Abstracts - posterkonkurrence DASAIMs Årsmøde 2015 Postersession IV
Abstract 19
Korresponderende forfatter Joachim Møller Frederiksen
Email joacfred@rm.dk
Afdeling Anæstesiologisk afdeling Hospital/institution Aarhus Universitetshospital, THG
Medforfattere Swati Rajesh Bhavsar, Hans Michael Betsch, Niels Kim Schønemann, Birgitte Brandsborg
Overskrift Mortalitet hos hæmatologiske patienter efter indlæggelse på intensiv afdeling - risikofaktorer og stillingtagen til behandlingsloft
Introduktion
Patienter med hæmatologisk sygdom, der indlægges på intensiv afdeling, har høj mortalitet. Vi fandt i 2006 en mortalitet på intensiv afde- ling, under indlæggelse og efter 1 år på henholdsvis 30.7 %, 52.3 % og 70.7 %, og lignende tal er fundet i andre studier (1,2). Disse resultater er siden brugt vejledende i forbindelse med stillingtagen til behandling på intensiv afdeling og eventuelt ophør af behandling. Det er derfor relevant igen at vurdere mortalitet sammenholdt med risikofaktorer og behandlingsloft.
Primære effektmål var mortalitet på intensiv afdeling, under hele indlæggelsen (intensiv + sengeafdeling) og efter 1 år. Sekundære effektmål var associationen mellem mortalitet og SAPS-2-score, neutropen sepsis og respirator-behandling samt hvorvidt der var lagt behandlingsloft.
Metode
Retrospektiv journalgennemgang af patienter med hæmatologisk sygdom indlagt på multidisciplinær intensiv afdeling (6 senge) på Aarhus Universitetshospital i perioden fra 1.januar 2012 til 31.december 2013 (i alt 24 måneder).
Resultater
Der fandtes i perioden 153 patienter (median 65 år, range 16-87). Der var 103 mænd og 50 kvinder. Mortalitet på intensiv afdeling, under indlæggelse og efter 1 år var henholdsvis 28.1 %, 41.2 % og 75.8 %, se tabel 1. Ved univariat analyse var respiratorbehandling associeret med øget mortalitet på intensiv (X2, p<0.001) og under indlæggelsen (p<0.001), men ikke til 1-års mortaliteten (p=0.267). En højere SAPS-2 score var ligeledes associeret til øget mortalitet på intensiv (X2, p=0.005) og under indlæggelsen (p<0.001), men ikke til 1-års mortalite- ten (p=0.260). Neutropen sepsis var ikke associeret til øget mortalitet i nogen af perioderne. Hos 31 pt (20 %) var der lagt behandlingsloft indenfor de første 24 timer efter intensiv indlæggelse (87% nej til genoplivning, 74% nej til respiratorbehandling). Efter 24 timer var der lagt behandlingsloft på intensiv hos yderligere 33 pt (22 %; 97% nej til genoplivning, 73% nej til respiratorbehandling). Mortalitet hos pt. med behandlingsloft sat før eller efter 24 timer, var højere både på intensiv (53%), under indlæggelse (73%) og efter 1 år (94%) (X2, p<0.001).
Diskussion
Mortaliteten er uændret høj hos hæmatologiske pt. på intensiv, og der var lagt behandlingsloft hos 42 % før/under intensiv forløbet. Nogen af disse patienter skal måske slet ikke tilbydes intensiv terapi, men vi mangler detaljeret viden om prognostiske faktorer ved indlæggelsen.
Grænserne for behandlingsloft er til fortsat diskussion og der er her ikke medtaget f.eks. egenvurderet livskvalitet.
Konklusion
Fremtidige studier skal fokusere på udvikling af prognostiske redskaber til vurdering ved eventuelt overflytning til intensiv terapi.
Abstract S
Korresponderende forfatter Anne Grønborg Vedel
Email anne.groenborg.vedel@regionh.dk Afdeling Thoraxanæstesiologisk Klinik, Hjertecentret Hospital/institution Rigshospitalet
Medforfattere Hanne Berg Ravn, Frederik Holmgaard og Jens Chr. Nilsson
Overskrift Perfusion Pressure Cerebral Infarction (PPCI) trial - the importance of mean arterial pressure during cardiopulmonary bypass to prevent cerebral complications after cardiac surgery
– a protocol for a randomised clinical trial.
