Association of kidney function with effectiveness of procalcitonin-guided antibiotic treatment:A patient-level meta-analysis from randomized controlled trials

Patients with impaired kidney function have a significantly slower decrease of procalcitonin (PCT) levels during infection. Our aim was to study PCT-guided antibiotic stewardship and clinical outcomes in patients with impairments of kidney function as assessed by creatinine levels measured upon hospital admission. We pooled and analyzed individual data from 15 randomized controlled trials who were randomly assigned to receive antibiotic therapy based on a PCT-algorithms or based on standard of care. We stratified patients on the initial glomerular filtration rate (GFR, ml/min/1.73 m2) in three groups (GFR >90 [chronic kidney disease; CKD 1], GFR 15-89 [CKD 2-4] and GFR0.05). This individual patient data meta-analysis confirms that the use of PCT in patients with impaired kidney function, as assessed by admission creatinine levels, is associated with shorter antibiotic courses and lower mortality rates

Zorg: Afkortingen in het dagelijks taalgebruik: Stop ermee

Abbreviations are used more and more in physician common parlance and it seems they are on the way to becoming a new jargon. However, identical abbreviations may have different meanings, especially in different medical specialties. Moreover, many physicians do not know the meaning of specific abbreviations or are attributing the wrong meaning to the abbreviation. This will lead to misunderstanding and therefore danger to the patient. The authors are calling for a stop on the use of spoken abbreviations and for minimising the use of abbreviations in clinical notes and medical prescriptions

Severe electrolyte disorders following cardiac surgery: a prospective controlled observational study.

INTRODUCTION: Electrolyte disorders are an important cause of ventricular and supraventricular arrhythmias as well as various other complications in the intensive care unit. Patients undergoing cardiac surgery are at risk for development of tachyarrhythmias, especially in the period during and immediately after surgical intervention. Preventing electrolyte disorders is thus an important goal of therapy in such patients. However, although levels of potassium are usually measured regularly in these patients, other electrolytes such as magnesium, phosphate and calcium are measured far less frequently. We hypothesized that patients undergoing cardiac surgical procedures might be at risk for electrolyte depletion, and we therefore conducted the present study to assess electrolyte levels in such patients. METHODS: Levels of magnesium, phosphate, potassium, calcium and sodium were measured in 500 consecutive patients undergoing various cardiac surgical procedures who required extracorporeal circulation (group 1). A total of 250 patients admitted to the intensive care unit following other major surgical procedures served as control individuals (group 2). Urine electrolyte excretion was measured in a subgroup of 50 patients in both groups. RESULTS: All cardiac patients received 1 l cardioplegia solution containing 16 mmol potassium and 16 mmol magnesium. In addition, intravenous potassium supplementation was greater in cardiac surgery patients (mean +/- standard error: 10.2 +/- 4.8 mmol/hour in cardiac surgery patients versus 1.3 +/- 1.0 in control individuals; P < 0.01), and most (76% versus 2%; P < 0.01) received one or more doses of magnesium (on average 2.1 g) for clinical reasons, mostly intraoperative arrhythmia. Despite these differences in supplementation, electrolyte levels decreased significantly in cardiac surgery patients, most of whom (88% of cardiac surgery patients versus 20% of control individuals; P < 0.001) met criteria for clinical deficiency in one or more electrolytes. Electrolyte levels were as follows (mmol/l [mean +/- standard error]; cardiac patients versus control individuals): phosphate 0.43 +/- 0.22 versus 0.92 +/- 0.32 (P < 0.001); magnesium 0.62 +/- 0.24 versus 0.95 +/- 0.27 (P < 0.001); calcium 1.96 +/- 0.41 versus 2.12 +/- 0.33 (P < 0.001); and potassium 3.6 +/- 0.70 versus 3.9 +/- 0.63 (P < 0.01). Magnesium levels in patients who had not received supplementation were 0.47 +/- 0.16 mmol/l in group 1 and 0.95 +/- 0.26 mmol/l in group 2 (P < 0.001). Urinary excretion of potassium, magnesium and phosphate was high in group 1 (data not shown), but this alone could not completely account for the observed electrolyte depletion. CONCLUSION: Patients undergoing cardiac surgery with extracorporeal circulation are at high risk for electrolyte depletion, despite supplementation of some electrolytes, such as potassium. The probable mechanism is a combination of increased urinary excretion and intracellular shift induced by a combination of extracorporeal circulation and decreased body temperature during surgery (hypothermia induced diuresis). Our findings may partly explain the high risk of tachyarrhythmia in patients who have undergone cardiac surgery. Prophylactic supplementation of potassium, magnesium and phosphate should be seriously considered in all patients undergoing cardiac surgical procedures, both during surgery and in the immediate postoperative period. Levels of these electrolytes should be monitored frequently in such patients

Protocols for the obvious: Where does it start, and stop?

Protocols can be helpful in specific situations and may have show benefits in clinical trials. So-called evidence based protocols and checklists frequently remind clinicians to do the obvious, but may also contain as part of a bundle, elements that are not based on the best current evidence. However, so called quality improvement programs frequently call for implementation of the total bundle. We think this is basically wrong and warn against that practice