Papers by Rinaldo Bellomo
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2015
Fluid bolus therapy (FBT) is common in critically ill patients. With the exception of use in pati... more Fluid bolus therapy (FBT) is common in critically ill patients. With the exception of use in patients with traumatic brain injury, FBT with human albumin solution (HAS) appears safe and perhaps superior in severe sepsis. To determine the physiological effects of FBT with 4% v 20% HAS. A retrospective observational study of 202 critically ill patients receiving FBT with HAS in a tertiary intensive care unit between April 2012 and March 2013. FBT was instituted with 4% or 20% HAS, according to clinician preference. We compared biochemical and haemodynamic data between groups at baseline and at 1, 2 and 4 hours after FBT. Patients who had received 20% HAS had more liver disease, a greater need for renal replacement therapy and higher Acute Physiology and Chronic Health Evaluation III scores on admission. Patients who had received 4% HAS received a median volume of 500 mL (interquartile range [IQR], 350-500mL), compared with 100mL (IQR, 100- 200mL) in the 20% HAS group (P < 0.0001); ...
Australasian emergency nursing journal : AENJ, Jan 9, 2015
Rapid Response Team (RRT) calls can often occur within 24h of hospital admission to a general war... more Rapid Response Team (RRT) calls can often occur within 24h of hospital admission to a general ward. We seek to determine whether it is possible to identify these patients before there is a significant clinical deterioration. Retrospective case-controlled study comparing patient characteristics, vital signs, and hospital outcomes in patients triggering RRT activation within 24h of ED admission (cases) with matched ED admissions not receiving a RRT call (controls). Over 12 months, there were 154 early RRT calls. Compared with controls, cases had a higher heart rate (HR) at triage (92 vs. 84beats/min; p=0.008); after 3h in the ED (91 vs. 80beats/min; p=0.0007); and at ED discharge (91 vs. 81beats/min; p=0.0005). Respiratory rate (RR) was also higher at triage (21.2 vs. 19.2breaths/min; p=0.001). On multiple variable analysis, RR at triage and HR before ward transfer predicted early RRT activation: OR 1.07 [95% CI 1.02-1.12] for each 1breath/min increase in RR; and 1.02 [95% CI 1.002-1....
Current opinion in critical care, 2000
Renal dysfunction is common in critically ill patients and its presence has, in the past, posed s... more Renal dysfunction is common in critically ill patients and its presence has, in the past, posed serious challenges to nutritional support. Such challenges were due to the increased azotemia induced by protein or amino acid administration, the fluid overload caused by the administration of nutrients, and the difficulties associated with the control of these complications by means of conventional dialytic techniques.The development and increasing application of continuous renal replacement therapy has removed such concerns, because control of azotemia and fluid balance can be predictably and reliably achieved in all patients. Accordingly, the presence of renal failure should in no way influence the amount or type of nutritional support administered to a critically ill patient. We recommend that approximately 30-35 kCal/kg/d be administered enterally and begun within the first few hours of admission to the intensive care unit, and that protein intake be kept in the 1.5-2 g/kg/d range.A...
Journal of Critical Care, 2015
Changes in mean perfusion pressure (MPP) from premorbid resting values may contribute to the prog... more Changes in mean perfusion pressure (MPP) from premorbid resting values may contribute to the progression of septic acute kidney injury (AKI). In patients with septic shock, we aimed to investigate the association of changes from premorbid values with AKI severity and progression. We obtained premorbid resting mean arterial pressure (MAP), central venous pressure (CVP), and MPP, and then recorded data from intensive care unit admission 2 hourly for the first 24 hours to calculate hemodynamic deficits. We recorded 4-hourly creatinine measurements for 96 hours. The association of hemodynamic variables with progression of AKI by Kidney Disease: Improving Global Outcomes ≥2 stages was explored by multivariate logistic regression. Of 107 patients, 55 (51.4%) had severe AKI. Median MAP deficit was similar for patients with or without severe AKI. Median MPP deficit was 29% in patients with severe AKI and 24% in those without (P = .04), a difference determined by greater CVP levels. Central venous pressure was independently associated with worsening AKI (odds ratio, 1.26 [95% confidence interval, 1.01-1.58]; P = .04). Mean arterial pressure and MPP deficits were substantial in septic shock patients, with patients with severe AKI having a greater MPP deficit. However, only CVP was independently associated with AKI progression. These findings suggest a possible role for venous congestion in septic AKI.