Background
In Denmark, around 4500 patients are undertaken cardiac surgery with the use of cardiopulmonary bypass (CPB) annually. Previous studi- es using diffusion-weighed magnetic resonance imaging (DW-MRI) have reported stroke-like lesions in up to 51 % of patients after cardiac surgery (1). Debilitating brain injury occurs in 1-6 % of patients. The majority of the lesions seem to be caused by emboli compromising the cerebral circulation. In addition, inadequate blood flow due to atherosclerosis may contribute. Autoregulation during normal physiology maintains adequate blood flow to the brain over a wide blood pressure range. But during CPB, the blood pressure is often reduced below the level of autoregulation, and due to a maintained blood flow by the heart-lung machine, this is generally considered appropriate to avoid cerebral ischaemia. However, this concept has never been proven.
Methods/Design
The PPCI trial is a single-center superiority trial with blinded outcome assessment randomising 200 patients with coronary vessel and/or valve disease undergoing cardiac surgery with the use of CPB. The patients will be stratified by age and by type of cardiac surgery, and ran- domised 1:1 to either increased MAP (70-80 mm Hg) or ‘usual practice’ (typically 45-50 mm Hg) during CPB. In both groups CPB blood flow is intended equal and fixed.
The primary outcome measure is the total volume of new ischemic cerebral lesions (sum in mL), expressed as the difference between a ba- seline DW-MRI scan and an equal scan conducted day 3-6 postoperatively. Secondary endpoints are total number of new ischemic cerebral lesions, postoperative dysfunction at discharge and 3 months postoperatively, diffuse cerebral injury evaluated by MRI spectroscopy and evaluation of biochemical markers of cerebral injury at 4 time points.
Before commencing the PPCI trial, a pilot study including 12 patients demonstrated the feasibility of achieving a highly significant difference in average MAP between the intervention group and the control group (mean [SD] 68 [5.6] vs. 45 [4.3] mm Hg, p<0.0001). In 5 of 12 patients new infarctions were found using DW-MRI.
The sample size will enable us to detect a 50% reduction in the primary outcome measure in the intervention as compared to the control group at a significance level of 0.05 and with a power of 0.80.
Discussion
This is the first clinical, randomised study to evaluate whether blood pressure level during CPB influences the occurrence of brain lesions detected by MRI. If an increased blood pressure during CPB proves beneficial, the intervention to achieve this goal can easily be implemented in clinical management.
Reference
Knipp SC et al. Cognitive outcomes three years after coronary artery bypass surgery: relation to diffusion-weighted magnetic resonance ima- ging. Ann Thorac Surg 2008 March;85:872-9.
Abstract 26
Korresponderende forfatter Mikkel Filholm Lange
Email klontime@gmail.com
Afdeling ITA Nørrebrogade
Hospital/institution Aarhus Universitetshospital
Medforfattere Maiken Møller, Søren Nielsen, Kim Rishøj, Pia Dreyer og Helle Nibro
Overskrift The sound of the intensive care unit - 3 weeks of continuous sound recording Introduction
The Intensive Care Unit (ICU) is a noisy and disturbing environment known to cause sleep disruption in its patients. Sleep is essential to human life and sleep deprivation has numerous negative effects (1). This study investigates the suitability of the sound environment in a modern ICU in promoting sleep by analysing continuous audio recordings captured over the course of three weeks.
Methods
The study was carried out in a 3-bed room in the ICU ITA in Aarhus University Hospital. To enable elaborate analysis of the sound environ- ment a calibrated recorder was used, instead of a sound level meter. The recorder was placed over the head end of the middle bed. The recorded sound was analysed calculating the sound level of an event (a door being shut etc.) relative to the level of the background noise hereby deciding whether or not rest and sleep was promoted, and categorizing the time as restorative periods (RP), and non-restorative periods (NRP) (2).
