Publications by authors named "Hoi-Ping Shum"

26 Publications

  • Page 1 of 1

Effect of the underlying malignancy on critically ill septic patient's outcome.

Asia Pac J Clin Oncol 2021 Nov 24. Epub 2021 Nov 24.

Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.

Background: Sepsis is an important cause of mortality and morbidity among critically ill patients with underlying malignancy.

Methods: Patients with sepsis admitted to the intensive care unit (ICU) of the Pamela Youde Nethersole Eastern Hospital from January 1, 2010 to April 30, 2019 were recruited. Demographics, laboratory parameter, and outcome were analyzed. Those with underlying malignancy were matched with those without malignancy based on their severity of organ failure (defined by the sequential organ failure assessment [SOFA] score) and septic source.

Results: Two hundred sixty-three patients with underlying active malignancy were matched with 259 patients without malignancy. Those with malignancy had higher APACHE IV score (89 vs. 83), lower albumin (22.1 vs. 24.4), neutrophil count (6.0 vs. 9.3), hemoglobin (8.0 vs. 9.8), platelet count (113 vs. 133), less use of mechanical ventilation (35.7% vs. 45.9%), renal replacement therapy (22.1% vs. 28.2%) and vasopressor (66.2% vs. 74.9%), higher 30-day (34.2% vs. 24.3%) ICU (22.4% vs. 18.9%), and 1-year (62.4% vs. 36.7%) mortality compared with those without malignancy. A higher APACHE IV score and pulmonary sepsis were predictors of 30-day mortality by Cox regression analysis.

Conclusion: Disease severity and pulmonary sepsis, but not underlying malignancy, predicted short-term mortality among critically ill septic patients.
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http://dx.doi.org/10.1111/ajco.13638DOI Listing
November 2021

Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018.

J Intensive Care 2021 Jan 6;9(1). Epub 2021 Jan 6.

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4/F Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, Hong Kong, China.

Background: Globally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong.

Methods: This was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed.

Results: From 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by - 0.15 (95% CI - 0.18 to - 0.11) per year (Pearson's R = - 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer-Lemeshow test p < 0.001).

Conclusions: Despite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong.
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http://dx.doi.org/10.1186/s40560-020-00513-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788755PMC
January 2021

Triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial.

Lancet 2020 05 10;395(10238):1695-1704. Epub 2020 May 10.

Department of Microbiology, United Christian Hospital, Hong Kong SAR, China.

Background: Effective antiviral therapy is important for tackling the coronavirus disease 2019 (COVID-19) pandemic. We assessed the efficacy and safety of combined interferon beta-1b, lopinavir-ritonavir, and ribavirin for treating patients with COVID-19.

Methods: This was a multicentre, prospective, open-label, randomised, phase 2 trial in adults with COVID-19 who were admitted to six hospitals in Hong Kong. Patients were randomly assigned (2:1) to a 14-day combination of lopinavir 400 mg and ritonavir 100 mg every 12 h, ribavirin 400 mg every 12 h, and three doses of 8 million international units of interferon beta-1b on alternate days (combination group) or to 14 days of lopinavir 400 mg and ritonavir 100 mg every 12 h (control group). The primary endpoint was the time to providing a nasopharyngeal swab negative for severe acute respiratory syndrome coronavirus 2 RT-PCR, and was done in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT04276688.

Findings: Between Feb 10 and March 20, 2020, 127 patients were recruited; 86 were randomly assigned to the combination group and 41 were assigned to the control group. The median number of days from symptom onset to start of study treatment was 5 days (IQR 3-7). The combination group had a significantly shorter median time from start of study treatment to negative nasopharyngeal swab (7 days [IQR 5-11]) than the control group (12 days [8-15]; hazard ratio 4·37 [95% CI 1·86-10·24], p=0·0010). Adverse events included self-limited nausea and diarrhoea with no difference between the two groups. One patient in the control group discontinued lopinavir-ritonavir because of biochemical hepatitis. No patients died during the study.

Interpretation: Early triple antiviral therapy was safe and superior to lopinavir-ritonavir alone in alleviating symptoms and shortening the duration of viral shedding and hospital stay in patients with mild to moderate COVID-19. Future clinical study of a double antiviral therapy with interferon beta-1b as a backbone is warranted.

Funding: The Shaw-Foundation, Richard and Carol Yu, May Tam Mak Mei Yin, and Sanming Project of Medicine.
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http://dx.doi.org/10.1016/S0140-6736(20)31042-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211500PMC
May 2020

Critically ill patients with COVID-19 in Hong Kong: a multicentre retrospective observational cohort study

Crit Care Resusc 2020 04 6;22(2):119-125. Epub 2020 Apr 6.

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China.

