, the treatment will be selected for each patient; it may be functional, medical or surgical, according to the types of lesion, age and physical activity, motivation and patient discomfort. It is important to be aware of the natural outcome of these instabilities in order to prevent lesions leading to osteoarthritis (OA). [ABSTRACT FROM AUTHOR]

Summary Background Rapid Response Team (RRT) calls can often occur within 24 h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration. Methods Retrospective case–controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24 h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls). Results Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84 beats/min; p = 0.008); after 3 h in the ED (91 vs. 80 beats/min; p = 0.0007); and at ED discharge (91 vs. 81 beats/min; p = 0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2 breaths/min; p = 0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02–1.12] for each 1 breath/min increase in RR; and 1.02 [95% CI 1.002–1.030] for each beat/minute increase in HR, respectively. Study patients required transfer to the intensive care in approximately 20% of cases and also had a greater mortality: (21% vs. 6%; OR 4.65 [95% CI 1.86–11.65]; p = 0.0003) compared with controls. Conclusions Patients that trigger RRT calls within 24 h of admission have a fourfold increase in risk of in-hospital mortality. Such patients may be identified by greater tachycardia and tachypnoea in the ED. [ABSTRACT FROM AUTHOR]

Objectives To determine the ability of urinary neutrophil gelatinase-associated lipocalin (uNGAL) to predict cardiac surgery-associated acute kidney injury (CSA-AKI), continuous renal replacement therapy (CRRT), mortality, and a composite outcome of major adverse kidney events at 365 days (MAKE 365 ), and to investigate the influence of cardiopulmonary bypass (CPB) on NGAL release. Design A prospective observational study. Setting A single-center university hospital. Participants A cohort of 288 adult cardiac surgery patients. Interventions uNGAL was measured at baseline, immediately after surgery, and on days 1 and 2 postoperatively. The authors used the recent Kidney Disease Improving Global Outcomes consensus criteria to define CSA-AKI. Measurements and Main Results CSA-AKI occurred in 36.1% of patients. uNGAL rapidly became significantly higher in patients who developed AKI, with peak value immediately after surgery (349.9 [76.6-1446.6] v 90.1 [20.8-328] ng/mg creatinine; p<0.001). No measure of uNGAL (peak, postsurgery, day 1 or 2 postsurgery) accurately predicted CSA-AKI, CRRT, mortality, or MAKE 365 . However, immediately after surgery, CPB induced greater uNGAL release compared with off-pump surgery (265.5 µmol/L [71-989.6] v 48.7 ng/mg creatinine [17-129.8]; p<0.001). Moreover, such early uNGAL release correlated with CPB duration (r = 0.505; p<0.001) but not with peak serum creatinine values on day 3 or 7 after surgery. Conclusions uNGAL had a limited predictive ability for CSA-AKI or other relevant clinical outcomes after cardiac surgery and appeared to be more closely related to the use and duration of CPB. Thus, its levels may represent the aggregate effect of an inflammatory response to CPB as well as a renal response to cardiac surgery and inflammation. [ABSTRACT FROM AUTHOR]

Purpose: The safety of femoral vein (FV) catheterization for continuous renal replacement therapy is uncertain. We sought to determine the incidence of clinically manifest venous thromboembolism (VTE) in such patients. Methods: We retrospectively studied patients with femoral high flow catheters (⩾13F) (December 2005 to February 2011). Discharge diagnostic codes were independently screened for VTE. The incidence of VTE was also independently similarly assessed in a control cohort of patients ventilated for more than 2 days (January 2011 to December 2011) in the same intensive care unit (ICU). Results: We studied 380 patients. Their mean age was 61 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation III score was 84; average duration of continuous renal replacement therapy was 74 hours, and 232 patients (61%) survived to hospital discharge with an average length of hospital stay of 22 days. Only 5 patients (1.3%) had clinically manifest VTE after FV catheterization. In the control cohort of 514 ICU patients, the incidence of VTE was 4.4% (P b .05 compared with FV group). Conclusion: The incidence of clinically manifest VTE after FV catheterization with high flow catheters is low and lower to that seen in general ICU patients [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to establish the