Results
The mean sound pressure level (LAeq) of the whole period was 53 (min./max. 48.7/56.2) A-weighted decibels (dBA) during the day (07:00- 23:00) and 50 (min./max. 43.7/54.4) dBA during the night (23:00-07:00) (fig. 1). The LAeq of weekdays compared to weekend showed no significant difference. The morning and afternoon shift showed no significant difference, with the night shift having a slightly lower LAeq in comparison. The mean RP was 6.2 minutes, with several hundred NRP every day (fig. 2). Only 7 restorative periods above or equal to 90 minutes was seen during the 21 days of recording. The longest continuous RP was 173 minutes.
Discussion
We found the average sound pressure level during both day and night to be much higher than the levels recommended by the WHO, 35 dBA at night and 40 dBA at day. Furthermore, it is highly concerning that only a third of the recorded days contained one or more RP ≥ 90 minutes. Considering that the human sleep cycle is 90-110 minutes, it must be rare for the intensive care patient to complete such a cycle.
Conclusion
Our data describes a highly disruptive noise environment in the modern ICU, with constant fluctuations in sound levels, potentially interrup- ting the sleep cycle. To deal with these issues, constant awareness on work routines and demand for equipment to be more silent with intel- ligent alarm sound levels are, among other things, required. The next step is to investigate to what extent these constant sound fluctuations results in arousals to the intensive care patients, by measuring the patients’ sleep and correlating it to the sound environment.
1. Pulak, Lisa M., and Louise Jensen. ”Sleep in the Intensive Care Unit A Review.” J. Intensive care medicine (June 2014).
2. Park, Munhum, et al. ”Analysis of the soundscape in an intensive care unit based on the annotation of an audio recording.” J. Acoustical Society of America 135.4 (2014): 1875-1886.
Abstract 29
Korresponderende forfatter Frederik Holmgaard Email frederik.holmgaard@regionh.dk
Afdeling Thoraxanæstesiologisk Klinik, 4142, HjerteCentret Hospital/institution Rigshospitalet
Medforfattere Anne G. Vedel, Annika Langkilde, Jens Chr. Nilsson, Hanne Berg Ravn
Overskrift Har størrelsen af sinus frontalis indflydelse på Near InfraRed Spectroscopy under hjertekirurgi?
INTRODUKTION
Som led i et pågående randomiseret, klinisk studie (Perfusion Pressure Cerebral Infarct (PPCI) trial) med hjertekirurgiske patienter har vi på magnetisk resonans (MR) skanning af cerebrum kunnet måle størrelsen af sinus frontalis (SF). Det er velkendt, at der er stor variation i stør-
relsen af SF.
Near InfraRed Spectroscopy (NIRS) anvender optoder på panden af patienten - svarende til frontallapperne - og afspejler regional ilt saturati- on i det underliggende væv i 1,5-2cms dybde. Hos patienter med store SF kan SF teoretisk påvirke NIRS.
Formålet med denne case-series er at undersøge, om der ved obligate ændringer i NIRS værdierne er forskel på den relative ændring mellem patienter med store hhv. små SF. Dette undersøges ved at sammenligne faldet i NIRS værdier, der opstår som følge af akut hæmodilution ved start af hjertelungemaskine (HLM) pga. clear-priming, mellem de to grupper.
METODE
Ud af 144 inkluderede patienter i PPCI trial viste præoperative MR billeder en SF størrelse (maksimal længde opmålt i AP-retning) > 17,1mm (figur 1) hos 11 patienter. Peroperativ noradrenalin (NA) er tidligere vist at kunne påvirke NIRS[1] og som følge af dette blev 6 ud af de 11 patienter ekskluderet.
Kontrolgruppen (n=5) blev matchet mht. NA peroperativt = 0mL, alder, køn, operationstype, hæmatokrit-niveau og middelarterieblodtryk un- der HLM og samtidigt med mindst mulige SF størrelse vurderet ud fra MR billeder. De to gruppers NIRS værdier blev efterfølgende analyseret som gennemsnitsværdier 30 sekunder præ HLM og 30 sekunder efter start af HLM.
