Publications by authors named "Linda M Peelen"

97 Publications

Extracellular vesicle Cystatin C and CD14 are associated with both renal dysfunction and heart failure.

ESC Heart Fail 2020 10 10;7(5):2240-2249. Epub 2020 Jul 10.

Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Aims: Extracellular vesicles (EVs) are small double-membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients.

Methods And Results: Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m . The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub-fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co-morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub-fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub-fractions, and with presence of heart failure in the high density lipoprotein sub-fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub-fractions and in plasma, but not with renal dysfunction.

Conclusions: We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment.
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http://dx.doi.org/10.1002/ehf2.12699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524227PMC
October 2020

Prediction models for development of retinopathy in people with type 2 diabetes: systematic review and external validation in a Dutch primary care setting.

Diabetologia 2020 06 3;63(6):1110-1119. Epub 2020 Apr 3.

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

Aims/hypothesis: The aims of this study were to identify all published prognostic models predicting retinopathy risk applicable to people with type 2 diabetes, to assess their quality and accuracy, and to validate their predictive accuracy in a head-to-head comparison using an independent type 2 diabetes cohort.

Methods: A systematic search was performed in PubMed and Embase in December 2019. Studies that met the following criteria were included: (1) the model was applicable in type 2 diabetes; (2) the outcome was retinopathy; and (3) follow-up was more than 1 year. Screening, data extraction (using the checklist for critical appraisal and data extraction for systemic reviews of prediction modelling studies [CHARMS]) and risk of bias assessment (by prediction model risk of bias assessment tool [PROBAST]) were performed independently by two reviewers. Selected models were externally validated in the large Hoorn Diabetes Care System (DCS) cohort in the Netherlands. Retinopathy risk was calculated using baseline data and compared with retinopathy incidence over 5 years. Calibration after intercept adjustment and discrimination (Harrell's C statistic) were assessed.

Results: Twelve studies were included in the systematic review, reporting on 16 models. Outcomes ranged from referable retinopathy to blindness. Discrimination was reported in seven studies with C statistics ranging from 0.55 (95% CI 0.54, 0.56) to 0.84 (95% CI 0.78, 0.88). Five studies reported on calibration. Eight models could be compared head-to-head in the DCS cohort (N = 10,715). Most of the models underestimated retinopathy risk. Validating the models against different severities of retinopathy, C statistics ranged from 0.51 (95% CI 0.49, 0.53) to 0.89 (95% CI 0.88, 0.91).

Conclusions/interpretation: Several prognostic models can accurately predict retinopathy risk in a population-based type 2 diabetes cohort. Most of the models include easy-to-measure predictors enhancing their applicability. Tailoring retinopathy screening frequency based on accurate risk predictions may increase the efficiency and cost-effectiveness of diabetic retinopathy care.

Registration: PROSPERO registration ID CRD42018089122.
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http://dx.doi.org/10.1007/s00125-020-05134-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228897PMC
June 2020

Anaesthesia geriatric evaluation to guide patient selection for preoperative multidisciplinary team care in cardiac surgery.

Br J Anaesth 2020 Feb 14. Epub 2020 Feb 14.

Department of Anesthesiology, Intensive Care, and Pain Medicine, St Antonius Hospital, Nieuwegein, the Netherlands. Electronic address:

Background: A multidisciplinary approach to improve postoperative outcomes in frail elderly patients is gaining interest. Multidisciplinary team care should be targeted at complex patients at high risk for adverse postoperative outcome to limit the strain on available resources and to prevent an unnecessary increase in patient burden. This study aimed to improve patient selection for multidisciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients.

Methods: This was a two-centre prospective cohort study of 537 patients aged ≥70 yr undergoing elective cardiac surgery. Before surgery, 11 frailty characteristics were investigated. Outcome was disability at 3 months defined as World Health Organization Disability Assessment Schedule 2.0 ≥25%. Multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index was used to identify factors contributing to patient selection.

Results: Disability occurred in 91 (17%) patients. Ten out of 11 frailty characteristics were associated with disability. A multivariable model, including the European System for Cardiac Operative Risk Evaluation II and preoperative haemoglobin, yielded a c-statistic of 0.71 (95% confidence interval [CI]: 0.66-0.77). After adding pre-specified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health-related quality of life, and living alone) to this model, the c-statistic improved to 0.78 (95% CI: 0.73-0.83). The net reclassification index was 0.32 (P<0.001), showing improved discrimination for patients at risk for disability at 3 months.

Conclusions: The addition of preoperative frailty characteristics to a multivariable model improved discrimination between elderly patients with and without disability at 3 months after cardiac surgery, and can be used to guide patient selection for preoperative multidisciplinary team care.

Clinical Trial Registration: NCT02535728.
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http://dx.doi.org/10.1016/j.bja.2019.12.042DOI Listing
February 2020

Artifact Processing Methods Influence on Intraoperative Hypotension Quantification and Outcome Effect Estimates.

Anesthesiology 2020 04;132(4):723-737

From the Medical Center Utrecht (W.P., L.M.P., W.A.v.K.) the Department of Epidemiology, Julius Center for Health Sciences and Primary Care (L.M.P.), Utrecht University, Utrecht, The Netherlands The Netherlands Organization for Applied Scientific Research and Department of Methodology and Statistics, Faculty of Social and Behavioural Sciences, University of Utrecht (S.v.B.), Utrecht, The Netherlands the Department of Anesthesiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands (J.C.d.G.).

Background: Physiologic data that is automatically collected during anesthesia is widely used for medical record keeping and clinical research. These data contain artifacts, which are not relevant in clinical care, but may influence research results. The aim of this study was to explore the effect of different methods of filtering and processing artifacts in anesthesiology data on study findings in order to demonstrate the importance of proper artifact filtering.

