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Kawati, Rafael
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Publications (10 of 18) Show all publications
Jung, C., Wernly, B., Muessig, J. M., Kelm, M., Boumendil, A., Morandi, A., . . . Nalapko, Y. (2019). A comparison of very old patients admitted to intensive care unit after acute versus elective surgery or intervention. Journal of critical care, 52, 141-148
Open this publication in new window or tab >>A comparison of very old patients admitted to intensive care unit after acute versus elective surgery or intervention
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2019 (English)In: Journal of critical care, ISSN 0883-9441, E-ISSN 1557-8615, Vol. 52, p. 141-148Article in journal (Refereed) Published
Abstract [en]

Background: We aimed to evaluate differences in outcome between patients admitted to intensive care unit (ICU) after elective versus acute surgery in a multinational cohort of very old patients (80 years; VIP). Predictors of mortality, with special emphasis on frailty, were assessed.

Methods: In total, 5063 VIPs were induded in this analysis, 922 were admitted after elective surgery or intervention, 4141 acutely, with 402 after acute surgery. Differences were calculated using Mann-Whitney-U test and Wilcoxon test. Univariate and multivariable logistic regression were used to assess associations with mortality.

Results: Compared patients admitted after acute surgery, patients admitted after elective surgery suffered less often from frailty as defined as CFS (28% vs 46%; p < 0.001), evidenced lower SOFA scores (4 +/- 5 vs 7 +/- 7; p < 0.001). Presence of frailty (CFS >4) was associated with significantly increased mortality both in elective surgery patients (7% vs 12%; p = 0.01), in acute surgery (7% vs 12%; p = 0.02).

Conclusions: VIPs admitted to ICU after elective surgery evidenced favorable outcome over patients after acute surgery even after correction for relevant confounders. Frailty might be used to guide clinicians in risk stratification in both patients admitted after elective and acute surgery. 

Place, publisher, year, edition, pages
W B SAUNDERS CO-ELSEVIER INC, 2019
Keywords
Critically ill, Frailty, Elective, Outcome, Older, Old
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-390079 (URN)10.1016/j.jcrc.2019.04.020 (DOI)000471240500022 ()31055187 (PubMedID)
Available from: 2019-08-06 Created: 2019-08-06 Last updated: 2019-08-06Bibliographically approved
Schumann, S., Vimlati, L., Kawati, R., Guttmann, J. & Lichtwarck-Aschoff, M. (2018). Cardiogenic oscillations to detect intratidal derecruitment and overdistension in a porcine model of healthy and atelectatic lungs. British Journal of Anaesthesia, 121(4), 928-935
Open this publication in new window or tab >>Cardiogenic oscillations to detect intratidal derecruitment and overdistension in a porcine model of healthy and atelectatic lungs
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2018 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 121, no 4, p. 928-935Article in journal (Refereed) Published
Abstract [en]

Background: Low positive end-expiratory pressure (PEEP) can result in alveolar derecruitment, and high PEEP or high tidal volume (V-T) in lung overdistension. We investigated cardiogenic oscillations (COS) in the airway pressure signal to investigate whether these oscillations can assess unfavourable intratidal events. COS induce short instantaneous compliance increases within the pressure-volume curve, and consequently in the compliance-volume curve. We hypothesised that increases in COS-induced compliance reflect non-linear intratidal respiratory system mechanics. Methods: In mechanically ventilated anaesthetised pigs with healthy (n = 13) or atelectatic (n = 12) lungs, pressure-volume relationships and the ECG were acquired at a PEEP of 0, 5, 10, and 15 cm H2O. During inspiration, the peak compliance of successive COS (C-COS) was compared with intratidal respiratory system compliance (C-RS) within incremental volume steps up to the full V-T of 12 ml kg(-1). We analysed whether C-COS variation corresponded with systolic arterial pressure variation. Results: C-COS-volume curves showed characteristic intratidal patterns depending on the PEEP level and on atelectasis. Increasing C-RS- or C-COS-volume patterns were associated with intratidal derecruitment with low PEEP, and decreasing patterns above 6 ml kg(-1) and high PEEP showed overdistension. C-COS was not associated with systolic arterial pressure variations. Conclusions: Heartbeat-induced oscillations within the course of the inspiratory pressure-volume curve reflect nonlinear intratidal respiratory system mechanics. The analysis of these cardiogenic oscillations can be used to detect intratidal derecruitment and overdistension and, hence, to guide PEEP and V-T settings that are optimal for respiratory system mechanics.