RESULTATER
Gruppen med store SF havde en gennemsnit længde af SF = 18,1 vs 3,2mm ved gruppen med små SF. Gruppen med store SF vs små SF havde gennemsnitsalder 67 vs 69 år, gennemsnitshæmatokrit 31 vs 30% under HLM og middelarterieblodtryk 49 vs 46mmHg under HLM (begge grupper havde fikseret flow under HLM). Begge grupper bestod udelukkende af mænd.
Hos patienter med store SF blev der observeret et fald i NIRS værdier ved overgang til HLM (mean [min;max]) = -6,9% [-1,6;-11,3] vs -5.8%
[-1,29;-12,9] (p = 0.54) i gruppen med små SF. I begge grupper blev der fundet NIRS værdier < baseline under hele HLM forløbet med normali- sering post HLM. Der blev ikke observeret kritisk lave værdier i nogen af grupperne.
DISKUSSION
NIRS optoder placeres normalt op mod hårgrænsen, hvilket kan være med til at minimere en eventuel betydning af SF.
KONKLUSION
I dette præliminære studie kan der ikke påvises indflydelse fra SF i NIRS monitoreringen hos patienter med store SF. Hvorvidt NIRS monitore- ring hos patienter med store SF afspejler blodgennemstrømning i andet end hjernevæv kan ikke afgøres ud fra disse observationer. Fremad- rettet vil der blive foretaget supplerende undersøgelser til at belyse disse forhold.
[1] Sørensen H. et al. Cutaneous Vasoconstriction Affects Near-Infrared Spectroscopy Determined Cerebral Oxygen Saturation during Admini- stration of Norepinephrine. Anasthesiology. 117, 263-70 (2012).
Abstract 34
Korresponderende forfatter Karoline Myglegård Mortensen Email karoline.myglegaard@gmail.com Afdeling Department of Anaesthesiology
Hospital/institution Nordsjællands Hospital, University of Copenhagen, Denmark
Medforfattere Theis Itenov(1), Nicolai Haase(2), Rasmus Müller(3), Sisse Rye Ostrowski(4), Pär Ingemar Johansson(4,5), Niels Vidiendal Olsen(6), Morten Bestle(1)
Overskrift Endogenous inhibition of nitrogen oxide synthase increase mortality in patients with severe sepsis or septic shock
Introduction
Pharmacological unselective inhibition of nitrogen synthases has previously been found to have a negative impact on survival [1]. Asymme- tric dimethyl arginine (ADMA) is an unselective endogen inhibitor of nitrogen oxide synthase (NOS) [2] and has been found to be elevated in patients with septic shock. The aim of the present study was to investigate the association between plasma levels of ADMA and 90-day mortality in patients with severe sepsis or septic shock.
Method
We included adult severe sepsis and septic shock patients from the Scandinavian Starch for Severe Sepsis and Septic Shock (6S) trial [3], from
whom pre-intervention plasma samples were available. The 6S study was approved by the local ethics committee (protocol.no: H-A-2009- 056), and all patients or their legal representatives gave written informed consent. ADMA was measured by enzyme-linked immunosorbent assay (DLD Diagnostica, Germany). The association between ADMA and mortality was analysed by Cox regression.
Results
A total 223 patients were included in the present study (baseline characteristics, Table 1), of whom 123/223 (55.2%) died within 90 days of randomisation. An ADMA level in the upper quartile vs the three lower quartiles was independently associated with increased 90-day mortality with a hazard ratio of 1.85 (95% confidence interval 1.23-2.78), p=0.003, when adjusted for gender, mechanical ventilation, need for vasopressor, age (dichotomized at 65 years), highest quartile of creatinine and bilirubin, and lowest quartile of PaO2/FiO2, mean arterial pressure and platelet count. None of the latter variables were independently associated with 90-day mortality. The survival curve for highest vs. lower ADMA quartiles are shown in figure 1.
Discussion
We found that high plasma ADMA levels were associated with increased mortality in a large cohort of patients with severe sepsis or septic shock. The present study is of observational design and a causal link between ADMA inhibition of NOS and mortality is only suggestive. Ran- domized, controlled intervention studies with pharmacological lowering of ADMA are needed to consolidate this link.