Objective: To report the first eight cases of critically ill patients with coronavirus disease 2019 (COVID-19) in Hong Kong, describing the treatments and supportive care they received and their 28-day outcomes.

Design: Multicentre retrospective observational cohort study.

Setting: Three multidisciplinary intensive care units (ICUs) in Hong Kong.

Participants: All adult critically ill patients with confirmed COVID-19 admitted to ICUs in Hong Kong between 22 January and 11 February 2020.

Main Outcome Measure: 28-day mortality.

Results: Eight out of 49 patients with COVID-19 (16%) were admitted to Hong Kong ICUs during the study period. The median age was 64.5 years (range, 42–70) with a median admission Sequential Organ Failure Assessment (SOFA) score of 6 (IQR, 4–7). Six patients (75%) required mechanical ventilation, six patients (75%) required vasopressors and two (25%) required renal replacement therapy. None of the patients required prone ventilation, nitric oxide or extracorporeal membrane oxygenation. The median times to shock reversal and extubation were 9 and 11 days respectively. At 28 days, one patient (12%) had died and the remaining seven (88%) all survived to ICU discharge. Only one of the survivors (14%) still required oxygen at 28 days.

Conclusion: Critically ill patients with COVID-19 often require a moderate duration of mechanical ventilation and vasopressor support. Most of these patients recover and survive to ICU discharge with supportive care using lung protective ventilation strategies, avoiding excess fluids, screening and treating bacterial co-infection, and timely intubation. Lower rather than upper respiratory tract viral burden correlates with clinical severity of illness.
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April 2020

Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study.

Crit Care Res Pract 2019 6;2019:7584573. Epub 2019 Dec 6.

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, China.

In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients' demographics, comorbidities, radiological findings, clinical grades of SAH, PO and PCO within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO > 200 mmHg) and hypercapnia (PCO > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131-12.690, =0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted =0.006,  = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.
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http://dx.doi.org/10.1155/2019/7584573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925754PMC
December 2019

The aquarium in the right heart.

Echocardiography 2018 09 5;35(9):1482-1483. Epub 2018 Aug 5.

Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong.

We presented a case with massive hepatic portovenous gas (HPVG) and gastric emphysema, probably due to increased intraluminal pressure in the stomach after bagging and noninvasive ventilation. There are multiple microbubbles in the inferior vena cava, right atrium and right ventricle. There has been only one case report ever published showing the similar features of the "aquarium sign" in the right heart in a patient with intussusception. We believe our case is a good illustration of this extremely rare entity in echocardiography.
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http://dx.doi.org/10.1111/echo.14110DOI Listing
September 2018

A Case of Lemierre's Syndrome in Intensive Care Unit.

Indian J Crit Care Med 2018 Feb;22(2):122-124

Department of Microbiology, The University of Hong Kong, Hong Kong SAR, China.

We report a 21-year-old young male with Lemierre's syndrome presented as tonsillitis and with respiratory failure and required intensive care. Lemierre's syndrome is the septic embolic complication of recent pharyngeal illness. spp. accounts for the majority of cases. High index of suspicion is needed and prolonged antibiotic is advised. It is seldom seen in intensive care but should never be forgotten.
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http://dx.doi.org/10.4103/ijccm.IJCCM_388_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842455PMC
February 2018

Treatment of Acute Kidney Injury Complicating Septic Shock with EMiC2 High-cutoff Hemofilter: Case Series.

Indian J Crit Care Med 2017 Nov;21(11):751-757

Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.

Introduction: Extracorporeal blood purification therapies have been proposed to improve outcomes of patients with severe sepsis, with or without accompanying acute kidney injury (AKI), by removal of excessive inflammatory mediators.

Materials And Methods: We report our experience with EMiC2 high-cutoff continuous venovenous hemofiltration/hemodialysis (HCO-CVVH/HD) in seven patients with AKI complicating septic shock.

Results: The median treatment duration was 71 h, and the procedure was well tolerated. Trough serum albumin level of 20 g/L was observed after 2 h of treatment and none of the patients required albumin supplement. The hospital mortality rate was 29%, which appeared more favorable than the predicted mortality of 60%-78% based on disease severity scores. Circulating levels of interleukin-6 (IL-6), IL-10, and tumor necrosis factor-alpha improved over time.

Conclusion: This case series shows that HCO-CVVH/CVVHD using EMiC2 hemofilter may provide good cytokine modulation, when used along with good quality standard sepsis therapy. A further large-scale prospective randomized controlled trial is recommended.
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http://dx.doi.org/10.4103/ijccm.IJCCM_338_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699003PMC
November 2017

Emergence of carbapenem-resistant hypervirulent Klebsiella pneumoniae.

Lancet Infect Dis 2018 01 1;18(1):24. Epub 2017 Nov 1.