Methods: The authors performed a systematic literature search to identify artifact filtering methods. Subsequently, these methods were applied to the data of anesthesia procedures with invasive blood pressure monitoring. Different hypotension measures were calculated (i.e., presence, duration, maximum deviation below threshold, and area under threshold) across different definitions (i.e., thresholds for mean arterial pressure of 50, 60, 65, 70 mmHg). These were then used to estimate the association with postoperative myocardial injury.

Results: After screening 3,585 papers, the authors included 38 papers that reported artifact filtering methods. The authors applied eight of these methods to the data of 2,988 anesthesia procedures. The occurrence of hypotension (defined with a threshold of 50 mmHg) varied from 24% with a median filter of seven measurements to 55% without an artifact filtering method, and between 76 and 90% with a threshold of 65 mmHg. Standardized odds ratios for presence of hypotension ranged from 1.16 (95% CI, 1.07 to 1.26) to 1.24 (1.14 to 1.34) when hypotension was defined with a threshold of 50 mmHg. Similar variations in standardized odds ratios were found when applying methods to other hypotension measures and definitions.

Conclusions: The method of artifact filtering can have substantial effects on estimates of hypotension prevalence. The effect on the association between intraoperative hypotension and postoperative myocardial injury was relatively small. Nevertheless, the authors recommend that researchers carefully consider artifacts handling and report the methodology used.
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http://dx.doi.org/10.1097/ALN.0000000000003131DOI Listing
April 2020

Patient and anesthesia characteristics of children with low pre-incision blood pressure: A retrospective observational study.

Acta Anaesthesiol Scand 2020 04 22;64(4):472-480. Epub 2019 Dec 22.

Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.

Background: Intraoperative blood pressure has been suggested as a key factor for safe pediatric anesthesia. However, there is not much insight into factors that discriminate between children with low and normal pre-incision blood pressure. Our aim was to explore whether children who have a low blood pressure during anesthesia are different than those with normal blood pressure. The focus of the present study was on the pre-incision period.

Methods: This retrospective study included pediatric patients undergoing anesthesia for non-cardiac surgery at a tertiary pediatric university hospital, between 2012 and 2016. We analyzed the association between pre-incision blood pressure and patient- and anesthesia characteristics, comparing low with normal pre-incision blood pressure. This association was further explored with a multivariable linear regression.

Results: In total, 20 962 anesthetic cases were included. Pre-incision blood pressure was associated with age (beta -0.04 SD per year), gender (female -0.11), previous surgery (-0.15), preoperative blood pressure (+0.01 per mm Hg), epilepsy (0.12), bronchial hyperactivity (-0.18), emergency surgery (0.10), loco-regional technique (-0.48), artificial airway device (supraglottic airway device instead of tube 0.07), and sevoflurane concentration (0.03 per sevoflurane %).

Conclusions: Children with low pre-incision blood pressure do not differ on clinically relevant factors from children with normal blood pressure. Although the present explorative study shows that pre-incision blood pressure is partly dependent on patient characteristics and partly dependent on anesthetic technique, other unmeasured variables might play a more important role.
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http://dx.doi.org/10.1111/aas.13520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079014PMC
April 2020

Incorporating repeated measurements into prediction models in the critical care setting: a framework, systematic review and meta-analysis.

BMC Med Res Methodol 2019 10 26;19(1):199. Epub 2019 Oct 26.

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.

Background: The incorporation of repeated measurements into multivariable prediction research may greatly enhance predictive performance. However, the methodological possibilities vary widely and a structured overview of the possible and utilized approaches lacks. Therefore, we [1] propose a structured framework for these approaches, [2] determine what methods are currently used to incorporate repeated measurements in prediction research in the critical care setting and, where possible, [3] assess the added discriminative value of incorporating repeated measurements.

Methods: The proposed framework consists of three domains: the observation window (static or dynamic), the processing of the raw data (raw data modelling, feature extraction and reduction) and the type of modelling. A systematic review was performed to identify studies which incorporate repeated measurements to predict (e.g. mortality) in the critical care setting. The within-study difference in c-statistics between models with versus without repeated measurements were obtained and pooled in a meta-analysis.

Results: From the 2618 studies found, 29 studies incorporated multiple repeated measurements. The annual number of studies with repeated measurements increased from 2.8/year (2000-2005) to 16.0/year (2016-2018). The majority of studies that incorporated repeated measurements for prediction research used a dynamic observation window, and extracted features directly from the data. Differences in c statistics ranged from - 0.048 to 0.217 in favour of models that utilize repeated measurements.

Conclusions: Repeated measurements are increasingly common to predict events in the critical care domain, but their incorporation is lagging. A framework of possible approaches could aid researchers to optimize future prediction models.
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http://dx.doi.org/10.1186/s12874-019-0847-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815391PMC
October 2019

The intermediate care unit as a cost-reducing critical care facility in tertiary referral hospitals: a single-centre observational study.

BMJ Open 2019 06 4;9(6):e026359. Epub 2019 Jun 4.

Department of Trauma, University Medical Center Utrecht, Utrecht, The Netherlands.

Objectives: To determine whether and to what extent the surgical intermediate care unit (IMCU) reduces healthcare costs.

Design: Retrospective cohort study.

Setting: The mixed-surgical IMCU of a tertiary academic referral hospital.

Participants: All admissions (n=2577) from 2012 to 2015.

Primary And Secondary Outcome Measures: The outcome measure was the hypothetical cost savings due to the presence of the IMCU. For this, each admission day was classified as either low-acuity or high-acuity, based on the Therapeutic Intervention Scoring System-28, the required specific nursing interventions and the indication for admission at the IMCU. Costs (2018) used were €463 per hospital ward, €1307 per IMCU and €2224 per intensive care unit (ICU) admission day. Savings were calculated by subtracting the actual IMCU costs from the hypothetical costs in the absence of the IMCU.