Conclusion
High plasma ADMA levels were independently associated with 90-day mortality in patients with severe sepsis and septic shock. This makes pharmacological lowering of ADMA an interesting field of future research.
References
[1] López A et al. Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med 2004;32:21–30.
[2] Tran CT et al. The DDAH/ADMA/NOS pathway. Atheroscler Suppl 2003;4:33–40.
[3] Perner A et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 2012;367:124–34.
Abstract 43
Korresponderende forfatter Anne Pernille Toft-Petersen1
Email aptp@rn.dk
Afdeling Anæstesi og Intensiv Afdeling1, Lungemedicinsk Afdeling2 og Klinisk Epidemiologisk Afdeling3 Hospital/institution Aalborg Universitetshospital/Aalborg Universitet
Medforfattere Torp-Pedersen C3, Weinreich UM2, Rasmussen BS1
Overskrift Previous hospitalizations are predictors of hospital mortality in ventilated COPD patients Introduction
The frequency of acute exacerbations vary extensively among COPD patients and a “frequent exacerbators phenotype” has been suggested 1. Previous studies have shown an association between prior exacerbations and mortality in COPD patients in general2, but the association has not been studied specifically in the subgroup of COPD patients subjected to assisted ventilation. We examined whether previous hospita- lizations were independently associated with in-hospital as well as long-term mortality among first time ventilated COPD patients.
Methods
In the Danish National Patient Registry we established a cohort of patients previously medicated for COPD who were ventilated for the first time due to an acute exacerbation of COPD from 2003 through 2011. Ventilation is defined as either invasive or non-invasive mechanical ventilation. We assessed the number of hospitalizations for COPD in the preceding year, age, sex, the Charlson comorbidity index, mode of ventilation, survival to discharge and days to death beyond discharge.
Results: The cohort consisted of 6,656 patients of which 66% had not been hospitalized for COPD in the previous year, 18% had been hospi- talized once, 8% twice and 9% thrice or more. In-hospital mortality was 45% and of patients alive at discharge 11% died within a month and 39% within a year. In multivariate models, adjusted for age, sex, Charlson Comorbidity index and mode of ventilation, odds ratios for death in-hospital with 95% confidence intervals were 1.26 [1.11-1.44], 1.43 [1.19-1.72] and 1.56 [1.30-1.87] with 1, 2 and 3 or more hospitalizations (figure 1). Hazard ratios for death beyond discharge with 95% confidence intervals were 1.32 [1.19-1.46], 1.76 [1.52-2.02] and 2.07 [1.80-2.38]
with 1, 2 and 3 or more hospitalizations (figure 2).
Discussion
It is well known, that a need of assisted ventilation in COPD patients having an acute exacerbations is a marker of severe respiratory insuffi- ciency and is associated with a high mortality. Our study shows that the number of previous hospitalizations might predict mortality among COPD patients treated with assisted ventilation for the first time. Our population is unique in that it encompasses only COPD patients with severe acute respiratory failure and only patients whose prognosis have not been considered to grim to warrant assisted ventilation. The association found in our population thus points to independence, but with odds and hazard ratios in the range of 1.3 to 2.0, previous admissi- ons cannot in themselves be regarded as a contraindication to assisted ventilation.
Conclusion
Preceding hospitalizations are associated with in-hospital as well as long-term mortality in a population of COPD patients with acute severe respiratory failure defined as need of assisted ventilation for the first time.
Figure 1 Odds ratios for the association between patient characteristics known at admission and in-hospital mortality.
7
Figure 1 Hazard ratios for the association between patient cahracteristics known at admission and mortality after discharge.
Abstract 14
Korresponderende forfatter Robin Lohse
Email robin.lohse@gmail.com Afdeling Intensiv Terapiklinik Afsnit 4131 Hospital/institution Rigshospitalet
Medforfattere Michael Ibsen, Jørgen Wiis, Anders Perner and Mette Brimnes Damholt
Overskrift Lower mortality in ICU patients on chronic dialysis than in those requiring dialysis for acute kidney injury Background
The mortality of patients requiring acute renal replacement therapy (RRT) (continuous or intermittent) in the intensive care unit (ICU) is high. In this study we aim to investigate to what extent this may rely upon the lack of renal function. Thus we compared the mortality of ICU patients requiring acute RRT with that of patients who were on chronic dialysis before ICU admission.