Keywords
blood pressure, lung compliance, mechanical ventilation, positive end-expiratory pressure, respiratory mechanics, ventilators
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-368990 (URN)10.1016/j.bja.2018.02.068 (DOI)000447401000029 ()30236255 (PubMedID)
Available from: 2018-12-14 Created: 2018-12-14 Last updated: 2018-12-14Bibliographically approved
Horst, S., Kawati, R., Rasmusson, J., Pikwer, A., Castegren, M. & Lipcsey, M. (2018). Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit. Acta Anaesthesiologica Scandinavica, 62(9), 1261-1266
Open this publication in new window or tab >>Impact of resuscitation fluid bag size availability on volume of fluid administration in the intensive care unit
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2018 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 62, no 9, p. 1261-1266Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Iatrogenic fluid overload is associated with increased mortality in the intensive care unit (ICU). Decisions on fluid therapy may, at times, be based on other factors than physiological endpoints. We hypothesized that because of psychological factors volume of available fluid bags would affect the amount of resuscitation fluid administered to ICU patients.

METHODS: We performed a prospective intervention cross-over study at 3 Swedish ICUs by replacing the standard resuscitation fluid bag of Ringer's Acetate 1000 mL with 500 mL bags (intervention group) for 5 separate months and then compared it with the standard bag size for 5 months (control group). Primary endpoint was the amount of Ringer's Acetate per patient during ICU stay. Secondary endpoints were differences between the groups in cumulative fluid balance and change in body weight, hemoglobin and creatinine levels, urine output, acute kidney failure (measured as the need for renal replacement therapy, RRT) and 90-day mortality.

RESULTS: Six hundred and thirty-five ICU patients were included (291 in the intervention group, 344 in the control group). There was no difference in the amount of resuscitation fluid per patient during the ICU stay (2200 mL [1000-4500 median IQR] vs 2245 mL [1000-5630 median IQR]), RRT rate (11 vs 9%), 90-day mortality (11 vs 10%) or total fluid balance between the groups. The daily amount of Ringer's acetate administered per day was lower in the intervention group (1040 (280-2000) vs 1520 (460-3000) mL; P = .03).

CONCLUSIONS: The amount of resuscitation fluid administered to ICU patients was not affected by the size of the available fluid bags. However, altering fluid bag size could have influenced fluid prescription behavior.

Keywords
adverse effects, critical care, crystalloid solutions, fluid therapy, psychological factors
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-362676 (URN)10.1111/aas.13161 (DOI)000443673500011 ()29851027 (PubMedID)
Available from: 2018-10-08 Created: 2018-10-08 Last updated: 2018-11-06Bibliographically approved
Höstman, S., Kawati, R., Perchiazzi, G. & Larsson, A. (2018). THAM administration reduces pulmonary carbon dioxide elimination in hypercapnia: an experimental porcine study. Acta Anaesthesiologica Scandinavica, 62(6), 820-828
Open this publication in new window or tab >>THAM administration reduces pulmonary carbon dioxide elimination in hypercapnia: an experimental porcine study
2018 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 62, no 6, p. 820-828Article in journal (Refereed) Published
Abstract [en]

Background: In a previous study, we found a rebound of arterial carbon dioxide tension (PaCO2) after stopping THAM buffer administration. We hypothesized that this was due to reduced pulmonary CO2 elimination during THAM administration. The aim of this study was to investigate this hypothesis in an experimental porcine hypercapnic model.

Methods: In seven, initially normoventilated, anesthetized pigs (22-27 kg) minute ventilation was reduced by 66% for 7 h. Two hours after commencing hypoventilation, THAM was infused IV for 3 h in a dose targeting a pH of 7.35 followed by a 2 h observation period. Acid-base status, blood-gas content and exhaled CO2 were measured.

Results: THAM raised pH (7.07 0.04 to 7.41 +/- 0.04, P < 0.05) and lowered PaCO2 (15.2 +/- 1.4 to 12.2 +/- 1.1 kPa, P < 0.05). After the infusion, pH decreased and PaCO2 increased again. At the end of the observation period, pH and PaCO2 were 7.24 +/- 0.03 and 16.6 +/- 1.2 kPa, respectively (P < 0.05). Pulmonary CO2 excretion decreased from 109 +/- 12 to 74 +/- 12 ml/min (P < 0.05) during the THAM infusion but returned at the end of the observation period to 111 +/- 15 ml/min (P < 0.05). The estimated reduction of pulmonary CO2 elimination during the infusion was 5800 ml.