validity and reliability of measuring weight in critically ill patients with electronic weighing beds. Methods: All patients admitted to a private intensive care unit (ICU) after cardiac surgery over a 7-month period were weighed on admission and then twice daily (1200 and 2400 hours) using electronic weighing beds (Hill-Rom, Batesville, AR). For each measurement, nonremovable items were recorded, and an average value was deducted from measured weight. We compared differences in body weights (BWs) between 2 consecutive 12-hour periods with the corresponding fluid balance (FB). In addition, we compared weights obtained with electronic weighing beds with those obtained with a regular calibrated scale on ICU discharge. Results: We obtained data in 103 patients for 414 (75.5%) of 548 of all possible BW measurements. On average, we identified a total of 3.5 kg (SD, 1.4) of nonremovable items on patients' beds. The correlation between 12- hourly changes in BW and FB was weak (r = 0.28; 95% confidence interval [CI], 0.17-0.39), even after correction for insensible fluid losses (r=0.27; 95% CI, 0.15-0.38) and when only values obtained in intubated patients were taken into account (r=0.34; 95% CI, 0.16-0.49). Similarly, limits of agreements were wide (95% CI, -3.3 to 3.5 kg). There was also poor agreement between weights obtained on electronic beds and those obtained on the regular scale on ICU discharge (95% CI, -7.6 to 7.6 kg). Conclusion: Body weight measured by electronic weighing beds does not seem sufficiently robust or accurate to replace daily FB in ICU. The clinical value of purchasing such beds remains uncertain. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to compare the biochemical effects of Phoxilium (containing phosphate at 1.2 mmol/L; Gambro Lundia AB, Lund, Sweden) and Hemosol-B0 (Gambro Lundia AB) as dialysate and/or replacement fluid during continuous renal replacement therapy (CRRT). Methods: We examined serum biochemistry in critically ill patients for 42 hours of Phoxilium administration for the prevention of hypophosphatemia during CRRT and compared them with corresponding results in random historical controls who received Hemosol-B0. Results: We studied 15 patients in each arm (Phoxilium vs Hemosol-B0). Respective median ages were 57 (49-68) and 64 (57-67) years. Baseline patient illness severity scores, prescribed CRRT effluent rates, and cumulative phosphate intakes were comparable. After 36 to 42 hours of Phoxilium administration, serum phosphate levels increased from 0.95 (0.81-1.13) to 1.44 (1.23-1.78) mmol/L, in contrast to the decline from 1.71 (1.09-2.00) to 0.83 (0.55-1.59) mmol/L with Hemosol-B0 (P = .0001). Serum ionized calcium levels decreased from 1.27 (1.22-1.37) to 1.12 (1.06-1.21) mmol/L with Phoxilium, compared with an increase from 1.09 (0.90-1.19) to 1.20 (1.16-1.25) mmol/L with Hemosol-B0 (P b .0001). Serum bicarbonate, base excess levels, and effective strong ion difference decreased with Phoxilium and were lower than those with Hemosol-B0 at 36 to 42 hours (P b .05). Conclusion: Phoxilium effectively prevented hypophosphatemia during CRRT but was associated with relative metabolic acidosis and hypocalcemia compared with Hemosol-B0 use. [ABSTRACT FROM AUTHOR]

Purpose: Comparison of illness severity for intensive care unit populations assessed according to different scoring systems should increase our ability to compare and meta-analyze past and future trials but is currently not possible. Accordingly, we aimed to establish a methodology to translate illness severity scores obtained from one system into another. Materials and methods: Using the Australian and New-Zealand intensive care adult patient database, we obtained simultaneous admission Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores and Simplified Acute Physiology Score (SAPS) II in 634428 patients admitted to 153 units between 2001 and 2010. We applied linear regression analyses to create models enabling translation of one score into another. Sensitivity analyses were performed after removal of diagnostic categories excluded from the original APACHE database, after matching for similar risk of death, after splitting data according to country of origin (Australia or New Zealand) and after splitting admissions occurring before or after 2006. Results: The translational models were APACHE III = 3.08 × APACHE II + 5.75; APACHE III = 1.47 × SAPS II + 8.6; and APACHE II = 0.36 × SAPS II + 4.4. The area under the receiver operating curve for mortality prediction was 0.853 (95% confidence interval, 0.851-0.855) for the "APACHE II derived APACHE III" score and 0.854 (0.852-0.855) for the "SAPS II derived APACHE III" vs 0.854 (0.852- 0.855) for the original APACHE III score. Similarly, it was 0.841 (0.839-0.843) for the "SAPS II derived APACHE II score" vs 0.842 (0.840-0.843) for the original APACHE II score. Correlation coefficients as well as intercepts remained very similar in all subgroups analyses. Conclusions: Simple and robust translational formulas can be developed to allow clinicians to compare illness severity between studies involving critically ill patients. Further studies in other countries and health care systems are needed to confirm the generalizability of these results. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to assess the association of phosphate concentration with key clinical outcomes in a heterogeneous cohort of critically ill patients. Materials and Methods: This was a retrospective observational study at a general intensive care unit (ICU) of an Australian university teaching hospital enrolling 2730 adult critically ill patients. Results: We studied 10 504 phosphate measurements with a mean value of 1.17 mmol/L (measurements every 28.8 hours on average). Hyperphosphatemia (inorganic phosphate [iP] concentration N 1.4 mmol/L) occurred in 45% and hypophosphatemia (iP . 0.6 mmol/L) in 20%. Among patients without any episodes of hyperphosphatemia, patients with at least 1 episode of hypophosphatemia had a higher ICU mortality than those without hypophosphatemia (P = .004). In addition, ICU nonsurvivors had lower minimum phosphate concentrations than did survivors (P = .009). Similar results were seen for hospital mortality. However, on multivariable logistic regression analysis, hypophosphatemia was not independently associated with ICU mortality (adjusted odds ratio, 0.86 [95% confidence interval, 0.66-1.10]; P = .24) and hospital mortality (odds ratio, 0.89 [0.73-1.07]; P = .21). Even when different cutoff points were used for hypophosphatemia (iP . 0.5, 0.4, 0.3, or 0.2 mmol/L), hypophosphatemia was not an independent risk factor for ICU and hospital morality. In addition, timing of onset and duration of hypophosphatemia were not independent risk factor for ICU and hospital mortality. Conclusions: Hypophosphatemia behaves like a general marker of illness severity and not as an independent predictor of ICU or in-hospital mortality in critically ill patients. [ABSTRACT FROM AUTHOR]

Purpose: Monitoring of fluid balance (FB) can be achieved by subtracting recorded fluid output from input or by measuring changes in body weight (BW). The latter approach is difficult in the critically ill. Recently, hospital beds have become available with the ability to directly weigh patients in the intensive care unit (ICU) patients directly. We sought to compare FB estimates obtained by these 2 methods in a cohort of critically ill patients. Materials and Methods: Between November 2010 and May 2011, all patients admitted in our ICU for more than 2 consecutive days and nursed on a Hill-Rom (Batesville, Ind) Total Care bed were weighed daily at midnight hours. Fluids charting was done by electronic spreadsheet with automated 24 hours calculation. Differences in BW and FB between 2 consecutive days were compared using correlation and Bland-Altman analysis. Corrections for unmeasured fluids losses were performed using a predetermined formula based on peak temperature and intubation status. Results: We obtained complete data in 160 (31%) of 504 admissions exceeding 2 days (153 patients) resulting in 435 data points. The change in BW over 24 hours and FB for the same period was only weakly correlated before (r = 0.34; P < .001; Fig. 1) or after correction for insensible fluid losses (r = 0.34; P < .001). On Bland-Altman plot, the mean bias was small (0.07 kg), but the 95% limits of agreement, very large (-5.8 and 6.0 kg). The lack of agreement increased with the magnitude of the changes. Conclusion: Obtaining daily weights in ICU patients proved difficult. Compliance was poor. The correlation between changes in BWs and FB was weak. Further studies are required to establish if accurate and reproducible daily weighing of ICU patients is feasible. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: It is controversial whether all critically ill patients with risk, injury, failure, loss, and end-stage renal failure (RIFLE) F class acute kidney injury (AKI) should receive renal replacement therapy (RRT). We reviewed the outcome of open heart surgery patients with severe RIFLE-F AKI who did not receive RRT. Materials and Methods: We identified all patients with AKI after cardiac surgery over 4 years and obtained baseline characteristics, intraoperative details, and in-hospital outcomes. We analyzed physiologic and biochemical features at RRT initiation or at peak creatinine if no RRT was provided. Results: We reviewed 1504 patients. Of these, 137 (9.1%) developed postoperative AKI with 71 meeting RIFLE-F criteria and 23 (32.4% of RIFLE-F cases) not receiving RRT. Compared with RRT-treated RIFLE-F patients, “no-RRT” patients had lower Acute Physiology and Chronic Health Evaluation III scores, less intra-aortic balloon pump requirements, shorter intensive care stay, and a trend toward lower mortality. At peak RIFLE score, their urinary output, arterial pH, and Pao 2/fraction of inspired oxygen ratio were all significantly higher. Their serum creatinine was also higher (304 vs 262 μmol/L; P = .02). Only 3 RIFLE-F no-RRT patients died in-hospital. Detailed review of cause and mode of death was consistent with non–RRT-preventable deaths. In contrast, 27 patients with RIFLE-R or RIFLE-I class received RRT. Compared with RRT-treated RIFLE-F patients, such RIFLE-R or RIFLE-I treated patients had a more severe presentation and higher mortality (51.8% vs 29.2%; P = .02). Conclusions: After cardiac surgery, RRT was typically applied to patients with the most severe clinical presentation irrespective of creatinine levels. A RIFLE score–based trigger for RRT is unlikely to improve patient survival. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: It is controversial whether all critically ill patients with risk, injury, failure, loss, and end-stage renal failure (RIFLE) F class acute kidney injury (AKI) should receive renal replacement therapy (RRT). We reviewed the outcome of open heart surgery patients with severe RIFLE-F AKI who did not receive RRT. Materials and Methods: We identified all patients with AKI after cardiac surgery over 4 years and obtained baseline characteristics, intraoperative details, and in-hospital outcomes. We analyzed physiologic and biochemical features at RRT initiation or at peak creatinine if no RRT was provided. Results: We reviewed 1504 patients. Of these, 137 (9.1%) developed postoperative AKI with 71 meeting RIFLE-F criteria and 23 (32.4% of RIFLE-F cases) not receiving RRT. Compared with RRT-treated RIFLE-F patients, “no-RRT” patients had lower Acute Physiology and Chronic Health Evaluation III scores, less intra-aortic balloon pump requirements, shorter intensive care stay, and a trend toward lower mortality. At peak RIFLE score, their urinary output, arterial pH, and Pao 2/fraction of inspired oxygen ratio were all significantly higher. Their serum creatinine was also higher (304 vs 262 μmol/L; P = .02). Only 3 RIFLE-F no-RRT patients died in-hospital. Detailed review of cause and mode of death was consistent with non–RRT-preventable deaths. In contrast, 27 patients with RIFLE-R or RIFLE-I class received RRT. Compared with RRT-treated RIFLE-F patients, such RIFLE-R or RIFLE-I treated patients had a more severe presentation and higher mortality (51.8% vs 29.2%; P = .02). Conclusions: After cardiac surgery, RRT was typically applied to patients with the most severe clinical presentation irrespective of creatinine levels. A RIFLE score–based trigger for RRT is unlikely to improve patient survival. [Copyright &y& Elsevier]

Abstract: Purpose: The purpose of the study was to determine the effects of Plasma-Lyte 148 (PL) vs 0.9% saline (NS) fluid resuscitation in diabetic ketoacidosis (DKA). Methods: A multicenter retrospective analysis of adults admitted for DKA to the intensive care unit, who received almost exclusively PL or NS infusion up until 12 hours, was performed. Results: Nine patients with PL and 14 patients with NS were studied. Median serum bicarbonate correction was higher in the PL vs NS groups at 4 to 6 hours (8.4 vs 1.7 mEq/L) and 6 to 12 hours (12.8 vs 6.2 mEq/L) from baseline (P < .05). Median standard base excess improved by 10.5 vs 4.2 mEq/L at 4 to 6 hours and by 16.0 vs 9.1 mEq/L at 6 to 12 hours in the PL and NS groups, respectively (P < .05). Chloride levels increased significantly in the NS vs PL groups over 24 hours. Potassium levels were lower at 6 to 12 hours in the PL group. Mean arterial blood pressure was higher at 2 to 4 hours in the PL group, whereas cumulative urine output was lower at 4 to 6 hours in the NS group. There were no differences in glycemic control or duration of intensive care unit stay. Conclusion: Patients with DKA resuscitated with PL instead of NS had faster initial resolution of metabolic acidosis and less hyperchloremia, with a transiently improved blood pressure profile and urine output. [Copyright &y& Elsevier]