Methods
All adult patients admitted to the multidisciplinary ICU, Rigshospitalet, from Jan 1st 2005 to Dec 31st 2012 were identified through the ICU database, excluding repeat admittances. Chronic dialysis patients were identified from the Danish Society of Nephrology database. Kap- lan-Meier plots were calculated for the mortality of the first 30-days after ICU admission.
Results
We included 5927 patients of whom 1004 (16.9 %) received acute RRT and 161 (2.7 %) were on chronic dialysis before admission. The mean age (IQR) was 61 years (52-71) for acute RRT patients vs. 60 years (52-70) for chronic dialysis patients (p=0.330). The mean SAPS II score was 59 (46-70) for acute RRT patients vs. 56 (45-65) for chronic dialysis patients (p=0.075). The mean of the highest SOFA score during admission was 14 (12-17) for acute RRT patients vs. 12 (10-14) for chronic dialysis patients (p<0.001). Thirty-day mortality (95 % CI) was 41.9 % (38.6 % - 45.0 %) for acute RRT patients and 28.1 % (20.6 % - 34.9 %) for chronic dialysis patients. For non-dialysis patients 30-day mortality was 16.3 % (15.3 % - 17.4 %).
Conclusion
Patients with acute RRT in the ICU had a significantly higher mortality compared to patients on chronic dialysis. This may have reflected acute RRT patients being more severely ill, particularly during the course of their ICU stay. It may be speculated that lack of renal function in itself does not explain the high mortality in ICU patients requiring acute RRT.
Abstract 8
Korresponderende forfatter Robin Lohse
Email robin.lohse@gmail.com Afdeling Intensiv Terapiklinik Afsnit 4131 Hospital/institution Rigshospitalet
Medforfattere Mette Brimnes Damholt , Jørgen Wiis, Anders Perner, Theis Lange and Michael Ibsen Overskrift Long term mortality and risk of end-stage renal disease following acute RRT in ICU patients Introduction
In the intensive care unit (ICU) the need for acute renal replacement therapy (aRRT) is associated with high mortality and risk of end-stage renal disease (ESRD). We investigated long term mortality and progression to ESRD in ICU patients requiring aRRT and factors associated to these.
Methods
Retrospective analysis of all adult patients admitted to the general ICU, Rigshospitalet, from 1/1-2005 to 31/12-2012, identified through the ICU database, excluding chronic dialysis patients. ESRD was defined as the need of dialysis >90 days or kidney transplant.
Results
Of 5766 patients included, 931 (16%) received aRRT, 4762 (83%) did not receive any RRT and 73 (1%) only received aRRT during a later ICU admission. The 90-day mortality was 55% for aRRT patients and 22% for those not requiring aRRT (p<0.001). The median (IQR) age was 61 (49 - 68) for aRRT 90-day survivors and 65 (55 - 73) for aRRT non-survivors (p<0.001). The median SAPS II score was 53 (43 - 64) for aRRT 90- day survivors and 61 (49 - 74) for aRRT non-survivors (p<0.001). Characteristics of aRRT patients developing ESRD and those that did not, are displayed in table 1. The 7-year risk of ESRD for patients surviving 90 days after admission was 10% (7 - 14) for aRRT patients as compared to 0.5% (95% CI 0.3-0.9) for those not receiving aRRT (p<0.001).
Conclusions
The aRRT patients surviving 90 days were younger and less severely ill at ICU admission as compared to the non-survivors. The survivors developing ESRD had more frequently preexisting chronic kidney disease and higher APACHE II scores as compared to those who did not de- velop ESRD. aRRT patients had increased risk of ESRD up to 7 years after ICU admission, emphasizing the KDIGO recommendations to follow up AKI patients due to their increased risk for CKD.