Shenzhen Key lab for Food Biological Safety Control, Food Safety and Technology Research Center, Hong Kong PolyU Shen Zhen Research Institute, Shenzhen, China; State Key Lab of Chirosciences, Department of Applied Biology and Chemical Technology, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region, China. Electronic address:

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http://dx.doi.org/10.1016/S1473-3099(17)30629-1DOI Listing
January 2018

Impact of renal replacement therapy on survival in patients with KDIGO stage 3 acute kidney injury: A propensity score matched analysis.

Nephrology (Carlton) 2018 Dec;23(12):1081-1089

Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.

Aim: To investigate the impact of renal replacement therapy (RRT) on 90-day mortality in critically ill patients suffering from KDIGO stage 3 acute kidney injury (AKI) with or without life-threatening complications using propensity score matching analysis.

Methods: We conducted a retrospective analysis of critically ill adult patients with KDIGO Stage 3 AKI with or without RRT during ICU stay between 1/1/2011-31/12/2013. Cox regression analysis and propensity score matching methods were used to determine predictors for 90-day mortality.

Results: Among 661 patients, 50.5% received RRT. The unadjusted 90-day mortality rate was 42.5% and 54.1% in patients who had or had not received RRT, respectively. After adjustment with propensity score based on the probability of receiving RRT, the cox regression analysis showed that RRT was associated with a lower 90-day mortality (p<0.001). Among 322 propensity-matched pairs, RRT was associated with lower ICU (23.6% vs. 39.8%, p=0.002), hospital (33.5% vs. 55.9%, p<0.001) and 90-day mortality (34.2% vs. 58.4%, p<0.001), and a higher 90-day renal recovery rate (57.8% vs. 45.3% full recovery, p=0.026) compared with no RRT. When an alternate propensity model was used, the benefits associated with RRT were very similar, except 90-day renal recovery became insignificant.

Conclusion: Our observational study found that in critically ill patients with KDIGO Stage 3 AKI, RRT may be associated with lower 90-day mortality. The benefit of RRT on renal recovery was less prominent. Medical futility and practice variations may complicate study interpretation. To avoid these limitations, large-scale multicenter, non-observational study is recommended.
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http://dx.doi.org/10.1111/nep.13164DOI Listing
December 2018

Experiences with Continuous Venovenous Hemofiltration using 18mmol/L predilution Citrate anticoagulation and a Phosphate Containing Replacement Solution.

Indian J Crit Care Med 2017 Jan;21(1):11-16

Department of Intensive Care, Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong.

Context: Regional citrate anticoagulation for continuous renal replacement therapy is associated with a longer filter-life, less bleeding events and improved mortality. Problems associated with using Prismocitrate 10/2 solution in continuous renal replacement therapy, include hypomagnesemia, hypophosphatemia and the need for additional bicarbonate infusion.

Aims: This study uses the new Prismocitrate 18/0 solution for improved buffer balance and Phoxilium solution for a more favourable electrolyte profile.

Settings And Design: A retrospective analysis of patients who underwent continuous venovenous hemofiltration (CVVH) using Prismocitrate 18/0 and Phoxilium in our 21-bed ICU was conducted from March to July 2014.

Methods And Material: Continuous venovenous hemofiltration (CVVH) was performed at fixed rate by using Prismocitrate 18/0 predilution at 1250 ml/hour, a blood flow rate of 110 ml/min and post-replacement with Phoxilium at 1250 ml/hr. CVVH was run for 72 h or until filter clotting, transportation, or achievement of the clinical target.

Statistical Analysis Used: The results were displayed as the median with the interquartile range (IQR). The trend in pH, electrolytes, and base excess are shown using a standard box plot. All analyses were performed by the Statistical Package for Social Science for Windows, version 17 (SPSS, Chicago, IL, USA).

Results: Forty-five CVVH episodes were analysed. The median circuit lifetime was 44 h (interquartile range, IQR 29-55). Metabolic alkalosis, hypophosphatemia and hypomagnesemia occurred in 8.3%, 3.5% and 40.2% of the blood samples, respectively. No patient developed hypokalemia or citrate toxicity.

Conclusions: This new CVVH regime is safe and easy to administer for critically ill patients.
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http://dx.doi.org/10.4103/0972-5229.198311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278584PMC
January 2017

Preoperative red cell distribution width: Not a useful prognostic indicator for 30-day mortality in patients who undergo major- or ultra-major noncardiac surgery.

Indian J Crit Care Med 2016 Nov;20(11):647-652

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China.

Background: Red cell distribution width (RDW) has been shown to be associated with mortality in cardiac surgical patients. This study investigates the association of RDW with the 30-day mortality for those patients who undergo major- or ultra-major noncardiac surgery.

