Khaled Taema

Objective: A study was made to validate two previously derived lung injury prediction scores (LIPS) for the prediction of acute respiratory distress syndrome (ARDS) in high risk intensive care patients, with the incorporation of C-reactive protein (CRP) for improving score accuracy. Design: A prospective, observational cohort study was carried out. Patients: A total of 200 patients with APACHE II score ≥15 and at least one ARDS risk factor upon ICU admission were included. Interventions: Calculation of LIPS using formulas developed by Cartin-Ceba et al. (2009) and Trillo-Alvarez et al. (2011) (LIPS-2009 and LIPS-2011). C-reactive protein was measured upon admission (CRP-0) and after 48 h (CRP-48). Main variables of interest: Independent variables: LIPS-2009, LIPS-2011 and CRP values. Dependent variable: development of ARDS. Results: Eighty-eight patients (44%) developed ARDS after a median (Q1–Q3) of 2.5 (1.3–6.8) days. The LIPS-2009 and LIPS-2011 scores were 4 (3–6) and 5 (3.6–6.5) in ARDS patients compared to 2 (1–4) and 3.5 (1.5–4.5) in non-ARDS patients (p < 0.001). CRP-48 was 96 (67.5–150.3) mg/L and 48 (24–96) mg/L in the two groups, respectively (p < 0.001). ΔCRP (i.e., CRP-48 minus CRP-0) was significantly higher in the ARDS patients (p < 0.001). The AUC was 0.740 and 0.738 for LIPS-2011 and LIPS-2009, respectively – the difference being nonsignificant (p = 0.9, 0.9 and 0.8 for pairwise comparison of the different ROC curves). Integrating ΔCRP with LIPS-2011 using binary logistic regression analysis identified a new score (LIPS-N) with AUC 0.803, which was significantly higher than the AUC of LIPS-2011 (p = 0.01). Conclusions: Both LIPS scores are equally effective in predicting ARDS in high risk ICU patients. Integrating the change in CRP within the score might improve its accuracy.

Background: The timing of initiation of Norepinephrine (NEP) in septic shock is controversial. Aim of the study: We evaluated the impact of early NEP simultaneously with fluids in those patients. Methods: We randomized 101 patients admitted to the emergency department with septic shock to early NEP simultaneously with IV fluids (early group) or after failed fluids trial (late group). The primary outcome was the in-hospital survival while the secondary outcomes were the time to target mean arterial pressure (MAP) of 65 mmHg, lactate clearance and resuscitation volumes. Results: There was no significant difference between the two groups regarding the baseline characteristics. NEP infusion started after 25 (20–30) and 120 (120–180) min in the early and late groups (p = 0.000). MAP of 65 mmHg was achieved faster in the early group (2 [1–3.5] h vs. 3 [2–4.75] h, p = 0.003). Serum lactate was decreased by 37.8 (24–49%) and 22.2 (3.3–38%) in both groups respectively (p = 0.005). Patients with early NEP were resuscitated by significantly lower volume of fluids (25 [18.8–28.7] mL/kg vs. 32.5 [24.4–34.6] mL/kg) in the early and late groups (p = 0.000). The early group had survival rate of 71.9% compared to 45.5% in the late group (p = 0.007). NEP started after 30 (20–120 min) in survivors vs. 120 (30–165 min) in non-survivors (p = 0.013). Conclusions: We concluded that early Norepinephrine in septic shock might cause earlier restoration of blood pressure, better lactate clearance and improve in-hospital survival.

Background: We intended to create a new acute respiratory distress syndrome (ARDS) prediction score in high-risk critically ill patients. Methods: We recruited 200 patients [63 (43-70) years, 120 (60%) males] admitted to the ICU with APACHE-II scores of ≥15 and at least one ARDS risk factor, after excluding patients with ARDS on admission, cardiac patients, and readmissions. The presence of risk factors together with the admission and 48-hour CRP (CRP-0 and CRP-48) were tested in univariate then multivariate regression models for identifying significant predictors whose weights were assigned according to the β-coefficient of the regression model. Our score was compared with the score previously proposed by Trillo-Alvarez et al. on 2011 (LIPS-T). The primary and secondary outcomes were the development of ARDS and in-hospital mortality, respectively. Results: ARDS developed in 88 patients (44%). Logistic regression revealed that pneumonia, tachypnoea, increased heart rate, and increased CRP-48 are significant ARDS predictors. The weight of each predictor was estimated according to its β-coefficient. The new score was 35.5 (27-44) and 14 (9-24.3) in ARDS and non-ARDS patients, respectively (p=0.000). The AUC of the new score was 0.827 compared with 0.74 for the LIPS-T (p=0.014). A score of 20 had a sensitivity and specificity of 82% and 71%, respectively, in predicting ARDS. Our score was significantly lower in survivors compared with non-survivors (p=0.000) and its AUC in predicting in-hospital mortality was 0.761 compared with 0.657 for the LIPS-T (p=0.0045). Conclusions: We have created a new simple LIPS score which could be better than the scores previously proposed in terms of ARDS and in-hospital mortality prediction in critically ill patients.

