Category Archives: Renal

New developments that every intensivist should know about…..

Cardiology

Prof S Price

COVID-19

2020 Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-Segment Elevation (Management of) Guidelines

  • Rapid rule in/rule out algorithms now recommended to use ESC 0h/1h algorithm ( or 1h/2h algorithm (second best option) if a hs-cTn test with a validated algorithm is available
  • If elective non-invasive/invasive imaging is needed after the rule-out of MI, invasive angiography is the best option in those with a very high clinical likelihood of UA. Stress testing with imaging or CCTA is best in those with low-to-modest clinical risk.
  • Rhythm monitoring for up to 24 h or to PCI (whichever comes first) is recommended for those at low risk for arrhythmias and monitoring >24h if at increased risk
  • Early routine invasive approach within 24 hours for NSTEMI based on hs-cTn measurements, GRACE score >140, dynamic/new STT changes.

Clinical application of the 4th Universal Definition of Myocardial Infarction

Temporary circulatory support for cardiogenic shock

Pulmonology

EJ Nossent

Potential therapies

Pirfenidone for idiopathic pulmonary fibrosis: analysis of pooled data from three multinational phase 3 trials

Efficacy and Safety of Nintedanib in Idiopathic Pulmonary Fibrosis

Nintedanib for Systemic Sclerosis–Associated Interstitial Lung Disease

Nintedanib in Progressive Fibrosing Interstitial Lung Diseases

Take home message

  • ILD is not one disease
  • Acute excacerbation in every type of ILD
  • The landscape is changing; finally…
  • Position antifibrotic therapy fibrotic ILD not clear yet; immunosuppressants.

From the disease lung fibrosis to criteria, towards phenotyping, towards personalized medicine.

Neurology

Prof S Koch

COVID-19

Conclusion

EID risk is increasing due to climate change and loss of biodiversity
-> we need to adress this now

Neurological manifestation of Covid-19 occur in ~ 36%

Cerebrovasculare Manifestions occur in ~ 5% of Covid-19 patients based on
–pathological coagulation or hyperinflammation
–includes younger patients or patients with typical riskfactors
–leads to more severe outcome
-> check carefully coagulation parameters and risk factors

Altered conscious state is seen in ~ 65% of Covid-19 ICU patients
–based on encephalopathy or seizures
-> EEG monitoring, MRI

Anaesthesiology

S Loer

Optimizing preoperative fluid therapy Encourage use of clear carbohydrate drinks up until 2 h prior to surgery!

  • Less catabolism
  • Less postoperative nausea and vomiting
  • Less insulin resistance
  • Less perioperative anxiety

Intraoperative fluids

Impact of intraoperative goal-directed fluid therapy on major morbidity and mortality after transthoracic oesophagectomy: a multicentre, randomised controlled trial

Perioperative goal-directed therapy: what’s the best study design to investigate its impact on patient outcome?

Anesthesia-induced immune modulation

Post-op delirium

Postoperative delirium: perioperative assessment, risk reduction, and management

Post-op pain

Renske chats with Jim Watchorn and Sam Hutchings about the kidney! At #LIVES2019

 

ABSTRACT

All adult intubated patients in critical care were eligible for inclusion using an emergency waiver of consent. A minimum of four standardized video clips were taken by an investigator using an incident dark field (IDF) video-microscope (Cytocam, Braedius Medical, NL) who subsequently calculated a POEM score and recorded the time taken. On completion a second investigator blinded to the results of the first repeated this process. At a later stage (>1 month) investigators re-scored their own and their co-investigators images. Scores were analysed using Cohens weighted Kappa score to provide intra-user, inter-user and test-retest reliability. A kappa statistic was also calculated for test-retest reliability for POEM score 1-3 against POEM score 4-5 which is the threshold for fluid administration used in an ongoing interventional study (Clinical Trials.gov  ID).