Methods: Patients who received major- or ultra-major noncardiac surgery between July 2012 and May 2013 were included in the study and patients those with preoperative hemoglobin <10 g/day were excluded from the study. Patients were followed till day 30 from the date of surgery or death, whichever occurred earlier.

Results: The overall 30-day mortality for major- and ultra-major surgery was 11.4%. The mean RDW of the 30-day survivors was 13.6 ± 1.6 and that of nonsurvivors was 14.2 ± 2.1 ( < 0.001). Other factors that were significantly different ( < 0.05) between survivors and nonsurvivors included age, sex, preoperative pulse rate, current or ex-alcoholic, the American Society of Anesthesiologists score, diabetes mellitus, use of antihypertensives, sepsis with 48 h before surgery, preoperative hemoglobin, white cell count, sodium, urea, creatinine, albumin, international normalized ratio (INR), pH, base excess, estimated blood loss, and emergency surgery. Logistic regression revealed that preoperative RDW > 13.35% ( = 0.025, odds ratio [OR]: 1.52), INR ( = 0.008, OR: 4.49), albumin level ( < 0.001, OR: 1.10), use of antihypertensives ( = 0.001, OR: 1.82), and preoperative pulse rate ( = 0.006, OR: 1.02) independently predicted the 30-day mortality. However, the area under receiver operating characteristic curve for the prediction of 30-day mortality using RDW was only 0.614.

Conclusions: Although preoperative RDW independently predicted 30-day mortality in patients who underwent major- or ultra-major noncardiac surgery, it may not serve as an influential prognostic indicator in view of its low sensitivity and specificity.
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http://dx.doi.org/10.4103/0972-5229.194008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5144526PMC
November 2016

Clinical Outcomes of Extended Versus Intermittent Infusion of Piperacillin/Tazobactam in Critically Ill Patients: A Prospective Clinical Trial.

Pharmacotherapy 2017 01 6;37(1):109-119. Epub 2017 Jan 6.

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, China.

Study Objective: To determine whether critically ill patients receiving extended-infusion (EI) piperacillin/tazobactam would have improved clinical outcomes compared with patients receiving intermittent infusions.

Design: Single-center, open-label, prospective study.

Setting: Twenty-two-bed intensive care unit (ICU) in a regional hospital in Hong Kong.

Patients: A total of 367 adults who had a diagnosis of either bacterial infection or neutropenic fever and had received treatment with piperacillin/tazobactam for at least 48 hours between December 1, 2013, and August 31, 2015.

Intervention: Patients were assigned to receive piperacillin/tazobactam as either a 4-hour EI (182 patients [EI group]) or a 30-minute intermittent infusion (185 patients [non-extended infusion (NEI) group]).

Measurements And Main Results: All patients were followed for at least 14 days after treatment assignment. The primary outcome was the 14-day mortality rate after initiation of piperacillin/tazobactam. Secondary outcomes included in-hospital mortality rate, time to defervescence, duration of mechanical ventilatory support, length of ICU stay, and duration of hospital stay. Both groups demonstrated similar 14-day mortality (11.5% in the EI group vs 15.7% in the NEI group, p=0.29). The mean time to defervescence was significantly reduced in the EI group (4 days in the EI group vs 6 days in the NEI group, p=0.01); no significant differences between groups were noted in the other secondary outcomes. An Acute Physiology and Chronic Health Evaluation II score of 29.5 or higher was found to strongly predict 14-day mortality (p=0.03) by Classification and Regression Tree analysis. In the post hoc analyses, a 14-day mortality benefit was demonstrated in patients in the EI group in whom infectious organisms were identified (mortality rate 9.3% in the EI group vs 22.4% in the NEI group, p=0.01) and in whom respiratory tract infection was diagnosed (mortality rate 8.9% in the EI group vs 18.7% in the NEI group, p=0.02).

Conclusion: Both the EI and NEI groups demonstrated similar 14-day mortality. Post hoc subgroup analysis revealed a mortality benefit in patients in the EI group who had infectious organisms identified or were diagnosed with respiratory tract infections.
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http://dx.doi.org/10.1002/phar.1875DOI Listing
January 2017

Septic acute kidney injury in critically ill patients - a single-center study on its incidence, clinical characteristics, and outcome predictors.

Ren Fail 2016 Jun 16;38(5):706-16. Epub 2016 Mar 16.

c Department of Medicine , the University of Hong Kong, Queen Mary Hospital , Pokfulam , Hong Kong SAR , China.