Conclusions: In this respiratory acidosis model, THAM reduced PaCO2, but seemed not to increase the total CO2 elimination due to decreased pulmonary CO2 excretion(,) suggesting only cautious use of THAM in hypercapnic acidosis.

National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-358364 (URN)10.1111/aas.13097 (DOI)000434205100012 ()29532468 (PubMedID)
Funder
Swedish Research CouncilSwedish Heart Lung Foundation
Available from: 2018-08-31 Created: 2018-08-31 Last updated: 2018-08-31Bibliographically approved
Gavali, H., Mani, K., Tegler, G., Kawati, R., Covaciu, L. & Wanhainen, A. (2017). Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome. European Journal of Vascular and Endovascular Surgery, 54(2), 157-163
Open this publication in new window or tab >>Editor's Choice - Prolonged ICU Length of Stay after AAA Repair: Analysis of Time Trends and Long-term Outcome
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2017 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 2, p. 157-163Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of the study was to investigate the frequency and outcome of prolonged intensive care unit (ICU) length of stay (LOS) after abdominal aortic aneurysm (AAA) repair in the endovascular era.

Methods: All patients operated on for AAA between 1999 and 2013 at Uppsala University hospital were identified. Data were retrieved from the Swedish Vascular registry, the Swedish Intensive Care registry, the National Population registry, and case records. Prolonged ICU LOS was defined as >= 48 h during the primary hospital stay. Patients surviving >= 48 h after AAA surgery were included in the analysis.

Results: A total of 725 patients were identified, of whom 707 (97.5%) survived >= 48 h; 563 (79.6%) underwent intact AAA repair and 144 (20.4%) ruptured AAA repair. A total of 548 patients (77.5%) required < 48 h of intensive care, 115 (16.3%) 2-6 days and 44 (6.2%) >= 7 days. The rate of prolonged ICU LOS declined considerably over time, from 41.4% of all AAA repairs in 1999 to 7.3% in 2013 (p < .001) whereas the use of endovascular aortic repair (EVAR) increased from 6.9% in 1999 to 78.0% in 2013 (p < .001). The 30 day survival rate was 98.2% for those with < 48 h ICU stay versus 93.0% for 2-6 days versus 81.8% for >= 7 days (p < .001); the corresponding 90 day survival was 97.1% versus 86.1% versus 63.6% (p < .001) respectively. For patients surviving 90 days after repair, there was no difference in long-term survival between the groups.

Conclusion: During the period of progressively increasing use of EVAR, a simultaneous significant reduction in frequency of prolonged ICU LOS occurred. Although prolonged ICU LOS was associated with a high short-term mortality, long-term outcome among those surviving the initial 90 days was less affected.

Keywords
Abdominal aortic aneurysm, Critical care, Length of stay, Outcome, Time trends
National Category
Surgery Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-334093 (URN)10.1016/j.ejvs.2017.05.014 (DOI)000407536300005 ()28648757 (PubMedID)
Available from: 2017-11-21 Created: 2017-11-21 Last updated: 2017-11-21Bibliographically approved
Perchiazzi, G., Höstman, S., Kawati, R. & Larsson, A. (2017). Tham Administration Reduces Pulmonary Carbon Dioxide Elimination, Causing Rebound In Arterial Carbon Dioxide Tension: An Experimental Study In Hypoventilated Pigs. Paper presented at International Conference of the American-Thoracic-Society (ATS), MAY 19-24, 2017, Washington, AFGHANISTAN. American Journal of Respiratory and Critical Care Medicine, 195, Article ID A7518.
Open this publication in new window or tab >>Tham Administration Reduces Pulmonary Carbon Dioxide Elimination, Causing Rebound In Arterial Carbon Dioxide Tension: An Experimental Study In Hypoventilated Pigs
2017 (English)In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 195, article id A7518Article in journal, Meeting abstract (Other academic) Published
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:uu:diva-332910 (URN)000400372507620 ()
Conference
International Conference of the American-Thoracic-Society (ATS), MAY 19-24, 2017, Washington, AFGHANISTAN
Funder
Swedish Research Council, K2015-99X-22731-01-4Swedish Heart Lung Foundation
Available from: 2017-11-06 Created: 2017-11-06 Last updated: 2017-11-06Bibliographically approved
Lipcsey, M., Tenhunen, J., Sjölin, J., Frithiof, R., Bendel, S., Flaatten, H., . . . Rubertsson, S. (2016). Abdominal Septic Shock - Endotoxin Adsorption Treatment (ASSET) - endotoxin removal in abdominal and urogenital septic shock with the Alteco (R) LPS Adsorber: study protocol for a double-blinded, randomized placebo-controlled trial. Trials, 17, Article ID 587.
Open this publication in new window or tab >>Abdominal Septic Shock - Endotoxin Adsorption Treatment (ASSET) - endotoxin removal in abdominal and urogenital septic shock with the Alteco (R) LPS Adsorber: study protocol for a double-blinded, randomized placebo-controlled trial
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2016 (English)In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 17, article id 587Article in journal (Refereed) Published
Abstract [en]