Nephrology (Carlton, Vic.), Jan 19, 2015
Whilst patients with chronic kidney disease have reduced health-related quality of life (HRQOL), ... more Whilst patients with chronic kidney disease have reduced health-related quality of life (HRQOL), long-term HRQOL of survivors of severe acute kidney injury (AKI) remains unclear. We analysed HRQOL from the Prolonged Outcomes Study of the Randomised Evaluation of Normal vs. Augmented Level Replacement Therapy (POST-RENAL) study and compared findings with those from a general Australian adult population enrolled in the Australian Diabetes, Obesity and Lifestyle (AusDiab) study. We used a multivariate analysis adjusted for baseline characteristics along with sensitivity analysis using age and sex- matched case controls. In the POST-RENAL study 282 participants had HRQOL data collected using the SF-12 questionnaire. This was compared with 6330 participants from the AusDiab study. Unadjusted analyses showed that POST-RENAL participants had lower physical component scores (PCS, mean score 40.0 vs. 49.8, P<0.0001) and lower mental component scores (MCS, mean score 49.8 vs. 53.9, P<0....
Trials, 2015
Cardiac arrest causes ischaemic brain injury. Arterial carbon dioxide tension (PaCO2) is a major ... more Cardiac arrest causes ischaemic brain injury. Arterial carbon dioxide tension (PaCO2) is a major determinant of cerebral blood flow. Thus, mild hypercapnia in the 24 h following cardiac arrest may increase cerebral blood flow and attenuate such injury. We describe the Carbon Control and Cardiac Arrest (CCC) trial. The CCC trial is a pilot multicentre feasibility, safety and biological efficacy randomized controlled trial recruiting adult cardiac arrest patients admitted to the intensive care unit after return of spontaneous circulation. At admission, using concealed allocation, participants are randomized to 24 h of either normocapnia (PaCO2 35 to 45 mmHg) or mild hypercapnia (PaCO2 50 to 55 mmHg). Key feasibility outcomes are recruitment rate and protocol compliance rate. The primary biological efficacy and biological safety measures are the between-groups difference in serum neuron-specific enolase and S100b protein levels at 24 h, 48 h and 72 h. Secondary outcome measure include ...
American journal of physiology. Regulatory, integrative and comparative physiology, Jan 11, 2015
The role of renal cortical and medullary hypoxia in the development of acute kidney injury is con... more The role of renal cortical and medullary hypoxia in the development of acute kidney injury is controversial, partly due to a lack of techniques for the long-term measurement of intra-renal oxygenation and perfusion in conscious animals. We have therefore developed methodology to chronically implant combination probes to chronically measure renal cortical and medullary tissue perfusion and oxygen tension (tPO2) in conscious sheep, and evaluated their responsiveness and reliability. A transit-time flow probe and a vascular occluder were surgically implanted on the left renal artery. At the same operation, dual fiber-optic probes, comprising a fluorescence optode to measure tPO2 and a laser-Doppler probe to assess tissue perfusion, were inserted into the renal cortex and medulla. In recovered conscious sheep (n=8) breathing room air, mean 24 h cortical and medullary tPO2 were similar (31.4±0.6 and 29.7±0.7 mmHg, respectively). In the renal cortex and medulla, a 20% reduction in renal b...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2015
The physiological changes associated with fluid bolus therapy (FBT) for patients with infection-a... more The physiological changes associated with fluid bolus therapy (FBT) for patients with infection-associated hypotension in the emergency department (ED) are poorly understood. We describe the physiological outcomes of FBT in the first 6 hours (primary FBT) for patients presenting to the ED with infection-associated hypotension. We studied 101 consecutive ED patients with infection and a systolic blood pressure (SBP)<100 mmHg who underwent FBT in the first 6 hours. We screened 1123 patients with infection and identified 101 eligible patients. The median primary FBT volume given was 1570 mL (interquartile range, 1000- 2490 mL). The average mean arterial pressure (MAP) did not change from admission to 6 hours in the whole cohort, or in patients who were hypotensive on arrival at the ED. However, the average MAP increased from its lowest value during the first 6 hours (66 mmHg [SD, 10 mmHg]) to its value at 6 hours (73 mmHg [SD, 12 mmHg]; P<0.001). The mean heart rate, body tempera...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2015
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2014
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 2014
To describe recent insights into glomerular haemodynamics in septic acute kidney injury (AKI). We... more To describe recent insights into glomerular haemodynamics in septic acute kidney injury (AKI). We reviewed the literature with particular emphasis on recent findings in animal experiments and human studies in relation to renal macro- and micro-renal haemodynamics during septic AKI. The dominant paradigm is that septic AKI is due to decreased renal perfusion with ischaemic loss of glomerular filtration rate (GFR), ischaemic tubular cell injury and acute tubular necrosis (ATN). However, recent experimental and human studies challenge this view of the pathogenesis of septic AKI. In addition, rapid post-mortem and experimental histological studies do not support ATN as the histological substrate of septic AKI. Finally, more recent experimental evidence suggests that changes in the glomerular and peri-glomerular haemodynamics provide a more likely explanation for the loss of GFR seen in the early phases of septic AKI. Despite a long-standing paradigm that septic AKI is due to renal hypo-...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2014
To identify risk factors for development of hypophosphataemia in patients treated with two differ... more To identify risk factors for development of hypophosphataemia in patients treated with two different intensities of continuous renal replacement therapy (CRRT) and to assess the independent association of hypophosphataemia with major clinical outcomes. We performed secondary analysis of data collected from 1441 patients during a large, multicentre randomised controlled trial of CRRT intensity. We allocated patients to two different intensities of CRRT (25mL/kg/hour vs 40 mL/kg/hour of effluent generation) and obtained daily measurement of serum phosphate levels. We obtained 14 115 phosphate measurements and identified 462 patients (32.1%) with hypophosphataemia, with peak incidence on Day 2 and Day 3. With lower intensity CRRT, there were 58 episodes of hypophosphataemia/1000 patient days, compared with 112 episodes/1000 patient days with higher intensity CRRT (P < 0.001). On multivariable logistic regression analysis, higher intensity CRRT, female sex, higher Acute Physiology an...
