Recently published papers: Renal support in acute kidney injury - is low dose the new high dose?

Despite 21st century definitions, the management of acute kidney injury remains steadfastly rooted in the 20th century with treatment being principally supportive. Protection from potential causative agents is an essential part of management and to that end protection against contrast-induced nephropathy has received yet more attention. When optimization of volume status, haemodynamic parameters, electrolyte and acid-base disturbances have failed we turn to renal replacement therapy. The time 'bought' on renal support gives a period for renal recovery but although renal replacement therapy is widely employed, many management issues remain unanswered, including the timing, duration and the dose of treatment. In contrast to respiratory support for acute lung injury, for example, there is a paucity of large randomized studies addressing these fundamental issues. We describe some recent studies focusing on these issues with the hope that they may lead to better treatment for our patients

Survival implications vs. complications: unraveling the impact of vitamin D adjunctive use in critically ill patients with COVID-19—A multicenter cohort study

BackgroundDespite insufficient evidence, vitamin D has been used as adjunctive therapy in critically ill patients with COVID-19. This study evaluates the effectiveness and safety of vitamin D as an adjunctive therapy in critically ill COVID-19 patients.MethodsA multicenter retrospective cohort study that included all adult COVID-19 patients admitted to the intensive care units (ICUs) between March 2020 and July 2021. Patients were categorized into two groups based on their vitamin D use throughout their ICU stay (control vs. vitamin D). The primary endpoint was in-hospital mortality. Secondary outcomes were the length of stay (LOS), mechanical ventilation (MV) duration, and ICU-acquired complications. Propensity score (PS) matching (1:1) was used based on the predefined criteria. Multivariable logistic, Cox proportional hazards, and negative binomial regression analyses were employed as appropriate.ResultsA total of 1,435 patients were included in the study. Vitamin D was initiated in 177 patients (12.3%), whereas 1,258 patients did not receive it. A total of 288 patients were matched (1:1) using PS. The in-hospital mortality showed no difference between patients who received vitamin D and the control group (HR 1.22, 95% CI 0.87–1.71; p = 0.26). However, MV duration and ICU LOS were longer in the vitamin D group (beta coefficient 0.24 (95% CI 0.00–0.47), p = 0.05 and beta coefficient 0.16 (95% CI −0.01 to 0.33), p = 0.07, respectively). As an exploratory outcome, patients who received vitamin D were more likely to develop major bleeding than those who did not [OR 3.48 (95% CI 1.10, 10.94), p = 0.03].ConclusionThe use of vitamin D as adjunctive therapy in COVID-19 critically ill patients was not associated with survival benefits but was linked with longer MV duration, ICU LOS, and higher odds of major bleeding

Green-route synthesis and ab-initio studies of a highly efficient nano photocatalyst:Ce/zinc-oxide nanopetals

In the present work, Zinc-oxide nanostructures and Ce/Zinc-oxide nanopetals were synthesized by a new environmentally friendly green synthesis method using the Withania coagulans plant. Cerium nitrate Ce(NO3)3 and zinc nitrate Zn(NO3)2 were used as precursors. The prepared nanostructures were characterized by X-ray diffraction (XRD), scanning electron microscopy (SEM), and ultraviolet spectroscopy (UV–vis). Crystal planes (100), (002), (101), (102), (110), (103), (200), (112) and (201) at 2θ 31.75°, 34.35°, 36.2°, 47.55°, 56.6°, 62.75°, 66.3°, 67.9°, and 69.09° respectively confirmed the hexagonal wurtzite crystal structure of Zinc-oxide. Angular shifts for Ce1% doped Zinc-oxide and Ce3% doped Zinc-oxide nanopetal nanostructures were observed in the (100) and (101) planes of the crystal. More specifically, using Scherrer's equation, the crystallite sizes of Zinc-oxide, Ce1% doped Zinc-oxide nanopetals, Ce3% doped Zinc-oxide nanopetals, and Ce5% doped Zinc-oxide nanopetals were 16.48 ± 02 nm, 17.8 ± 2 nm, 18.8 ± 2 nm, and 18.87 ± 2 nm, respectively. The pure Zinc-oxide grain had the appearance of a nanoflower. On the other hand, the nanopetal structure of Ce5% doped Zinc-oxide nanopetals had oval-shaped nanopetal morphology. The absorption peaks were observed at 373, 376.4, 377, and 378 nm for Zinc-oxide, Ce1% doped Zinc-oxide nanopetals, Ce3% doped Zinc-oxide nanopetals, and Ce5% doped Zinc-oxide nanopetals, respectively, which results in a progressive redshift. The gap energies of Zinc-oxide, Ce1% doped Zinc-oxide nanopetals, Ce3% doped Zinc-oxide nanopetals, and Ce5% doped Zinc-oxide nanopetals were 2.796, 2.645, 2.534, and 2.448 eV, respectively. Photodegradation under visible light (>400 nm) indicates the high efficiency of the photocatalyst based on Ce5% doped Zinc-oxide nanopetals. DFT calculations, structural changes, charge analysis, and electronic band structures were carried out to confirm the experiment

Low Systemic Oxygen Delivery and BP and Risk of Progression of Early AKI

BACKGROUND AND OBJECTIVES: The optimal hemodynamic management of patients with early AKI is unknown. This study aimed to investigate the association between hemodynamic parameters in early AKI and progression to severe AKI and hospital mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study retrospectively analyzed the data of all patients admitted to the adult intensive care unit in a tertiary care center between July 2007 and June 2009 and identified those with stage 1 AKI (AKI I) per the AKI Network classification. In patients in whom hemodynamic monitoring was performed within 12 hours of AKI I, hemodynamic parameters in the first 12 hours of AKI I and on the day of AKI III (if AKI III developed) or 72 hours after AKI I (if AKI III did not develop) were recorded. Risk factors for AKI III and mortality were identified using univariate and multivariate logistic regression analyses. RESULTS: Among 790 patients with AKI I, 210 (median age 70 years; 138 men) had hemodynamic monitoring within 12 hours of AKI I; 85 patients (41.5%) progressed to AKI III and 91 (43%) died in the hospital. AKI progressors had a significantly higher Sequential Organ Failure Assessment score (8.0 versus 9.6; P<0.001), lower indexed systemic oxygen delivery (DO(2)I) (median 325 versus 405 ml/min per m(2); P<0.001), higher central venous pressure (16 versus 13; P=0.02), and lower mean arterial blood pressure (MAP) (median 71 versus 74 mmHg; P=0.01) in the first 12 hours of AKI I compared with nonprogressors. Multivariate analysis confirmed that raised lactate, central venous pressure, and Sequential Organ Failure Assessment score as well as mechanical ventilation were independently associated with progression to AKI III; higher DO(2)I and MAP were independently associated with a lower risk of AKI III but not survival. The associations were independent of sepsis, heart disease, recent cardiac surgery, or chronic hypertension. CONCLUSIONS: Higher DO(2)I and MAP in early AKI were independently associated with a lower risk of progression

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients from 29 Countries

Importance: Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. Objective: To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. Design, Setting, and Participants: The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. Exposures: Tracheal intubation. Main Outcomes and Measures: The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure &lt;65 mm Hg at least once, &lt;90 mm Hg for &gt;30 minutes, new or increase need of vasopressors or fluid bolus &gt;15 mL/kg), severe hypoxemia (peripheral oxygen saturation &lt;80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. Results: Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. Conclusions and Relevance: In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events - in particular cardiovascular instability - were observed frequently