IntroductionThe administration of loop diuretics in the management of acute decompensated heart failure (ADHF) whether IV boluses or continuous infusion is still controversial. We intended to evaluate differences between the two administration routes on the thoracic fluid content (TFC) and the renal functions.
Methods
Sixty patients with ADHF admitted to the critical care medicine department (Cairo University, Egypt) were initially enrolled in the study. Twenty patients were excluded due to EF > 40%, myocardial infarction within 30 days, and baseline serum creatinine level > 4.0 mg/dL. Furosemide (120 mg/day) was given to the remaining 40 pts who continued the study after 1:1 randomization to either continuous infusion (group-I, 20 pts) or three equal intermittent daily doses (group-II, 20 pts). Subsequent dose titration was allowed after 24 h, but not earlier, according to patient’s response. No other diuretic medications were allowed. All patients were daily evaluated for NYHA class, urine output, TFC, body weight, serum K+, and renal chemistry.
Results
The median age (Q1–Q3) was 54.5 (43.8–63.8) years old with 24 (60%) males. Apart from TFC which was significantly higher in group-I, the admission demographic, clinical, laboratory and co-morbid conditions were similar in both groups. There was statistically insignificant tendency for increased urine output during the 1st and 2nd days in group-I compared to group-II (p = .08). The body weight was decreased during the 1st day by 2 (1.5–2.5) kg in group-I compared to 1.5 (1–2) kg in group-II, (p = .03). These changes became insignificant during the 2nd day (p = .4). The decrease of TFC was significantly higher in group-I than in group-II [10 (6.3–14.5) vs 7 (3.3–9.8) kΩ−1 during the first day and 8 (6–11) vs 6 (3.3–8.5) kΩ−1 during the second day in groups-I&II respectively, P = .02 for both]. There was similar NYHA class improvement in both groups (p = .7). The serum creatinine was increased by 0.2 (0.1–0.5) vs 0 (−0.1 to 0.2) mg% and the CrCl was decreased by 7.4 (4.5–12.3) vs 3.1 (0.2–8.8) ml/min in groups-I&II respectively (p = .009 and .02 respectively).
Conclusions
We concluded that continuous furosemide infusion in ADHF might cause greater weight loss and more decrease in TFC with no symptomatic improvement and possibly with more nephrotoxic effect.

Early identification of sepsis and its differentiation from non-infective SIRS are important for sepsis outcome. We intended to evaluate the use of presepsin in differentiating sepsis from noninfectious SIRS and its prognostic value compared to CRP. We included 31 patients (median age 60year old, 16 males) admitted with SIRS to El-Sahel Teaching Hospital, Egypt after excluding 21 patients with preadmission corticosteroids therapy, blood transfusion, immunosuppressive illness, and ICU length of stay (ICU-LOS) less than 24-hours. Patients were classified into non-infective SIRS group (13 patients) and sepsis group (18 patients). Presepsin, CRP and SOFA score were measured on admission and on days 2 and 4 of admission. The outcome parameters studied were ICU-LOS and in-hospital survival. Apart from temperature and AST which were significantly higher in sepsis group, the two groups were comparable. All the presepsin levels and CRP on days 2 and 4 were significantly higher in sepsis than in SIRS groups. The ICU-LOS was positively correlated with all the presepsin levels and with the CRP levels on days 2 and 4. All presepsin values were significantly higher in survivors while none of the CRP levels were significantly different in survivors and non-survivors. The decrease of presepsin over time was significantly associated with better survival. It was found to be 70% sensitive and 91% specific for predicting survival in SIRS patients. This relation was not found in CRP levels. We concluded that the presepsin can be used for early differentiation between sepsis and non-infectious SIRS and predict higher mortality.