Purpose The objective of this study is to examine the incidence, clinical characteristics, and outcome (90-day mortality) of critically ill Chinese patients with septic AKI. Methods Patients admitted to the ICU of a regional hospital from 1 January 2011 to 31 December 2013 were included, excluding those on chronic renal replacement therapy. AKI was defined using KDIGO criteria. Patients were followed till 90 days from ICU admission or death, whichever occurred earlier. Demographics, diagnosis, clinical characteristics, and outcome were analyzed. Results In total, 3687 patients were included and 54.7% patients developed AKI. Sepsis was the most common cause of AKI (49.2%). Compared to those without AKI, AKI patients had higher disease severity, more physiological and biochemical disturbance, and carried significant co-morbidities. Ninety-day mortality increased with severity of AKI (16.7, 27.5, and 48.3% for KDIGO stage 1, 2, and 3 AKI, p < 0.001). Full renal recovery was achieved in 71.6% of AKI patients. Compared with non-septic AKI, septic AKI was associated with higher disease severity and required more aggressive support. Non-recovery of renal function occurred in 2.5% of patients with septic AKI, compared with 6.4% in non-septic AKI (p < 0.001). Cox regression analysis showed that age, emergency ICU admission, post-operative cases, admission diagnosis, etiology of AKI, disease severity score, mechanical ventilation, vasopressor support, and blood parameters (like albumin, potassium and pH) independently predicted 90-day mortality. Conclusions AKI, especially septic AKI is common in critically ill Chinese patients and is associated with poor patient outcome. Etiology of AKI has a significant impact on 90-day mortality and may affect renal outcome.
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http://dx.doi.org/10.3109/0886022X.2016.1157749DOI Listing
June 2016

Recent knowledge on the pathophysiology of septic acute kidney injury: A narrative review.

J Crit Care 2016 Feb 25;31(1):82-9. Epub 2015 Sep 25.

Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong, China SAR.

Sepsis is the commonest cause of acute kidney injury in critically ill patients. Its pathophysiology is complex and not well understood. Until recently, it was believed that kidney hypoperfusion is the major contributor of septic acute kidney injury. However, recent publications have improved our understanding on this topic. We now know that its mechanisms included the following: (1) renal macrocirculatory and microcirculatory disturbance, (2) surge of inflammatory markers and oxidative stress, (3) coagulation cascade activation, and (4) bioenergetics adaptive response with controlled cell-cycle arrest aiming to prevent cell death. Uncovering these complicated mechanisms may facilitate the development of more appropriate therapeutic measures in the future.
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http://dx.doi.org/10.1016/j.jcrc.2015.09.017DOI Listing
February 2016

Predictive value of plasma neutrophil gelatinase-associated lipocalin for acute kidney injury in intensive care unit patients after major non-cardiac surgery.

Nephrology (Carlton) 2015 May;20(5):375-82

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.

Aim: The performance of plasma neutrophil gelatinase-associated lipocalin (pNGAL) for prediction of acute kidney injury (AKI) in non-cardiac surgical patients has not been well described. This study investigates the use of pNGAL for early detection of AKI in patients admitted to an intensive care unit (ICU) after major or ultra-major non-cardiac surgery.

Methods: A total of 151 patients were recruited. Blood samples at 0 h and 6 h post-ICU admission were collected. Primary outcome was occurrence of AKI within 48 h of ICU admission defined using Acute Kidney Injury Network (AKIN) classification.

Results: Forty-five (29.8%) patients developed AKI within 48 h of ICU admission. Among them, 22, 14, and nine were classified as AKIN Stage 1, 2, and 3 respectively. pNGAL levels at 0 h and 6 h were significantly related to AKI severity. The AUROC for pNGAL at 0 h and 6 h increased with AKI severity (AKIN stage ≥1 0.671 ± 0.048 and 0.691 ± 0.047; stage ≥2 0.737 ± 0.055 and 0.796 ± 0.048; stage 3 0.829 ± 0.072 and 0.860 ± 0.065, respectively) and requirement of renal replacement therapy (0.880 ± 0.059 & 0.837 ± 0.088). Change of pNGAL from 0 h to 6 h showed no advantage in predictive power compared with pNGAL level at 0 h or 6 h alone. The addition of pNGAL into clinical AKI prediction model could only provide marginal benefit.

Conclusion: pNGAL correlated with severity of AKI and requirement of renal replacement therapy in ICU patients who received major or ultra-major non-cardiac surgery. However, the benefit of adding pNGAL into clinical AKI prediction model is marginal.
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http://dx.doi.org/10.1111/nep.12400DOI Listing
May 2015

Alteco endotoxin hemoadsorption in Gram-negative septic shock patients.

Indian J Crit Care Med 2014 Dec;18(12):783-8

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China.

Background And Aims: Severe sepsis and septic shock are common causes of mortality and morbidity in an intensive care unit setting. Endotoxin, derived from the outer membranes of Gram-negative bacteria, is considered a major factor in the pathogenesis of sepsis. This study investigated the effect of Alteco endotoxin hemoadsorption device on Gram-negative septic shock patients.