Results: There were 9037 admission days (n=2577 admissions) at the IMCU. The proportion of high-acuity admissions was 87.6%. Total costs at the IMCU were €11.808 888. Total hypothetical costs in absence of the IMCU were €18.115 284. Total cost savings were thus €6.306 395, or €1.576 599, per year.

Conclusions: The surgical IMCU may substantially reduce societal healthcare costs, making it a cost saving alternative to ICU care. Constant adequate triage is essential to optimise its potential.
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http://dx.doi.org/10.1136/bmjopen-2018-026359DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561455PMC
June 2019

When and how to use data from randomised trials to develop or validate prognostic models.

BMJ 2019 May 29;365:l2154. Epub 2019 May 29.

Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, 3508 GA Utrecht, Netherlands.

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http://dx.doi.org/10.1136/bmj.l2154DOI Listing
May 2019

Adjusting for Disease Severity Across ICUs in Multicenter Studies.

Crit Care Med 2019 08;47(8):e662-e668

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.

Objectives: To compare methods to adjust for confounding by disease severity during multicenter intervention studies in ICU, when different disease severity measures are collected across centers.

Design: In silico simulation study using national registry data.

Setting: Twenty mixed ICUs in The Netherlands.

Subjects: Fifty-five-thousand six-hundred fifty-five ICU admissions between January 1, 2011, and January 1, 2016.

Interventions: None.

Measurements And Main Results: To mimic an intervention study with confounding, a fictitious treatment variable was simulated whose effect on the outcome was confounded by Acute Physiology and Chronic Health Evaluation IV predicted mortality (a common measure for disease severity). Diverse, realistic scenarios were investigated where the availability of disease severity measures (i.e., Acute Physiology and Chronic Health Evaluation IV, Acute Physiology and Chronic Health Evaluation II, and Simplified Acute Physiology Score II scores) varied across centers. For each scenario, eight different methods to adjust for confounding were used to obtain an estimate of the (fictitious) treatment effect. These were compared in terms of relative (%) and absolute (odds ratio) bias to a reference scenario where the treatment effect was estimated following correction for the Acute Physiology and Chronic Health Evaluation IV scores from all centers. Complete neglect of differences in disease severity measures across centers resulted in bias ranging from 10.2% to 173.6% across scenarios, and no commonly used methodology-such as two-stage modeling or score standardization-was able to effectively eliminate bias. In scenarios where some of the included centers had (only) Acute Physiology and Chronic Health Evaluation II or Simplified Acute Physiology Score II available (and not Acute Physiology and Chronic Health Evaluation IV), either restriction of the analysis to Acute Physiology and Chronic Health Evaluation IV centers alone or multiple imputation of Acute Physiology and Chronic Health Evaluation IV scores resulted in the least amount of relative bias (0.0% and 5.1% for Acute Physiology and Chronic Health Evaluation II, respectively, and 0.0% and 4.6% for Simplified Acute Physiology Score II, respectively). In scenarios where some centers used Acute Physiology and Chronic Health Evaluation II, regression calibration yielded low relative bias too (relative bias, 12.4%); this was not true if these same centers only had Simplified Acute Physiology Score II available (relative bias, 54.8%).

Conclusions: When different disease severity measures are available across centers, the performance of various methods to control for confounding by disease severity may show important differences. When planning multicenter studies, researchers should make contingency plans to limit the use of or properly incorporate different disease measures across centers in the statistical analysis.
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http://dx.doi.org/10.1097/CCM.0000000000003822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629171PMC
August 2019

Effect of cytomegalovirus reactivation on the time course of systemic host response biomarkers in previously immunocompetent critically ill patients with sepsis: a matched cohort study.

Crit Care 2018 12 18;22(1):348. Epub 2018 Dec 18.

Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.

Background: Cytomegalovirus (CMV) reactivation in previously immunocompetent critically ill patients is associated with increased mortality, which has been hypothesized to result from virus-induced immunomodulation. Therefore, we studied the effects of CMV reactivation on the temporal course of host response biomarkers in patients with sepsis.

Methods: In this matched cohort study, each sepsis patient developing CMV reactivation between day 3 and 17 (CMV+) was compared with one CMV seropositive patient without reactivation (CMVs+) and one CMV seronegative patient (CMVs-). CMV serostatus and plasma loads were determined by enzyme-linked immunoassays and real-time polymerase chain reaction, respectively. Systemic interleukin-6 (IL-6), IL-8, IL-18, interferon-gamma-induced protein-10 (IP-10), neutrophilic elastase, IL-1 receptor antagonist (RA), and IL-10 were measured at five time points by multiplex immunoassay. The effects of CMV reactivation on sequential concentrations of these biomarkers were assessed in multivariable mixed models.

Results: Among 64 CMV+ patients, 45 could be matched to CMVs+ or CMVs- controls or both. The two baseline characteristics and host response biomarker levels at viremia onset were similar between groups. CMV+ patients had increased IP-10 on day 7 after viremia onset (symmetric percentage difference +44% versus -15% when compared with CMVs+ and +37% versus +4% when compared with CMVs-) and decreased IL-1RA (-41% versus 0% and -49% versus +10%, respectively). However, multivariable analyses did not show an independent association between CMV reactivation and time trends of IL-6, IP-10, IL-10, or IL-1RA.

Conclusion: CMV reactivation was not independently associated with changes in the temporal trends of host response biomarkers in comparison with non-reactivating patients. Therefore, these markers should not be used as surrogate clinical endpoints for interventional studies evaluating anti-CMV therapy.
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http://dx.doi.org/10.1186/s13054-018-2261-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299562PMC
December 2018

An observational study of end-tidal carbon dioxide trends in general anesthesia.

Can J Anaesth 2019 02 14;66(2):149-160. Epub 2018 Nov 14.

Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA.