Background: Severe sepsis and septic shock are common in intensive care and carry high mortality rates. In patients with Gram-negative infections, early and extensive removal of endotoxin may limit the inflammatory response that characterizes septic shock. The Alteco (R) LPS Adsorber (hereafter referred to cited as the lipopolysaccharide (LPS) Adsorber) can be used for endotoxin removal and attenuate the deleterious inflammatory and clinical responses seen in septic shock. Methods/design: The Abdominal Septic Shock - Endotoxin Adsorption Treatment (ASSET) trial is a pilot study investigating the feasibility and safety of LPS Adsorber therapy. This pilot, multicenter, stratified, parallel, double-blinded, randomized, phase IIa, feasibility clinical investigation will be performed in five Scandinavian intensive care units. Thirty-two subjects with early septic shock and organ failure, following adequate resuscitation, will be randomized to receive either: extracorporeal veno-venous hemoperfusion therapy with the LPS Adsorber or veno-venous hemoperfusion therapy with a placebo adsorber (without active LPS-binding peptide). Patients will be stratified by infection focus such that 20 subjects with an abdominal focus (stratum A) and 12 subjects with a urogenital focus (stratum B) will be included in a parallel design. Thereafter, an interim analysis will be performed and an additional 12 patients may be included in the study. The study is designed as adaptive a priori: the patients from this study can be included in a later phase IIb study. The aim of the study is to investigate the feasibility of LPS Adsorber therapy commenced early in the time-course of septic shock. The primary endpoint will be a characterization of all reported unanticipated serious adverse device effects and anticipated serious adverse device effects. Secondary outcomes are decrease in endotoxin plasma concentration, impact on clinical outcome measures and impact on inflammatory response by LPS Adsorber therapy, as well as detailed description of the relevant mediators bound to the LPS Adsorber. Recruitment of patients will start in September 2015. Discussion: The ASSET trial will give insight into the feasibility and safety of this LPS Adsorber therapy and preliminary data on its potential clinical effects in septic shock. Moreover, this pilot trial will provide with necessary data for designing future studies.

Keywords
Septic shock, Endotoxins, Hemoperfusion, Gram-negative bacteria
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-313532 (URN)10.1186/s13063-016-1723-4 (DOI)000390388800006 ()
Funder
Swedish Research Council, 523-2014-2569
Available from: 2017-02-01 Created: 2017-01-20 Last updated: 2017-11-29Bibliographically approved
Kawati, R. & Larsson, A. (2013). Brain death due to fat embolism - could moderate hypercapnia and prone position be blamed for the tonsillar herniation?. Upsala Journal of Medical Sciences, 118(4), 276-278
Open this publication in new window or tab >>Brain death due to fat embolism - could moderate hypercapnia and prone position be blamed for the tonsillar herniation?
2013 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 118, no 4, p. 276-278Article in journal (Refereed) Published
Abstract [en]

Fat embolism to the systemic circulation in polytrauma patients is very common. The fat embolism syndrome (FES), however, is a rare condition. We describe a case of traumatic femur fracture with FES that was presented as acute tonsillar herniation (coning) and brain death postoperatively. We believe that in this case the prone position and moderate hypercapnia contributed to the acute coning.