Materials And Methods: An open, controlled, prospective, randomized, single-center trial was conducted between February 2010 and June 2012. Patients with septic shock due to intra-abdominal sepsis were randomized to either conventional therapy (n = 8) or conventional therapy plus two 2-hourly sessions of Alteco endotoxin hemoadsorption (n = 7). Primary endpoint was the Sequential Organ Failure Assessment (SOFA) score changes from 0 to 72 h. Secondary end points included vasopressor requirement, PaO2/FiO2 ratio (PFR), length of stay (LOS), and 28-day mortality.

Results: This study was terminated early as interim analysis showed a low probability of significant findings. No significant difference was noted between the two groups with respect to change in SOFA score, vasopressor score, PFR, LOS, and 28-day mortality. Side-effect was minimal.

Conclusions: We could not identify any clinical benefit on the addition of Alteco endotoxin hemoadsorption to conventional therapy in patients who suffered from intra-abdominal sepsis with shock. The side effect profile of this novel device was acceptable.
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http://dx.doi.org/10.4103/0972-5229.146305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4271277PMC
December 2014

Insensible water loss through adult extracorporeal membrane oxygenation circuit: an in vitro study.

ASAIO J 2014 Sep-Oct;60(5):508-12

From the Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.

Patients on extracorporeal membrane oxygenation (ECMO) are critically ill, and fluid balance need to be managed as accurately as possible. Previous studies have focused on insensible water loss through neonatal ECMO circuit and showed that water loss through the ECMO circuit was correlated with the sweep-gas flow rates. Current study is the first study focusing on insensible water loss through adult ECMO circuit. An in vitro extracorporeal circuit consisting of Jostra Quadrox D membrane oxygenator and centrifugal pump was primed with normal saline. The amount of water loss through the ECMO circuit was found to be linearly correlated with the sweep-gas flow rate and fluid temperature. For every liter per minute of sweep-gas flow at 37°C, 0.046 ml/min of water will be lost, and for every change of fluid temperature by 1°C, water content loss will be changed by 0.0026 ml/min by multiple linear regression (R = 0.996). The average daily water loss for every liter per minute of sweep-gas flow at 33, 34, 35, 36, 37, 38, and 39°C were 51.3, 55, 58.8, 62.5, 66.2, 70.0, and 73.7 ml/day, respectively.
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http://dx.doi.org/10.1097/MAT.0000000000000098DOI Listing
June 2015

The use of regional citrate anticoagulation continuous venovenous hemofiltration in extracorporeal membrane oxygenation.

ASAIO J 2014 Jul-Aug;60(4):413-8

From the Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.

Patients on extracorporeal membrane oxygenation (ECMO) frequently requires continuous renal replacement therapy (CRRT). Additional anticoagulation for the CRRT circuit is usually not employed, but this may increases the risk of clot embolization, which shortens oxygenator lifespan and increases patient's risk. We report our experience on the use of regional citrate anticoagulation continuous venovenous hemofiltration (RCA-CVVH) connected to an ECMO circuit, which could be useful during low heparin or heparin-free ECMO situations. Regional citrate anticoagulation continuous venovenous hemofiltration was performed using AK200US machine with a blood flow of 150 ml/min, Acid Citrate Dextrose Solution prefilter infusion at 240 ml/hr, ultrafiltration rate of 2,040 ml/hr, and postdilutional online generated replacement fluid infused as appropriate. The circuit was aimed to run for 30 hrs. From May 2009 to May 2013, 63 patients received ECMO and 29 received RCA-CVVH. The median total CVVH time was 131 hrs (interquartile range [IQR]: 61-224 hrs), and hemofilter life was 27.2 hrs (IQR: 25.7-28.5 hrs). No hemofilter or oxygenator was changed because of clotting. Their hospital mortality was 27.6%. There were eight patients, who were judged to be too sick for anticoagulation, received predilution CRRT during the same period. Their hospital mortality was 75%. In conclusion, online postdilutional RCA-CVVH connected to an ECMO circuit is a feasible, safe, and effective CRRT technique.
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http://dx.doi.org/10.1097/MAT.0000000000000085DOI Listing
November 2015

Timing for initiation of continuous renal replacement therapy in patients with septic shock and acute kidney injury.

Ther Apher Dial 2013 Dec;17(6):643

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong.

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http://dx.doi.org/10.1111/1744-9987.12148DOI Listing
December 2013

Timing for initiation of continuous renal replacement therapy in patients with septic shock and acute kidney injury.

Ther Apher Dial 2013 Jun 7;17(3):305-10. Epub 2012 Dec 7.

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China.