Purpose: Despite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO) levels in surgical patients, there is still insufficient data to formulate guidelines for ideal intraoperative ETCO targets. As it is unclear which intraoperative ETCO levels are currently used and whether these levels have changed over time, we investigated the practice pattern using the Multicenter Perioperative Outcomes Group database.

Methods: This retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016. The primary outcome was a time-weighted average area-under-the-curve (TWA-AUC) for four ETCO thresholds (< 28, < 35, < 45, and > 45 mmHg). Additionally, a median ETCO was studied. A Kruskal-Wallis test was used to analyse differences between years. Random-effect multivariable logistic regression models were constructed to study variability.

Results: Both TWA-AUC and median ETCO showed a minimal increase in ETCO over time, with a median [interquartile range] ETCO of 33 [31.0-35.0] mmHg in 2008 and 35 [33.0-38.0] mmHg in 2016 (P <0.001). A large inter-hospital and inter-provider variability in ETCO were observed after adjustment for patient characteristics, ventilation parameters, and intraoperative blood pressure (intraclass correlation coefficient 0.36; 95% confidence interval, 0.18 to 0.58).

Conclusions: Between 2008 and 2016, intraoperative ETCO values did not change in a clinically important manner. Interestingly, we found a large inter-hospital and inter-provider variability in ETCO throughout the study period, possibly indicating a broad range of tolerance for ETCO, or a lack of evidence to support a specific targeted range. Clinical outcomes were not assessed in this study and they should be the focus of future research.
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http://dx.doi.org/10.1007/s12630-018-1249-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6331507PMC
February 2019

Optimizing critical care of the trauma patient at the intermediate care unit: a cost-efficient approach.

Trauma Surg Acute Care Open 2018 24;3(1):e000228. Epub 2018 Oct 24.

Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.

Background: The aim of this study was to describe the case load, safety, and cost savings of critical care of the trauma patient provided at the surgical intermediate care unit (IMCU).

methods: This cohort study included all trauma admissions between January 1, 2011 and January 7, 2015 at the general intensive care unit (ICU), stand-alone neuro(surgical) IMCU, and stand-alone (trauma) surgical IMCU. Trauma mechanism, Abbreviated Injury Scale score and Injury Severity Score (ISS), vital signs, laboratory parameters, admission duration, intubation duration, ICU transfer, and in-hospital mortality were prospectively collected. Hypothetical cost savings were calculated using the fixed cost price per IMCU (US$1500) and ICU (US$2500) admission day.

Results: A total of 1320 admissions were included, 675 (51.1%) at the IMCU and 645 (48.9%) at the ICU. Patients admitted at the IMCU had a median ISS of 17 (11, 22). Their median duration of admission was 32.8 hours (18.8, 62.5). At the IMCU, one patient died due to aneurogenic shock. A subsequent ICU transfer was required in 38 (5.6%) IMCU admissions. Of these transfers, four patients died due to neurological deterioration. At the ICU, the median ISS was 22 (14, 30). Nearly all (n=620, 96.3%) ICU trauma patients required mechanical ventilation. Expected total cost savings due to the presence of the IMCU were US$1 772 785.

Discussion: A substantial amount of trauma patients in need of critical care can safely be admitted at the IMCU, without the need for further mechanical ventilation. Thereby, the IMCU could fulfill an essential cost-saving role in the management of severely injured trauma patients.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1136/tsaco-2018-000228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203138PMC
October 2018

Joint management format at the mixed-surgical intermediate care unit: an interrupted time series analysis.

Trauma Surg Acute Care Open 2018 18;3(1):e000177. Epub 2018 Oct 18.

Division of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

Background: The management format of the mixed-surgical intermediate care unit (IMCU) affects its performance. A format of combined supervision of surgeons with additional critical care certifications and admitting specialists, named the "joint format", may herein be a promising new model of specialized critical care. This study aims to assess the performance of the joint management format.

Methods: This observational cohort study compared three IMCU management formats at the stand-alone, mixed-surgical IMCU of a tertiary referral hospital using interrupted time series analyses. All admissions from 2001 until 2015 were included. Predetermined criteria for performance (utilization, efficiency, and safety) were applied to three different management format periods: open (2001-2006), closed (2006-2011), and joint (2011-2015) formats.

Results: A total of 8894 admissions were analyzed. In terms of case load (utilization), there was an overall increase in the number of surgical patients (0.25%/year) (p<0.001), age (0.38/year) (p<0.001), and readmissions from the ward (0.16%/year) (p<0.001) and from the intensive care unit (ICU) (0.17%/year) (p=0.014). In terms of efficiency, the admission duration decreased (1.58 hours/year) (p<0.001). Transfer to the ICU within 24  hours, readmission within 24  hours from the ward, and unplanned mortality (eg, safety) did not change over time.

Discussion: At a time of increasingly complex case load, the joint format at the mixed-surgical IMCU is an efficient and safe management format in which the admitting specialist continues to provide specialized care. Specialty-specific supervision at IMCUs is a safe option which should be considered in healthcare policy decisions.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1136/tsaco-2018-000177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203139PMC
October 2018

Blood Pressure and End-tidal Carbon Dioxide Ranges during Aneurysm Occlusion and Neurologic Outcome after an Aneurysmal Subarachnoid Hemorrhage.

Anesthesiology 2019 01;130(1):92-105

From the Department of Anesthesiology (A.A., J.A.v.W., L.M.P., W.A.v.K.) the Department of Epidemiology, Julius Center for Health Sciences and Primary Care (L.M.P.) the Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus (G.J.R.), University Medical Center Utrecht, Utrecht University, The Netherlands.