Keywords
Fat embolism, hypercapnia, prone position, trauma
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-210568 (URN)10.3109/03009734.2013.818600 (DOI)000325527300011 ()
Available from: 2013-11-13 Created: 2013-11-11 Last updated: 2017-12-06Bibliographically approved
Schumann, S., Vimlati, L., Kawati, R., Guttmann, J. & Lichtwarck-Aschoff, M. (2011). Analysis of Dynamic Intratidal Compliance in a Lung Collapse Model. Anesthesiology, 114(5), 1111-1117
Open this publication in new window or tab >>Analysis of Dynamic Intratidal Compliance in a Lung Collapse Model
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2011 (English)In: Anesthesiology, ISSN 0003-3022, E-ISSN 1528-1175, Vol. 114, no 5, p. 1111-1117Article in journal (Refereed) Published
Abstract [en]

Background: For mechanical ventilation to be lung-protective, an accepted suggestion is to place the tidal volume (V-T) between the lower and upper inflection point of the airway pressure-volume relation. The drawback of this approach is, however, that the pressure-volume relation is assessed under quasistatic, no-flow conditions, which the lungs never experience during ventilation. Intratidal nonlinearity must be assessed under real (i.e., dynamic) conditions. With the dynamic gliding-SLICE technique that generates a high-resolution description of intratidal mechanics, the current study analyzed the profile of the compliance of the respiratory system (C-RS).

Methods: In 12 anesthetized piglets with lung collapse, the pressure-volume relation was acquired at different levels of positive end-expiratory pressure (PEEP: 0, 5, 10, and 15 cm H2O). Lung collapse was assessed by computed tomography and the intratidal course of C-RS using the gliding-SLICE method.

Results: Depending on PEEP, C-RS showed characteristic profiles. With low PEEP, C-RS increased up to 20% above the compliance at early inspiration, suggesting intratidal recruitment; whereas a profile of decreasing C-RS, signaling overdistension, occurred with V-T > 5 ml/kg and high PEEP levels. At the highest volume range, C-RS was up to 60% less than the maximum. With PEEP 10 cm H2O, C-RS was high and did not decrease before 5 ml/kg V-T was delivered.

Conclusions: The profile of dynamic C-RS reflects nonlinear intratidal mechanics of the respiratory system. The SLICE analysis has the potential to detect intratidal recruitment and overdistension. This might help in finding a combination of PEEP and V-T level that is protective from a lung-mechanics perspective.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-153651 (URN)10.1097/ALN.0b013e31820ad41b (DOI)000289980200015 ()21336098 (PubMedID)
Available from: 2011-05-17 Created: 2011-05-17 Last updated: 2017-12-11Bibliographically approved
Vimlati, L., Kawati, R., Hedenstierna, G., Larsson, A. & Lichtwarck-Aschoff, M. (2011). Spontaneous Breathing Improves Shunt Fraction and Oxygenation in Comparison with Controlled Ventilation at a Similar Amount of Lung Collapse. Anesthesia and Analgesia, 113(5), 1089-1095
Open this publication in new window or tab >>Spontaneous Breathing Improves Shunt Fraction and Oxygenation in Comparison with Controlled Ventilation at a Similar Amount of Lung Collapse
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2011 (English)In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 113, no 5, p. 1089-1095Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Spontaneous breathing (SB), when allowed during mechanical ventilation (MV), improves oxygenation in different models of acute lung injury. However, it is not known whether oxygenation is improved during mechanically unsupported SB. Therefore, we compared SB without any support with controlled MV at identical tidal volume (V(T)) and respiratory rate (RR) without positive end-expiratory pressure in a porcine lung collapse model.

METHODS: In 25 anesthetized piglets, stable lung collapse was induced by application of negative pressure, and animals were randomized to either resume SB or to be kept on MV at identical VT (5 mL/kg; 95% confidence interval: 3.8 to 6.4) and RR (65 per minute [57 to 73]) as had been measured during an initial SB period. Oxygenation was assessed by blood gas analysis (n = 15) completed by multiple inert gas elimination technique (n = 8 of the 15) for shunt measurement. In addition, possible lung recruitment was studied with computed tomography of the chest (n = 10).

RESULTS: After induction of lung collapse, PaO(2)/FIO(2) decreased to 90 mm Hg (76 to 103). With SB, PaO(2)/FIO(2) increased to 235 mm Hg (177 to 293) within 15 minutes, whereas MV at identical VT and RR did not cause any improvement in oxygenation. Intrapulmonary shunt by 45 minutes after induction of lung collapse was lower during SB (SB: 27% [24 to 30] versus MV: 41% [28 to 55]; P = 0.017). Neither SB nor MV reduced collapsed lung areas on computed tomography.

CONCLUSIONS: SB without any support improves oxygenation and reduces shunt in comparison with MV at identical settings. This seems to be achieved without any major signs of recruitment of collapsed lung regions.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-161927 (URN)10.1213/ANE.0b013e31822ceef8 (DOI)000296236200025 ()
Available from: 2011-11-23 Created: 2011-11-21 Last updated: 2017-12-08Bibliographically approved
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