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Vaara S.T.,University of Helsinki | Reinikainen M.,North Karelia Central Hospital | Wald R.,St. Michaels Hospital | Bagshaw S.M.,University of Alberta | Pettila V.,University of Helsinki
Clinical Journal of the American Society of Nephrology

Background and objectives: No data on the development of conventional indications for RRT (refractory acidosis, hyperkalemia, uremia, oliguria/anuria, and volume overload) related to timing of RRT exist. The prevalence of conventional indications among critically ill patients on RRT for AKI was evaluated, and patients manifesting indications versus patients without indications were compared in terms of crude and adjusted 90-day mortality. Design, setting, participants, & measurements: In this substudy of the Finnish Acute Kidney Injury study conducted in 2011 and 2012 in 17 intensive care units with 2901 patients, patients were classified as pre-emptive (no conventional indications) and classic (one ormore indications) RRT recipients. Patientswith classic RRTwere divided into classic-urg nt (RRT initiated#12 hours frommanifesting indications) and classic-delayed (RRT>12 hours fromfirst indication). Additionally, 2450 patients treated without RRT were matched to patients with preemptive RRT. Results: Of 239 patients treated with RRT, 134 (56.1%; 95%confidence interval [95%CI], 49.8% to 62.4%) fulfilled at least one conventional indication before commencing RRT. Crude 90-day mortality of 134 patients with classic RRTwas 48.5%(95%CI, 40.0%to 57.0%), and itwas 29.5%(95%CI, 20.8%to 38.2%) for the 105 patients with preemptive RRT. Classic RRT was associated with a higher risk formortality (adjusted odds ratio, 2.05; 95% CI, 1.03 to 4.09). Forty-four patients with classic–delayed RRT showed higher crude mortality (68.2%; 95% CI, 54.4% to 82.0%) compared with patients with classic–urgent RRT, and this association persisted after adjustment for known confounders (odds ratio, 3.85; 95% CI, 1.48 to 10.22). Crude 90-day mortality of 67 1:1 matched patients with pre-emptive RRT was 26.9% (95% CI, 6.3% to 37.5%), and it was 49.3% (95% CI, 37.3% to 61.2%; P=0.01) for their non-RRT matches. Conclusions: Patients on RRT after one or more conventional indications had both higher crude and adjusted 90-day mortality compared with patients without conventional indications. These findings require confirmation in an adequately powered, multicenter, randomized controlled trial. © 2014 by the American Society of Nephrology. Source

Vaahersalo J.,University of Helsinki | Bendel S.,Kuopio University Hospital | Reinikainen M.,North Karelia Central Hospital | Kurola J.,Kuopio University Hospital | And 5 more authors.
Critical Care Medicine

OBJECTIVES: Optimal oxygen and carbon dioxide levels during postcardiac arrest care are currently undefined and observational studies have suggested harm from hyperoxia exposure. We aimed to assess whether mean and time-weighted oxygen and carbon dioxide levels during the first 24 hours of postcardiac arrest care correlate with 12-month neurologic outcome. DESIGN: Prospective observational cohort study. SETTING: Twenty-one ICUs in Finland. PATIENTS: Out-of-hospital cardiac arrest patients treated in ICUs in Finland between March 2010 and February 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Arterial blood PaO2 and PaCO2 during the first 24 hours from admission were divided into predefined categories from the lowest to the highest. Proportions of time spent in different categories and the mean PaO 2 and PaCO2 values during the first 24 hours were included in separate multivariable regression models along with resuscitation factors. The cerebral performance category at 12 months was used as primary endpoint. A total of 409 patients with arterial blood gases analyzed at least once and with a complete set of resuscitation data were included. The average amount of PaO2 and PaCO2 measurements was eight per patient. The mean 24 hours PaCO2 level was an independent predictor of good outcome (odds ratio, 1.054; 95% CI, 1.006-1.104; p = 0.027) but the mean PaO2 value was not (odds ratio, 1.006; 95% CI, 0.998-1.014; p = 0.149). With multivariate regression analysis, time spent in the PaCO 2 band higher than 45 mm Hg was associated with good outcome (odds ratio, 1.015; 95% CI, 1.002-1.029; p = 0.024, for each percentage point increase in time) but time spent in different oxygen categories were not. CONCLUSIONS: In this multicenter study, hypercapnia was associated with good 12-month outcome in patients resuscitated from out-of-hospital cardiac arrest. We were unable to verify any harm from hyperoxia exposure. Further trials should focus on whether moderate hypercapnia during postcardiac arrest care improves outcome. © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Source

Sipila J.O.T.,North Karelia Central Hospital | Sipila J.O.T.,University of Turku | Rautava P.,University of Turku | Kyto V.,University of Turku
Annals of Medicine