Background: Hypocapnia, hypotension, and hypertension during aneurysm occlusion in patients with an aneurysmal subarachnoid hemorrhage may lead to a poor prognosis, but evidence for end-tidal carbon dioxide (ETCO2) and mean arterial pressure (MAP) targets is lacking. Within the ranges of standardized treatment, the authors aimed to study the association between hypocapnia (PaCO2 < 35 mmHg), hypotension (MAP < 80 mmHg), and hypertension (MAP >100 mmHg) during general anesthesia for aneurysm occlusion and neurologic outcome.

Methods: This retrospective observational study included patients who underwent early aneurysm occlusion after an aneurysmal subarachnoid hemorrhage under general anesthesia. ETCO2 and MAP were summarized per patient as the mean and time-weighted average area under the curve for various absolute (ETCO2 < 30, < 35, < 40, < 45 mmHg; and MAP < 60, < 70, < 80, > 90, > 100 mmHg) and relative thresholds (MAP < 70%, < 60%, < 50%). Clinical outcome was assessed with the Glasgow Outcome Scale at discharge and at three months, as primary and secondary outcome measure, respectively.

Results: Endovascular coiling was performed in 578 patients, and 521 underwent neurosurgical clipping. Of these 1,099 patients, 447 (41%) had a poor neurologic outcome at discharge. None of the ETCO2 and MAP ranges found within the current clinical setting were associated with a poor neurologic outcome at discharge, with an adjusted risk ratio for any ETCO2 value less than 30 mmHg of 0.95 (95% CI, 0.81 to 1.10; P < 0.496) and an adjusted risk ratio for any MAP less than 60 mmHg of 0.94 (95% CI, 0.78 to 1.14; P < 0.530). These results were not influenced by preoperative neurologic condition, treatment modality and timing of the intervention. Comparable results were obtained for neurologic outcome at three months.

Conclusions: Within a standardized intraoperative treatment strategy in accordance with current clinical consensus, hypocapnia, hypotension, and hypertension during aneurysm occlusion were not found to be associated with a poor neurologic outcome at discharge in patients with an aneurysmal subarachnoid hemorrhage.
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http://dx.doi.org/10.1097/ALN.0000000000002482DOI Listing
January 2019

Pulmonary Embolism After Endovascular Aortic Repair, a Retrospective Cohort Study.

Eur J Vasc Endovasc Surg 2019 02 20;57(2):304-310. Epub 2018 Oct 20.

Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.

Objectives: Endovascular aortic repair (EVAR) is associated with an increased risk of pulmonary embolism, which is often clinically silent and therefore difficult to recognise. The aim was to investigate the incidence of pulmonary embolism after EVAR using routinely performed pre- and post-operative aortic computed tomography angiography (CTA), and the association between pulmonary embolism and mortality.

Methods: This single centre retrospective cohort study included adult patients who underwent EVAR in the University Medical Centre Utrecht between January 2010 and July 2015 and who had a total aortic, thoracic aortic, or pulmonary CTA within one month post-operatively. Baseline and mortality data were obtained by reviewing hospital and general practitioner records. The primary outcome was pulmonary embolism within one month after surgery. Secondary outcomes were 30 day and six month mortality.

Results: During the study period, 526 EVARs were performed. Seventy-four of these procedures were included in the analysis of which there were 40 thoracic and 34 abdominal EVARs. In nine patients (12%, 95% CI 7-22) pulmonary embolism was observed of which one was central, two were segmental, and six were subsegmental. Seven were clinically silent and two were present on the pre-operative CTA. Thirty day mortality was significantly higher in patients with pulmonary embolism (relative risk 14.4, 95% CI 1.4-143, p = .037) though none of the deaths seemed directly attributable to it.

Conclusions: This study, although preliminary, suggests that silent pulmonary embolism after EVAR occurs in approximately one in 10 patients, despite routine thrombo-embolism prophylaxis. Pulmonary embolism was associated with a higher 30 day mortality risk yet it was not the cause of death in any of these patients.
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http://dx.doi.org/10.1016/j.ejvs.2018.08.054DOI Listing
February 2019

Assessment of the intermediate care unit triage system.

Trauma Surg Acute Care Open 2018 8;3(1):e000178. Epub 2018 Sep 8.

Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.

Background: An important critique with respect to the utilization of intermediate care units (IMCU) is that they potentially admit patients who would otherwise be cared for on the regular ward. This would lead to an undesired waste of critical care resources. This article aims to (1) describe the caseload at the IMCU and (2) to assess the triage system at the IMCU to determine potentially unnecessary admissions.

Methods: This cohort study included all admissions at the mixed-surgical IMCU from 2001 to 2015. The Therapeutic Intervention Scoring System-28 (TISS-28) was prospectively collected for all admissions to describe the caseload at the IMCU and to identify medical criteria for admission. These were combined with logistical criteria to assess the IMCU triage system.

Results: A total of 8816 admissions were included in the study. The average TISS-28 was 20.19 (95% CI 18.05 to 22.33), corresponding with 3.57 (95% CI 3.19 to 3.94) hours of direct patient-related work per patient per nursing shift. Over time, this increased by an average of 0.27 points/year (p<0.001). Of all admissions, 6539 (74.2%) were medically considered to be justly admitted, and 7093 (80.4%) were logistically considered to be justly admitted. With these criteria combined, a total of 8324 (94.4%) were correctly admitted.

Discussion: Most admissions to the IMCU are medically and/or logistically necessary, as the majority of admitted patients demand a higher level of nursing care than available on the general ward. Continuous triage is thereby essential. These findings support further utilization of the IMCU in our current healthcare system and has important implications for IMCU-related management decisions.

Level Of Evidence: Level VI.
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http://dx.doi.org/10.1136/tsaco-2018-000178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6135419PMC
September 2018

Causes and prevention of postoperative myocardial injury.

Eur J Prev Cardiol 2019 01 12;26(1):59-67. Epub 2018 Sep 12.

1 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands.

Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.
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http://dx.doi.org/10.1177/2047487318798925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6287250PMC
January 2019

Accuracy of remote continuous respiratory rate monitoring technologies intended for low care clinical settings: a prospective observational study.

