Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients – A prospective multicenter observational study (iSOFA study)

Background & aims: To develop a five grade score (0–4 points) for the assessment of gastrointestinal (GI) dysfunction in adult critically ill patients. Methods: This prospective multicenter observational study enrolled consecutive adult patients admitted to 11 intensive care units in nine countries. At all sites, daily clinical data with emphasis on GI clinical symptoms were collected and intra-abdominal pressure measured. In five out of 11 sites, the biomarkers citrulline and intestinal fatty acid-binding protein (I-FABP) were measured additionally. Cox models with time-dependent scores were used to analyze associations with 28- and 90-day mortality. The models were estimated with stratification for study center. Results: We included 540 patients (224 with biomarker measurements) with median age of 65 years (range 18–94), the Simplified Acute Physiology Score II score of 38 (interquartile range 26–53) points, and Sequential Organ Failure Assessment (SOFA) score of 6 (interquartile range 3–9) points at admission. Median ICU length of stay was 3 (interquartile range 1–6) days and 90-day mortality 18.9%. A new five grade Gastrointestinal Dysfunction Score (GIDS) was developed based on the rationale of the previously developed Acute GI Injury (AGI) grading. Citrulline and I-FABP did not prove their potential for scoring of GI dysfunction in critically ill. GIDS was independently associated with 28- and 90-day mortality when added to SOFA total score (HR 1.40; 95%CI 1.07–1.84 and HR 1.40; 95%CI 1.02–1.79, respectively) or to a model containing all SOFA subscores (HR 1.48; 95%CI 1.13–1.92 and HR 1.47; 95%CI 1.15–1.87, respectively), improving predictive power of SOFA score in all analyses. Conclusions: The newly developed GIDS is additive to SOFA score in prediction of 28- and 90-day mortality. The clinical usefulness of this score should be validated prospectively. Trial registration: NCT02613000, retrospectively registered 24 November 2015.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Skin blood flow in patients with circulatory shock

Skin blood flow in patients with circulatory shockWasineenart MONGKOLPUNErasme Hospital, Faculty of Medicine, Univerité Libre de Bruxelles (ULB)Introduction :In patients with circulatory shock, skin blood flow (SBF) is altered early before the significant change of global haemodynamic parameters. Moreover, skin hypoperfusion including its endothelial dysfunction persist after the treat of shock and are related to worst outcomes. Furthermore, an increase in SBF during resuscitation has been shown to be correlated with an improvement in organ function. Therefore, it should be monitored during resuscitation for diagnosis of tissue hypoperfusion and evaluating the resolution of tissue hypoperfusion. SBF is evaluated by physical examination: capillary refill time or the presence of mottled skin or cold, clammy extremities. However, because of difficulties in reliably assessing skin perfusion via clinical examination, skin laser doppler (SLD) has been developed to more precisely quantify SBF. Interestingly, non-invasive techniques such as SLD can assess SBF and skin microvascular endothelial function when combined with a local heating test (thermal challenge test; TCT). Nevertheless, the most suitable area to monitor SBF by SLD, the expression of the TCT response, the reliability and reproducibility all need to be studied and validated in patients with shockObjective :The aim of this thesis was to determine whether SBF and skin microvascular endothelial function (TCT), as measured using SLD, change during resuscitation and during therapeutic interventions and whether alterations in SBF and skin microvascular endothelial function are related to the severity of disease. Outline and Main results :Background part reviews current methods for assessing and monitoring skin perfusion, and Chapter 1 evaluates use of SBF, using SLD at finger, toe, forearm, and ear sites at different skin temperatures to discover which area is the most suitable for monitoring skin perfusion in circulatory shock, including its reliability and reproducibility. From Chapter 1, we demonstrated that SBF including TCT, measured on the finger and great toe were suitable area to monitor and they had good repeatability and reproducibility in patients with circulatory shock. The prognostic value of SBF including its response to a TCT measured using the SLD technique, on outcomes such as mortality or the development of organ dysfunction in patients with circulatory shock is presented in Chapter 2 and we observed that both SBF and endothelial function (TCT) were predictors of mortality. In Chapter 3, we consider the evolution of SBF and TCT during a fluid challenge to determine that the change is related to the correction of tissue hypoxia. In Chapters 4 and 5, we explain the evolution of SBF and TCT during fluid withdrawal therapy and their correlation with haemodynamic intolerance or development of acute kidney injury after a negative fluid balance was achieved or the alteration of tissue perfusion. Chapter 6, the final chapter, provides an overview of potential future approaches to monitoring skin perfusion using SLD during the treatment of shock.Conclusion :SBF measurement using SLD is a feasible technique to assess skin perfusion and skin microcirculatory endothelial function in patients with circulatory shock. This technique should be considered a useful tool to keep at the bedside to evaluate skin perfusion and skin endothelial vasodilatory function during the treatment of shock.Doctorat en Sciences médicales (Médecine)info:eu-repo/semantics/nonPublishe

Perioperative management of oral glucose-lowering drugs in the patient with type 2 diabetes

SCOPUS: re.jinfo:eu-repo/semantics/publishe

Monitoring skin blood flow to rapidly identify alterations in tissue perfusion during fluid removal using continuous veno-venous hemofiltration in patients with circulatory shock

Background: Continuous veno-venous hemofiltration (CVVH) can be used to reduce fluid overload and tissue edema, but excessive fluid removal may impair tissue perfusion. Skin blood flow (SBF) alters rapidly in shock, so its measurement may be useful to help monitor tissue perfusion. Methods: In a prospective, observational study in a 35-bed department of intensive care, all patients with shock who required fluid removal with CVVH were considered for inclusion. SBF was measured on the index finger using skin laser Doppler (Periflux 5000, Perimed, Järfälla, Sweden) for 3 min at baseline (before starting fluid removal, T0), and 1, 3 and 6 h after starting fluid removal. The same fluid removal rate was maintained throughout the study period. Patients were grouped according to absence (Group A) or presence (Group B) of altered tissue perfusion, defined as a 10% increase in blood lactate from T0 to T6 with the T6 lactate ≥ 1.5 mmol/l. Receiver operating characteristic curves were constructed and areas under the curve (AUROC) calculated to identify variables predictive of altered tissue perfusion. Data are reported as medians [25th–75th percentiles]. Results: We studied 42 patients (31 septic shock, 11 cardiogenic shock); median SOFA score at inclusion was 9 [8–12]. At T0, there were no significant differences in hemodynamic variables, norepinephrine dose, lactate concentration, ScvO2 or ultrafiltration rate between groups A and B. Cardiac index and MAP did not change over time, but SBF decreased in both groups (p < 0.05) throughout the study period. The baseline SBF was lower (58[35–118] vs 119[57–178] perfusion units [PU], p = 0.03) and the decrease in SBF from T0 to T1 (ΔSBF%) higher (53[39–63] vs 21[12–24]%, p = 0.01) in group B than in group A. Baseline SBF and ΔSBF% predicted altered tissue perfusion with AUROCs of 0.83 and 0.96, respectively, with cut-offs for SBF of ≤ 57 PU (sensitivity 78%, specificity 87%) and ∆SBF% of ≥ 45% (sensitivity 92%, specificity 99%). Conclusion: Baseline SBF and its early reduction after initiation of fluid removal using CVVH can predict worsened tissue perfusion, reflected by an increase in blood lactate levels.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

MOESM1 of Skin microcirculatory reactivity assessed using a thermal challenge is decreased in patients with circulatory shock and associated with outcome

Additional file 1: Tables S1–S4 and Figures S1–S5