From theory to practice – ARDS: An old syndrome, new organ interactions #EuAsia18

The lung and the kidneys (Ostermann)

When kidney function lost, –> reduced clearance , fluid overload, acidosis BUT also inflammation, cytokine release and cell death

The distant organ effects of acute kidney injury

AKI causes a higher degree of capillary leakage within the lungs

Ventilator induced kidney injury

IMG_3154

Bench-to-bedside review: Ventilation-induced renal injury through systemic mediator release – just theory or a causal relationship?
Mechanical ventilation as a mediator of multisystem organ failure in acute respiratory distress syndrome.

Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome

IMG_3155IMG_3154

Lung brain interactions (Oddo)

ARDS in the brain-injured patient: what’s different?

IMG_3158 IMG_3157

Issues to consider

  • Oxygenation
  • PEEP
  • CO2/TV

Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update
Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure.

Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates.
Screen Shot 2018-04-14 at 11.30.11

Heart lung interactions (Cecconi)

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Is tidal volume challenge the new PLR? Use of ‘tidal volume challenge’ to improve the reliability of pulse pressure variation

Or end-expiratory hold?
Predicting volume responsiveness by using the end-expiratory occlusion in mechanically ventilated intensive care unit patients.

 IMG_3162

Master Class: AKI and RRT #EuAsia18

Screen Shot 2018-04-12 at 12.03.43

Diagnostic workout of AKI

KDIGO guidelines http://kdigo.org/guidelines/

IMG_3069

 

Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study.

https://www.ncbi.nlm.nih.gov/pubmed/26162677

Basic investigation for all AKI

  • Renal ultrasound
  • Ca
  • Biochemistry
  • Urinalysis – microscopy and electrolytes

The subsequent tests are guided by the clinical picture and history

IMG_3075

A prospective evaluation of urine microscopy in septic and non-septic acute kidney injury.

https://www.ncbi.nlm.nih.gov/pubmed/21669886

Renal biopsy can be diagnostic and can provide information about background histology. 85% of pts develop peri-renal haematoma.

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Future – renal biomarkers

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Summary

IMG_3075

 

When to start and when to stop RRT

Does this patient with AKI need RRT? https://www.ncbi.nlm.nih.gov/pubmed/26690077 

IMG_3077

Strategies for the optimal timing to start renal replacement therapy in critically ill patients with acute kidney injury. https://www.ncbi.nlm.nih.gov/pubmed/28222898

Renal replacement therapy in critically ill patients with acute kidney injury–when to start.

https://www.ncbi.nlm.nih.gov/pubmed/22231034

The optimal time of initiation of renal replacement therapy in acute kidney injury: A meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620297/

Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial.

https://www.ncbi.nlm.nih.gov/pubmed/27209269

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit http://www.nejm.org/doi/full/10.1056/NEJMoa1603017

 

When to stop –

  1. Has the original precipitant for the AKI resolved?
  2. Is there evidence of some degree of recovery of kidney function?
  3. Has any fluid overload been resolved?

Can this patient be safely weaned from RRT?

https://link.springer.com/content/pdf/10.1007/s00134-017-4948-0

 

The terms ‘early’ and ‘late’ RRT should be replaced with TIMELY RRT

Furosemide stress test/challenge test – 0.5-1mg/kg.

 

How to select mode of RRT

Depends on resources, where you work

Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study

https://jamanetwork.com/journals/jama/fullarticle/201386

Intermittent versus continuous renal replacement therapy for acute renal failure in adults: cochrane review

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003773.pub3/full

 

Modality on mortality – no strong data to support continuous or intermittent RRT

 

Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

http://www.nejm.org/doi/full/10.1056/NEJMoa0902413

Nice comparison of IHD vs CRRT vs SLED https://lifeinthefastlane.com/ccc/ihd-vs-crrt-vs-sled/

 

The dose of RRT

No benefits to higher intensity RRT

Target 25ml/kg/hr

 

Drug dosing during RRT

Does anyone adjust drug dosing when pt is on SLEDD? If so, how? Even the pharmacist disagree on what to do – Survey of pharmacists’ antibiotic dosing recommendations for sustained low-efficiency dialysis. https://www.ncbi.nlm.nih.gov/pubmed/26499505

SaMpling Antibiotics in Renal Replacement Therapy (SMARRT): an observational pharmacokinetic study in critically ill patients

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773999/