Can J Anaesth 2018 12 7;65(12):1324-1332. Epub 2018 Sep 7.

Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.

Purpose: Altered respiratory rate (RR) has been identified as an important predictor of serious adverse events during hospitalization. Introduction of a well-tolerated continuous RR monitor could potentially reduce serious adverse events such as opioid-induced respiratory depression. The purpose of this study was to investigate the ability of different monitor devices to detect RR in low care clinical settings.

Methods: This was a prospective method-comparison study with a cross-sectional design. Thoracic impedance pneumography (IPG), frequency modulated continuous wave radar, and an acoustic breath sounds monitor were compared with the gold standard of capnography for their ability to detect RR in breaths per minute (breaths·min) in awake postoperative patients in the postanesthesia care unit. The Bland and Altman method for repeated measurements and mixed effect modelling was used to obtain bias and limits of agreement (LoA). Furthermore, the ability of the three devices to assist with correct treatment decisions was evaluated in Clarke Error Grids.

Results: Twenty patients were monitored for 1,203 min, with a median [interquartile range] of 61 [60-63] min per patient. The bias (98.9% LoA) were 0.1 (-7.9 to 7.9) breaths·min for the acoustic monitor, -1.6 (-10.8 to 7.6) for the radar, and -1.9 (-13.1 to 9.2) for the IPG. The extent to which the monitors guided adequate or led to inadequate treatment decisions (determined by Clarke Error Grid analysis) differed significantly between the monitors (P = 0.011). Decisions were correct 96% of the time for acoustic, 95% of the time for radar, and 94% of the time for IPG monitoring devices.

Conclusions: None of the studied devices (acoustic, IPG, and radar monitor) had LoA that were within our predefined (based on clinical judgement) limits of ± 2 breaths·min. The acoustic breath sound monitor predicted the correct treatment more often than the IPG and the radar device.
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http://dx.doi.org/10.1007/s12630-018-1214-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6244627PMC
December 2018

Predicting early deterioration of admitted patients at the Intermediate Care Unit.

J Crit Care 2018 12 16;48:97-103. Epub 2018 Aug 16.

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands; Departments of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands.

Purpose: Under-triage is a major threat when admitting patients at the Intermediate Care Unit (IMCU). This study aims to identify risk factors and predict early deterioration of IMCU admissions, to reduce the risk of under-triage.

Materials And Methods: This retrospective cohort study included all admissions to the mixed-surgical stand-alone IMCU of a tertiary referral hospital (2001-2015). Variables included were age, sex, admission indication, admitting specialty, re-admission, and nursing interventions. Early clinical deterioration was defined as ICU transfer or death ≤24 h of admission. Multinomial and logistic regression analyses were performed to identify risk factors and obtain predictions, for several frequently encountered subgroups.

Results: A total of 9103 admissions were included, of which 350 (3.8%) early deteriorated. Patients admitted for hemodynamic and respiratory instability had a high risk of early deterioration (OR 16.3 (CI 4.5-59.1)), probability 47.1%. Patients admitted with respiratory insufficiency and active diuresis or complicated sepsis had a high probability of early deterioration (≥29% and ≥26% respectively). The model had an optimism-corrected c-statistic of 0.79 (IQR 0.78-0.80).

Conclusions: Patients with combined hemodynamic and respiratory instability should not be admitted to the IMCU. Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring.
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http://dx.doi.org/10.1016/j.jcrc.2018.08.012DOI Listing
December 2018

A Proposal for an Intermediate Care Unit-Quality Measurement Framework.

Crit Care Res Pract 2018 29;2018:4560718. Epub 2018 Jul 29.

Division of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands.

, , . The Intermediate Care Unit (IMCU) is a hospital unit which is logistically situated between the hospital ward and the Intensive Care Unit (ICU). There is debate regarding the value of the IMCU. Understanding its value is compromised by the lack of adequate quality indicators. Therefore, this study identifies currently used IMCU indicators and evaluates their usefulness. . Through a systematic literature search, currently used quality indicators were identified and evaluated for their importance using a proposed IMCU-specific quality measurement framework. . From 4034 titles and abstracts, 168 articles were selected for full-text review. Of these, 22 articles were included, which reported IMCU quality at the level of the IMCU ( = 12), the ICU ( = 5), both IMCU and ICU ( = 3) or hospital level ( = 2). At the IMCU, the IMCU mortality ( = 16), discharge-to-ICU rate ( = 7), in-hospital IMCU mortality ( = 7), and length of stay ( = 6) were most frequently reported. Three studies compared the effect of different structures of the IMCU on its utilization or hospital outcome. . Current focus in IMCU quality research is towards measuring quality at the IMCU itself. Since the influence of the structure of IMCUs on its utilization and its effects on hospital outcome are only rarely investigated, attention should shift towards these important issues in further research. The proposed IMCU quality measurement framework can thereby serve as a helpful tool.
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http://dx.doi.org/10.1155/2018/4560718DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6087599PMC
July 2018

Validation of the VitalPAC Early Warning Score at the Intermediate Care Unit.

World J Crit Care Med 2018 Aug 4;7(3):39-45. Epub 2018 Aug 4.

Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht 3584 CX, The Netherlands.

Aim: To assess the performance and clinical relevance of the Early Warning Scoring (EWS) system at the Intermediate Care Unit (IMCU).

Methods: This cohort study used all the VitalPAC EWS (ViEWS) scores collected during each nursing shift from 2014 through 2016 at the mixed surgical IMCU of an academic teaching hospital. Clinical deterioration defined as transfer to the Intensive Care Unit (ICU) or mortality within 24 h was the primary outcome of interest.