Introduction Circadian rhythm disturbance increases cardiovascular risk but the effects of daylight saving time (DST) transitions on the risk of myocardial infarction (MI) are unclear.Methods We studied association of DST transitions in 2001-2009 with incidence and in-hospital mortality of MI admissions nationwide in Finland. Incidence rations (IR) of observed incidences on seven days following DST transition were compared to expected incidences.Results Incidence of MI increased on Wednesday (IR 1.16; CI 1.01-1.34) after spring transition (6298 patients cohort). After autumn transition (8161 patients cohort), MI incidence decreased on Monday (IR 0.85; CI 0.74-0.97) but increased on Thursday (IR 1.15; CI 1.02-1.30). The overall incidence of MI during the week after each DST transition did not differ from control weeks. Patient age or gender, type of MI or in-hospital mortality were not associated with transitions. Renal insufficiency was more common among MI patients after spring transition (OR 1.81; CI 1.06-3.09; p < 0.05). Diabetes was less common after spring transition (OR 0.71; CI 0.55-0.91; p = 0.007), but more common after autumn transition (OR 1.21; 1.00-1.46; p < 0.05).Conclusions DST transitions are followed by changes in the temporal pattern but not the overall rate of MI incidence. Comorbidities may modulate the effects DST transitions.KEY MESSAGESBoth spring and autumn daylight saving time transitions changed the temporal occurrence pattern but not the overall incidence of myocardial infarction occurrence on the week following the clock shift.The age or gender distribution of patients, ratio of different types of myocardial infarctions or in-hospital mortality were not affected by clock shifts.The effect of daylight saving time transitions on MI incidence may be modified by the presence of diabetes. © 2015 Taylor & Francis. Source

Vaara S.T.,University of Helsinki | Pettila V.,University of Helsinki | Reinikainen M.,North Karelia Central Hospital | Kaukonen K.-M.,University of Helsinki
Critical Care

Introduction: Acute kidney injury (AKI) increases mortality and morbidity of critically ill patients. Mortality of patients treated with renal replacement therapy (RRT) is high. We aimed to evaluate the nationwide incidence of RRT-treated AKI in Finland, hospital and six-month mortality, and health-related quality of life (HRQoL) of these patients.Methods: We performed a retrospective cohort study including all general intensive care unit (ICU) admissions in Finland in 2007 through 2008. We identified patients who had received RRT due to AKI (RRT patients) and compared these patients to ICU patients who were not treated with RRT (non-RRT patients). The HRQoL was assessed by the EQ-5D index and visual analogue scale (VAS).Results: We analysed the final cohort of 24,904 patients, of whom 1,686 received RRT due to AKI. The incidence of RRT-treated AKI was 6.8% (95% confidence interval (CI) 6.5 to 7.1%) among ≥ 15-year-old general ICU patients, which corresponds to a yearly population-based incidence of 19.2 per 100,000 (95% CI 17.9 to 20.5/100,000). According to RIFLE (Risk, Injury, Failure) classification 26.6% (95% CI 26.0 to 27.2%) of patients had AKI (RIFLE R-F). Hospital and six-month mortality of RRT patients were 35.0% and 49.4%. At six-months, RRT patients perceived their health as good as non-RRT patients by VAS.Conclusions: The population-based incidence of AKI treated with RRT was 19.2 per 100,000 in Finland and 6.8% of all general ICU patients. The hospital and six-month mortality rates were lower than previously reported for ICU-treated RRT patients. © 2012 Vaara et al.; licensee BioMed Central Ltd. Source

Raj R.,University of Helsinki | Skrifvars M.B.,University of Helsinki | Bendel S.,Kuopio University Hospital | Selander T.,Kuopio University Hospital | And 3 more authors.
Critical Care

Introduction: The aim of this study was to evaluate the usefulness of the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score II) and SOFA (Sequential Organ Failure Assessment) scores compared to simpler models based on age and Glasgow Coma Scale (GCS) in predicting long-term outcome of patients with moderate-to-severe traumatic brain injury (TBI) treated in the intensive care unit (ICU).Methods: A national ICU database was screened for eligible TBI patients (age over 15 years, GCS 3-13) admitted in 2003-2012. Logistic regression was used for customization of APACHE II, SAPS II and SOFA score-based models for six-month mortality prediction. These models were compared to an adjusted SOFA-based model (including age) and a reference model (age and GCS). Internal validation was performed by a randomized split-sample technique. Prognostic performance was determined by assessing discrimination, calibration and precision.Results: In total, 1,625 patients were included. The overall six-month mortality was 33%. The APACHE II and SAPS II-based models showed good discrimination (area under the curve (AUC) 0.79, 95% confidence interval (CI) 0.75 to 0.82; and 0.80, 95% CI 0.77 to 0.83, respectively), calibration (P > 0.05) and precision (Brier score 0.166 to 0.167). The SOFA-based model showed poor discrimination (AUC 0.68, 95% CI 0.64 to 0.72) and precision (Brier score 0.201) but good calibration (P > 0.05). The AUC of the SOFA-based model was significantly improved after the insertion of age and GCS ({increment}AUC +0.11, P < 0.001). The performance of the reference model was comparable to the APACHE II and SAPS II in terms of discrimination (AUC 0.77; compared to APACHE II, ΔAUC -0.02, P = 0.425; compared to SAPS II, ΔAUC -0.03, P = 0.218), calibration (P > 0.05) and precision (Brier score 0.181).Conclusions: A simple prognostic model, based only on age and GCS, displayed a fairly good prognostic performance in predicting six-month mortality of ICU-treated patients with TBI. The use of the more complex scoring systems APACHE II, SAPS II and SOFA added little to the prognostic performance. © 2014 Raj et al.; licensee BioMed Central Ltd. Source

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