The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into "early" (simplified RIFLE Risk) or "late" (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long-term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty-one (26%) underwent "early" while 89 (74%) had "late" CRRT. No significant difference was noted between groups on improvement of total SOFA/non-renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non-renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non-renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.
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http://dx.doi.org/10.1111/j.1744-9987.2012.01147.xDOI Listing
June 2013

A retrospective review of the use of regional citrate anticoagulation in continuous venovenous hemofiltration for critically ill patients.

Crit Care Res Pract 2013 28;2013:349512. Epub 2013 Jan 28.

Intensive Care Unit, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong.

Background. The emergence of a commercially prepared citrate solution has revolutionized the use of RCA in the intensive care unit (ICU). The aim of this study was to evaluate the safety profile of a commercially prepared citrate solution. Method. Predilution continuous venovenous hemofiltration (CVVH) was performed using Prismocitrate 10/2 at 2500 mL/h and a blood flow rate of 150 mL/min. Calcium chloride solution was infused to maintain ionized calcium within 1.0-1.2 mmol/L. An 8.4% sodium bicarbonate solution was infused separately. Treatment was stopped when the predefined clinical target was reached or the filter clotted. Result. 58 sessions of citrate RCA were analyzed. The median circuit lifetime was 26.0 h (interquartile range IQR 21.2-44.3). The percentage of circuits lasting more than 12 h, 24 h, and 48 h was 94.6%, 58.9%, and 16.1%, respectively. There was no incidence of hypernatremia and median pH was <7.5. Hypomagnesemia and hypophosphatemia were detected in 41.6% and 17.6% of blood samples taken, respectively. Although 16 episodes had a total calcium/ionized calcium (total Ca/iCa) >2.5, only four patients had evidence of citrate accumulation. Conclusion. The commercially prepared citrate solution could be used safely in critically ill patients who required CVVH with no major adverse events.
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http://dx.doi.org/10.1155/2013/349512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568867PMC
February 2013

Regional citrate anticoagulation in predilution continuous venovenous hemofiltration using prismocitrate 10/2 solution.

Ther Apher Dial 2012 Feb 3;16(1):81-6. Epub 2011 Oct 3.

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China.

Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) is associated with a longer filter life and fewer bleeding events. Complexity of the regimen is the major hurdle preventing widespread application. This study describes a simple predilution continuous venovenous hemofiltration (CVVH) protocol utilizing a commercially prepared replacement solution containing citrate (Prismocitrate 10/2). Ten patients with acute renal failure were evaluated. The Prismaflex system was used for predilution CVVH, with Prismocitrate 10/2 running at 2500 mL/h as the main predilution replacement. An 8.4% sodium bicarbonate solution was infused at 50 mL/h in the first 2 h followed by 30 mL/h; 10% calcium gluconate was given to achieve an ionized calcium (iCa) level of 1-1.2 mmol/L. The circuit was run for 72 h unless there was filter clotting, transportation was required, or the patient did not require further CRRT. Total treatment duration was 504.5 h. The post-dilution equivalent ultrafiltration rate was 32.9 mL/kg/h (interquartile range [IQR] 31.6-38.2) and the median circuit life was 50.3 h (IQR 25.5-72.0). None of the circuit was changed due to circuit clotting. The median systemic iCa was 0.98 mmol/L (IQR 0.91-1.08). The total calcium-to-iCa ratio was 2.33 (IQR 2.21-2.45). None of the patients developed hypernatremia (Na ≥ 150 mmol/L) or citrate toxicity (total Ca-to-iCa ratio > 2.5 plus increasing metabolic acidosis), and metabolic alkalosis (pH ≥ 7.5) occurred in one patient. This simple RCA CVVH protocol using commercially-prepared solution could be a feasible, relatively safe, and effective alternative to the conventional regimen for patients with a body weight up to 80 kg.
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http://dx.doi.org/10.1111/j.1744-9987.2011.01001.xDOI Listing
February 2012

Interaction between fluid balance and disease severity on patient outcome in the critically ill.

J Crit Care 2011 Dec 21;26(6):613-9. Epub 2011 Apr 21.

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China.

Purpose: There is evidence in literature regarding the benefits of immediate aggressive fluid resuscitation together with conservative fluid management approach after initial stabilization. This retrospective study assesses the relationship between fluid balance during intensive care unit (ICU) stay and outcomes among general critically ill patients. In addition, we also aim to see the effect of fluid gain among patients with different disease severity.

Methods: A total of 639 patients admitted into ICU who stayed for 3 days or more were evaluated. Fluid balances during ICU stay were recorded. A logistic regression analysis was performed to identify significant factors associated with hospital mortality.

Results: Acute Physiology and Chronic Health Evaluation IV predicted risk of death, fluid balance on the second plus third ICU days, and total fluid balance during ICU stay were positively associated with hospital death. Significant positive fluid balance on first ICU day, in contrast, was negatively associated with hospital mortality. The positive correlation between standardized mortality ratio (Acute Physiology and Chronic Health Evaluation IV) and fluid gain on the second plus third ICU days increases with disease severity.