Results: A total of 9113 aggregated ViEWS scores were obtained from 2113 admissions. The incidence of the combined outcome was 272 (3.0%). The area under the curve of the ViEWS was 0.72 (CI: 0.69-0.75). Using a threshold value of six, the sensitivity was 68% with a positive predictive value of 5% and a number needed to trigger (., false alarms) of 19%.

Conclusion: The ViEWS at the IMCU has a discriminative performance that is considerably lower than at the hospital ward. The number of false alarms is high, which may result in alarm fatigue. Therefore, use of the ViEWS in its current form at the IMCU should be reconsidered.
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http://dx.doi.org/10.5492/wjccm.v7.i3.39DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081388PMC
August 2018

Post Hoc Power Calculation: Observing the Expected.

Ann Surg 2019 01;269(1):e11

Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands Department of Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands Julius Center for Health Sciences, University Medical Center Utrecht, Utrecht University, The Netherlands Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, The Netherlands.

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http://dx.doi.org/10.1097/SLA.0000000000002910DOI Listing
January 2019

LDL extracellular vesicle coagulation protein levels change after initiation of statin therapy. Findings from the METEOR trial.

Int J Cardiol 2018 Nov 26;271:247-253. Epub 2018 May 26.

Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore & Cardiovascular Research Institute, National University Heart Centre Singapore, Singapore; Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht University, The Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht University, The Netherlands; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, The Netherlands. Electronic address:

Background: Statins are thought to have pleiotropic properties, including anticoagulant effects, in addition to reducing lipoprotein (LDL) levels. Plasma extracellular vesicles (EVs) are small bilayer membrane vesicles involved in various biological processes including coagulation. Since subsets of EVs in the LDL plasma fraction (LDL-EVs) correlate with thrombin activity, we hypothesized that changes in LDL-EVs after statin therapy may differ from that of serum levels of coagulation proteins, providing insight into the effects of statins on coagulation.

Methods: The study was conducted in 666 subjects with available serum from the METEOR trial, a trial of the effect of rosuvastatin versus placebo in patients with subclinical atherosclerosis. Changes in protein levels of von Willebrand Factor (VWF), SerpinC1 and plasminogen were measured in serum and in LDL-EVs, and were compared between the rosuvastatin and placebo groups.

Results: LDL-EV levels of plasminogen and VWF increased with rosuvastatin treatment compared to placebo (mean change of 126 ± 8 versus 17 ± 12 μg/mL for plasminogen (p < 0.001) and 310 ± 60 versus 64 ± 55 μg/mL for VWF (p = 0.015)). There was no difference between groups for change in LDL-EV-SerpinC1. In contrast, serum plasminogen levels increased to a lesser extent with rosuvastatin compared to placebo (23 ± 29 versus 67 ± 17 μg/mL, p = 0.024) and serum VWF levels showed no significant difference between both groups.

Conclusions: Rosuvastatin increases LDL-EV coagulation proteins plasminogen and VWF in patients with subclinical atherosclerosis, an effect that is different from the effect of rosuvastatin on the same proteins in serum. This identifies LDL-EVs as a newly detected possible intermediate between statin therapy and coagulation.
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http://dx.doi.org/10.1016/j.ijcard.2018.05.098DOI Listing
November 2018

Cardiac events within one year after a subarachnoid haemorrhage: The predictive value of troponin elevation after aneurysm occlusion.

Eur J Prev Cardiol 2019 03 17;26(4):420-428. Epub 2018 May 17.

1 Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht University, The Netherlands.

Background: Patients who survive after an aneurysmal subarachnoid haemorrhage (ASAH) have an increased incidence of cardiovascular events compared with the general population. We assessed whether troponin elevation after aneurysm occlusion, as marker of myocardial injury, can predict long-term cardiac events.

Methods: We analysed a prospectively collected cohort of 159 patients with ASAH and early aneurysm occlusion, in whom routine post-intervention troponin I (TnI) measurements were performed. With competing risk regression modelling we estimated the association between TnI elevation after aneurysm occlusion and major adverse cardiac events within one year. Secondary outcome measures were all-cause mortality and neurological condition within one year. The predictive value of post-intervention TnI was compared with the predictive value of pre-intervention characteristics using c-statistics and the integrated discrimination improvement index.

Results: Subdistribution hazard ratios for TnI elevation and major adverse cardiac events at one year were 1.05 (95% confidence interval (CI) 1.03-1.07) per 10 ng/l increase in TnI and 7.91 (95% CI 1.46-43.0) for any TnI elevation. After adjustment for pre-intervention variables, the subdistribution hazard ratios were 1.47 (95% CI 0.81-2.67) per 10 ng/l and 9.00 (95% CI 1.62-50.1) for any elevation. The c-statistic was 0.71 for TnI elevation as a continuous measure and 0.69 for any TnI elevation. The integrated discrimination improvement index showed a minimum improvement in prediction of 0.08 (interquartile range 0.06 to 0.09) for TnI as a continuous measure and 0.003 (interquartile range -0.004 to 0.01) for any TnI elevation, when compared with pre-intervention characteristics.

Conclusion: TnI elevation after occlusion of a ruptured intracranial aneurysm predicts the occurrence of a major adverse cardiac event within one year after ASAH.
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http://dx.doi.org/10.1177/2047487318776098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388411PMC
March 2019

Psychopathology prior to critical illness and the risk of delirium onset during intensive care unit stay.

Intensive Care Med 2018 08 30;44(8):1355-1356. Epub 2018 Apr 30.

Department of Intensive Care Medicine, University Medical Centre Utrecht, Room F06.149, 3508 GA, Utrecht, The Netherlands.

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http://dx.doi.org/10.1007/s00134-018-5195-8DOI Listing
August 2018

Acute Brain Dysfunction: Development and Validation of a Daily Prediction Model.

Chest 2018 08 24;154(2):293-301. Epub 2018 Mar 24.

Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN; Geriatric Research, Education and Clinical Center (GRECC) of the VA Tennessee Valley Healthcare System, Nashville, TN; Center for Health Services Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN. Electronic address:

Background: The goal of this study was to develop and validate a dynamic risk model to predict daily changes in acute brain dysfunction (ie, delirium and coma), discharge, and mortality in ICU patients.

Methods: Using data from a multicenter prospective ICU cohort, a daily acute brain dysfunction-prediction model (ABD-pm) was developed by using multinomial logistic regression that estimated 15 transition probabilities (from one of three brain function states [normal, delirious, or comatose] to one of five possible outcomes [normal, delirious, comatose, ICU discharge, or died]) using baseline and daily risk factors. Model discrimination was assessed by using predictive characteristics such as negative predictive value (NPV). Calibration was assessed by plotting empirical vs model-estimated probabilities. Internal validation was performed by using a bootstrap procedure.

Results: Data were analyzed from 810 patients (6,711 daily transitions). The ABD-pm included individual risk factors: mental status, age, preexisting cognitive impairment, baseline and daily severity of illness, and daily administration of sedatives. The model yielded very high NPVs for "next day" delirium (NPV: 0.823), coma (NPV: 0.892), normal cognitive state (NPV: 0.875), ICU discharge (NPV: 0.905), and mortality (NPV: 0.981). The model demonstrated outstanding calibration when predicting the total number of patients expected to be in any given state across predicted risk.

Conclusions: We developed and internally validated a dynamic risk model that predicts the daily risk for one of three cognitive states, ICU discharge, or mortality. The ABD-pm may be useful for predicting the proportion of patients for each outcome state across entire ICU populations to guide quality, safety, and care delivery activities.
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http://dx.doi.org/10.1016/j.chest.2018.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113630PMC
August 2018

The incidence of postoperative respiratory complications: A retrospective analysis of cuffed vs uncuffed tracheal tubes in children 0-7 years of age.

Paediatr Anaesth 2018 03;28(3):210-217

Department of Anesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Background: The use of cuffed vs uncuffed endotracheal tubes in pediatric anesthesia is widely debated. This study aimed to investigate whether the use of cuffed vs uncuffed tubes is associated with an increased incidence of acute postoperative respiratory complications.

Methods: We retrospectively studied all children aged 0-7 years in which the trachea was intubated between September 28, 2006 and August 26, 2016 in a pediatric university hospital. Logistic regression analysis was performed to estimate the association between tube design (cuffed vs uncuffed) and the incidence of acute postoperative respiratory complications (stridor, wheezing, or dyspnea; desaturations ≤90%) in need of intervention (epinephrine, dexamethasone, nebulizers, supplementary oxygen, or reintubation), adjusting for potential confounders.

Results: In 5247 of 6796 cases (77%), a cuffed tube was used. Acute postoperative respiratory complications in need of intervention occurred in 334 cases (4.9%) and were less common after cuffed than after uncuffed tubes (N = 236, 4.5% vs N = 98, 6.3%, respectively, odds ratio 0.70; 95%CI 0.55-0.89). Desaturation occurred less often after cuffed tubes (cuffed: N = 1365, 26.0%; uncuffed: N = 512, 33.1%; OR: 0.71 (0.61-0.84)). After adjusting for confounders, there was no difference in acute postoperative respiratory complications between cuffed tubes and uncuffed tubes (OR 0.74; 95%CI 0.55-1.01). Subgroup analyses in various age groups did not show significant differences between the use of cuffed or uncuffed tubes.

Conclusion: After adjustment for multiple confounders, the use of cuffed tubes was not associated with an increased incidence of acute respiratory complications in postanesthesia care unit.
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http://dx.doi.org/10.1111/pan.13340DOI Listing
March 2018

The association between aortic cross clamp time and postoperative morbidity and mortality in mitral valve repair: a retrospective cohort study.

J Cardiovasc Surg (Torino) 2018 Jun 8;59(3):453-461. Epub 2018 Feb 8.

Department of Anesthesiology, Intensive Care and Emergency Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.

Background: The aim of this study was to estimate the association between aortic cross clamp time and postoperative morbidity and mortality in patients undergoing mitral valve repair.

Methods: A retrospective cohort study between 2006 and 2014 was performed as a single Center study in the University Medical Center Utrecht. In total 1007 patients who underwent mitral valve repair were included. The patients were divided into a group who underwent isolated mitral valve repair and a group who underwent mitral valve repair with concomitant intervention(s). The primary endpoint was a composite consisting of in-hospital mortality or postoperative major complications.

Results: In the isolated mitral valve group (N.=405), patients were significantly younger, healthier and had fewer complications (9.9%). Patients with concomitant intervention(s) had a twofold higher rate of postoperative complications and mortality (18.1%). After adjustment for confounding there was no association between aortic cross clamp time and the primary endpoint in both the isolated mitral valve group (odds ratio 1.04; 95% CI: 0.98-1.11) and the group with concomitant interventions (odds ratio 1.02; 95% CI: 0.97-1.06).

Conclusions: In patients undergoing mitral valve repair surgery a longer aortic cross clamp time was not associated with postoperative complications and mortality. The higher postoperative morbidity and mortality in combined procedures appears to be due to a higher age, more comorbidities and an extra intervention rather than to the duration of aortic cross clamp time.
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http://dx.doi.org/10.23736/S0021-9509.18.10123-6DOI Listing
June 2018

Systemic Inflammation after Transcatheter Aortic Valve Implantation: A Prospective Exploratory Study.

J Cardiothorac Vasc Anesth 2018 08 30;32(4):e77-e82. Epub 2017 Dec 30.

Department of Anesthesiology Intensive Care and Pain Medicine, St. Antonius Hospital Nieuwegein, The Netherlands.

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http://dx.doi.org/10.1053/j.jvca.2017.12.051DOI Listing
August 2018