Acute kidney injury (AKI) following cardiac surgery (AKICS) is associated with increased postoperative (post-op) morbidity and mortality. A prognostic score system for AKI would help anticipate patient (pt) treatment. To develop a predictive score (AKICS) for AKI following cardiac surgery, we used a broad definition of AKI, which included perioperative variables. Six hundred three pts undergoing cardiac surgery were prospectively evaluated for AKI defined as serum creatinine above 2.0 mg/dl or an increase of 50% above baseline value. Univariate and multivariate analyses were used to evaluate pre-, intra-, and post-op parameters associated with AKI. The AKICS scoring system was prospectively validated in a new data set of 215 pts with an incidence of AKI of 14%. Variables included in the AKICS score were age greater than 65, pre-op creatinine above 1.2 mg/dl, pre-op capillary glucose above 140 mg/dl, heart failure, combined surgeries, cardiopulmonary bypass time above 2 h, low cardiac output, and low central venous pressure. The AKICS score presented good calibration and discrimination in both the study group and validation data set. The AKICS system that we developed, which incorporates five risk categories, accurately predicts AKI following cardiac surgery.

A liberal erythrocyte transfusion strategy with a hemoglobin trigger of 9 g/dl was associated with fewer major postoperative complications in patients having major cancer surgery compared with a restrictive strategy.

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F or patients with solid tumors, surgery is often the main treatment, but the issue of the potential benefits and risks of red blood cell (RBC) transfusions during surgery remains. Although previous studies have indicated that a restrictive RBC transfusion strategy is as safe and effective as a liberal one, patients with cancer are not included in most such trials. This parallel-group, doubleblind, superiority, randomized controlled trial was undertaken to determine whether a restrictive strategy of RBC transfusion was superior to a liberal one for reducing mortality and severe clinical complications in patients having major oncologic surgery.At the time of intensive care unit (ICU) admission, patients were randomized in a 1:1 ratio to either a restrictive or liberal RBC transfusion strategy. Patients in the restrictive strategy group received 1 RBC unit each time their hemoglobin (Hgb) concentration decreased to less than 7 g/dL; for those in the liberal strategy group, 1 RBC unit was administered when the Hgb concentration decreased to less than 9 g/dL. No additional units were given when the goal Hgb concentration was reached, that is, 7 and 9 g/dL for the respective strategies. The primary outcome was a composite end point of death from all causes or severe clinical complications within 30 days after randomization. Severe clinical complications included major cardiovascular complications, septic shock, acute kidney injury (AKI) requiring renal replacement therapy, acute respiratory distress syndrome, and reoperation. Secondary outcomes were the 30-day incidence of infection, development of AKI, need and duration of mechanical ventilation, duration of vasopressor therapy, ICU readmission, ICU and hospital lengths of stay, and 60-day mortality. Statistical analyses were performed using SPSS version 18.0 (SPSS Inc, Chicago, Ill); 2-sided P < 0.05 indicated statistical significance.Of 1521 patients screened for eligibility, the final cohort included 97 in the liberal group and 101 in the restrictive group. The 2 study groups were balanced in baseline characteristics. Most patients had a good performance status, localized disease, and elective surgery for gastrointestinal cancer. The primary composite end point at 30 days occurred in 19 patients (19.6%) in the liberal group and in 36 patients (35.6%) in the restrictive group (P = 0.012). This is an absolute risk reduction for the liberal strategy of 16% (95% confidence interval, 3.8%-28.2%) and a number needed to treat of 6.2 (95% confidence interval, 3.5-26.5) to avoid the composite outcome. At the 30-day follow-up, 31 patients (15.7%) died, 8 in the liberal group (8.2%) compared with 23 (22.8%) in the restrictive group (P = 0.005). At 60 days, the respective mortality rates were 11.3% and 23.8% (11 and 24 patients, respectively; P = 0.022). At 30 days, fewer patients in the liberal group had major cardiovascular events and a lower incidence of intra-abdominal infection. No difference was seen in the incidence of septic shock, and no statistically significant dif...

Patients developing AKI after cardiac surgery presented high prevalence of long-term incident CKD. The duration of AKI was a strong independent risk factor for this late CKD development. Recognition of predictive factors for CKD development following cardiac surgery-associated AKI may help to develop strategies to prevent or halt CKD progression in this population.

A cumulative positive fluid balance higher than 1100 ml/24 h was independently associated with mortality in patients with cancer. These findings highlight the importance of improving the evaluation of these patients' volemic state and indicate that defined goals should be used to guide fluid therapy.

Objective To compare outcomes between elderly (≥65 years old) and non-elderly (<65 years old) resuscitated severe sepsis and septic shock patients and determine predictors of death among elderly patients.Methods Retrospective cohort study including 848 severe sepsis and septic shock patients admitted to the intensive care unit between January 2006 and March 2012.Results Elderly patients accounted for 62.6% (531/848) and non-elderly patients for 37.4% (317/848). Elderly patients had a higher APACHE II score [22 (18-28) versus 19 (15-24); p<0.001], compared to non-elderly patients, although the number of organ dysfunctions did not differ between the groups. No significant differences were found in 28-day and in-hospital mortality rates between elderly and non-elderly patients. The length of hospital stay was higher in elderly compared to non-elderly patients admitted with severe sepsis and septic shock [18 (10-41) versus 14 (8-29) days, respectively; p=0.0001]. Predictors of death among elderly patients included age, site of diagnosis, APACHE II score, need for mechanical ventilation and vasopressors.Conclusion In this study population early resuscitation of elderly patients was not associated with increased in-hospital mortality. Prospective studies addressing the long-term impact on functional status and quality of life are necessary.

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