Conclusion: Early adequate fluid resuscitation together with conservative late fluid management may provide better patient outcomes. The effect of fluid management strategy on patient outcome may depend on the underlying disease severity.
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http://dx.doi.org/10.1016/j.jcrc.2011.02.008DOI Listing
December 2011

Triage decisions and outcomes for patients with Triage Priority 3 on the Society of Critical Care Medicine scale.

Crit Care Resusc 2010 Mar;12(1):42-9

Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China.

Objective: To identify factors associated with the triage decision for patients classified as Society of Critical Care Medicine (SCCM) Triage Priority 3, and their outcomes.

Design: Single-centre, prospective, observational cohort study.

Setting: General intensive care unit in a tertiary regional hospital, over the 9 months January to September 2007.

Patients: SCCM Triage Priority 3 patients.

Results: All patients were followed up for at least 6 months. Among the 1346 triaged patients, 250 were classified as SCCM Triage Priority 3. Fewer than a third of these (76, 30.4%) were admitted to the ICU. Medical patients were more likely to be rejected than surgical or neurosurgical patients. Those with a poorer physicianpredicted chance of long-term survival were more likely to be rejected than those with a better predicted prognosis. The MPMII0-predicted mortality was higher for those denied ICU admission. Non-postoperative status (odds ratio [OR], 26.3) and physician-predicted risk > 50% of death within 1 month (OR, 11.8) were independently correlated with denial of ICU admission in a multiple logistic regression analysis. Cox regression analysis showed that independent risk factors for mortality were denial of ICU admission (hazard ratio [HR], 2.80), higher MPMII0-predicted mortality (HR, 1.12 for every 10% increment) and the presence of renal disease as an admission diagnosis (HR, 2.28).

Conclusions: For SCCM Triage Priority 3 patients, postoperative status and better physician-predicted prognosis correlated with ICU admission. Patients had lower medium-term survival if they were denied ICU admission, or had higher MPMII0-predicted mortality, or renal disease as the admission diagnosis.
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March 2010

Risk factors for poor outcome of fungal peritonitis in Chinese patients on continuous ambulatory peritoneal dialysis.

Perit Dial Int 2003 Dec;23 Suppl 2:S123-6

Renal Unit, Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.

Objective: Fungal peritonitis is rare among end-stage renal disease patients treated with continuous ambulatory peritoneal dialysis (CAPD), but when it occurs, it is associated with a high risk of mortality and peritoneal membrane failure. In the present study, we identified risk factors for poor outcome and examined the effect of treatment profile on outcome in fungal peritonitis.

Patients And Methods: We identified cases of fungal peritonitis in CAPD patients in a regional dialysis center and analyzed the possible risk factors for poor outcome in fungal peritonitis. To estimate the amount of dextrose presented to the peritoneum, we scored the dextrose content of the peritoneal dialysis fluid used by the patient at the time of admission to hospital (1 point to each bag of 1.5% fluid, 2 points to each bag of 2.3% or 2.5% fluid, and 3 points to each bag of 4.25% fluid daily).

Results: Among 471 episodes of CAPD-related peritonitis in 7.8 years, we identified 22 episodes of fungal peritonitis (4.7%). The ratio of men to women in the fungal peritonitis group was 1.4:1. Seventeen patients (77.3%) practiced dialysis without a helper. Within the 3 months preceding the fungal peritonitis, 12 patients (55%) had had bacterial peritonitis. Among the cases of fungal peritonitis, we identified 9 cases of Candida parapsilosis and 13 cases of non C. parapsilosis. All of the patients received fluconazole, and 7 patients (31.8%) also received flucytosine. The Tenckhoff catheter was removed in 17 patients (77.3%). Eight patients (36.4%) either died or lost peritoneal function. The risk of mortality was increased if the fungal organism was C. parapsilosis [odds ratio (OR): 4.25; 95% confidence interval (CI): 1.8 to 10.0; p = 0.002], if a helper was involved (OR: 11.3; 95% CI: 1.1 to 114; p = 0.024), or if CAPD duration was more than 26 months (OR: 2.2; 95% CI: 1.3 to 3.5; p = 0.034). Addition of flucytosine to fluconazole did not significantly improve the mortality rate in either the C. parapsilosis or non C. parapsilosis group. Multivariate analysis showed that C. parapsilosis was an independent factor associated with mortality (p = 0.013). A dextrose score greater than 5 was associated with a trend toward increased risk of peritoneal failure (OR: 3.4; 95% CI: 1.6 to 7.1; p = 0.021).

Conclusion: C. parapsilosis is an independent risk factor for mortality in fungal peritonitis.
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December 2003
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