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia, 2002
Surgical treatment of tricuspid valve endocarditis (TVE) ranges from vegetectomy to valve replace... more Surgical treatment of tricuspid valve endocarditis (TVE) ranges from vegetectomy to valve replacement with the use of cardiopulmonary bypass (CPB), accompanied by risks of systemic and lung complications. We present our experience with tricuspid valve vegetectomy under inflow occlusion without CPB. Between July 1998 and July 2001, seven patients with a mean age of 26 years underwent tricuspid valve vegetectomy under vena caval inflow occlusion (VCIO). Five patients were intravenous drug users. None of them had left-sided heart valve involvement. The clinical indications for operating were recurrent septic pulmonary emboli with significant bilateral lung infiltrates and intractable infection with signs of severe systemic sepsis, despite treatment with appropriate intravenous antibiotics for a mean duration of 126 hours. The echocardiographic indication was very large localized >1 cm vegetations in all patients. Six patients had methicillin sensitive staphylococcus aureus and one h...
Contributions to nephrology, 2002
Critical care medicine, 2014
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 2015
The obective of this study was to perform a cost-effectiveness analysis comparing intermittent wi... more The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU). Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRR...
Advances in renal replacement therapy, 2002
A large number of patients develop acute renal failure in the intensive care unit and nephrology ... more A large number of patients develop acute renal failure in the intensive care unit and nephrology wards, and mortality remains high. In recent years, there have been considerable advances in our understanding and technical capabilities, but consensus over the optimal way to diagnose and treat acute renal failure does not exist. Consequently, a consensus conference under the auspices of the Acute Dialysis Quality Initiative (ADQI) has been held in Vicenza in the year 2002 after the previous conference held in New York in the year 2000. The ADQI aims at establishing an evidence-based appraisal and set of consensus recommendations to standardize care and direct further research. The first of these conferences held in June 2000 in New York focused on continuous renal replacement therapy (CRRT). The reports from this first consensus conference are now available online at www.ADQI.net and are also published in part in this issue. However, there remains a need for consensus in several other...
The Journal of Thoracic and Cardiovascular Surgery, 2015
To assess whether introduction of universal leukodepletion (ULD) of red blood cells (RBCs) for tr... more To assess whether introduction of universal leukodepletion (ULD) of red blood cells (RBCs) for transfusion was associated with improvements in cardiac surgery patient outcomes. Retrospective study (2005-2010) conducted at 6 institutions. Associations between leukodepletion and outcomes of mortality, infection, and acute kidney injury (AKI) were modeled by logistic regression, and intensive care unit length of stay (LOS) in survivors was explored using linear regression. To examine trends over time, odds ratios (ORs) for outcomes of transfused were compared with nontransfused patients, including a comparison with nontransfused patients who were selected based on propensity score for RBC transfusion. We studied 14,980 patients, of whom 8857 (59%) had surgery pre-ULD. Transfusions of RBCs were made in 3799 (43%) pre-ULD, and 2525 (41%) post-ULD. Administration of exclusively leukodepleted, versus exclusively nonleukodepleted, RBCs was associated with lower incidence of AKI (adjusted OR 0.80, 95% confidence interval [CI] 0.65-0.98, P = .035), but no difference in mortality or infection. For post-ULD patients, no difference was found in mortality (OR 0.96, 95% CI 0.76-1.22, P = .76) or infection (OR 0.91, 95% CI 0.79-1.03, P = .161); however, AKI was reduced (OR 0.79 95% CI 0.68-0.92, P = .003). However, ORs for post-ULD outcomes were not significantly different in nontransfused, versus transfused, patients. Furthermore, those who received exclusively nonleukodepleted RBCs were more likely to have surgery post-ULD. Universal leukodepletion was not associated with reduced mortality or infection in transfused cardiac surgery patients. An association was found between ULD and reduced AKI; however, this reduction was not significantly different from that seen in nontransfused patients, and other changes in care most likely explain such changes in renal outcomes.
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Papers by Rinaldo Bellomo