Andrew Ferguson | Belfast Health and Social Care Trust (original) (raw)
Papers by Andrew Ferguson
Seminars in Dialysis, 2011
Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems wo... more Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems worldwide. The prevalence of end-stage renal disease (ESRD) has increased by 20% since 2000 and stands at 1699 per million people
Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2012
Purpose Obesity is widespread, yet it is often understood primarily as a disorder of body structu... more Purpose Obesity is widespread, yet it is often understood primarily as a disorder of body structure. This article provides anesthesiologists with a synopsis of recent research into the complex pathophysiology of obesity. It emphasizes the importance of this information for the perioperative planning and management of this patient group and for reviewing some of the major perioperative challenges. Principal findings Obesity is a multisystem chronic proinflammatory disorder associated with increased morbidity and mortality. Adipocytes are far more than storage vessels for lipids. They secrete a large number of physiologically active substances called adipokines that lead to inflammation, vascular and cardiac remodelling, airway inflammation, and altered microvascular flow patterns. They contribute to linked abnormalities, such as insulin resistance and the metabolic syndrome, and they attract and activate inflammatory cells such as macrophages. Author contributions Aiden Cullen and Andrew Ferguson were responsible for the conception and design of the manuscript. They contributed to the literature search and screening of the resulting papers, and they both contributed to the original draft. Andrew Ferguson further revised the article critically for important intellectual content.
Critical care medicine, Oct 5, 2018
To characterize current practice in fluid administration and deresuscitation (removal of fluid us... more To characterize current practice in fluid administration and deresuscitation (removal of fluid using diuretics or renal replacement therapy), the relationship between fluid balance, deresuscitative measures, and outcomes and to identify risk factors for positive fluid balance in critical illness. Retrospective cohort study. Ten ICUs in the United Kingdom and Canada. Adults receiving invasive mechanical ventilation for a minimum of 24 hours. None. Four-hundred patients were included. Positive cumulative fluid balance (fluid input greater than output) occurred in 87.3%: the largest contributions to fluid input were from medications and maintenance fluids rather than resuscitative IV fluids. In a multivariate logistic regression model, fluid balance on day 3 was an independent risk factor for 30-day mortality (odds ratio 1.26/L [95% CI, 1.07-1.46]), whereas negative fluid balance achieved in the context of deresuscitative measures was associated with lower mortality. Independent predic...
Arici M (Editor). Managing chronic kidney disease: a clinician’s guide. 2014 (in press).
Faber P, Siervo M (Editors) Nutrition in Critical Care, 2014: 53-66
Can J Anaesth 2012; 59: 974-96, Jul 2012
""""Purpose Obesity is widespread, yet it is often understood primarily as a disorder of body ... more """"Purpose
Obesity is widespread, yet it is often understood primarily as a disorder of body structure. This article provides anesthesiologists with a synopsis of recent research into the complex pathophysiology of obesity. It emphasizes the importance of this information for the perioperative planning and management of this patient group and for reviewing some of the major perioperative challenges.
Principal findings
Obesity is a multisystem chronic pro-inflammatory disorder associated with increased morbidity and mortality. Adipocytes are far more than storage vessels for lipids. They secrete a large number of physiologically active substances called adipokines that lead to inflammation, vascular and cardiac remodelling, airway inflammation, and altered microvascular flow patterns. They contribute to linked abnormalities, such as insulin resistance and the metabolic syndrome, and they attract and activate inflammatory cells such as macrophages. These changes can lead ultimately to organ dysfunction, especially cardiovascular and pulmonary issues. In the respiratory system, anesthesiologists should be familiar not just with screening tools for obstructive sleep apnea but also with obesity hypoventilation syndrome, which is less well appreciated and carries a significant outcome disadvantage. Perioperative management is challenging. It is centred around cardiorespiratory and metabolic optimization, minimizing adverse effects of both pain and systemic opioids, effective use of regional anesthesia, and an emphasis on mobilization and nutrition − given the prevalence of micronutrient deficiencies in the severely obese. There is a risk of incorrect drug dosing in obesity, which requires an understanding of the appropriate dosing weights for perioperative medications.
Conclusion
The literature clearly highlights the complexity of severe obesity as a multisystem disease, and anesthesiologists caring for these patients perioperatively must have a sound understanding of the changes in order to offer the highest quality care to these patients.""""
Anesthesia & Analgesia, Jan 1, 2011
Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems wo... more Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems worldwide. The prevalence of end-stage renal disease (ESRD) has increased by 20% since 2000 and stands at 1699 per million people in the USA. ESRD is associated with an increased risk of cardiovascular comorbidity, increased severity of cardiovascular disease, and an adjusted all-cause mortality rate that is 6.4–7.8-fold higher than the general population. These patients may present electively or emergently for surgery related to, or remote from, the CKD. In any perioperative setting, the patient with hemodialysis-dependent CKD represents a significant clinical challenge, and successful management of these patients requires effective cooperation and communication between nephrology, anesthesia, and surgical staff. The ESRD patient’s nephrologist will have the best knowledge of their medical history, comorbidities, and future management goals and may have been the clinician who instigated the referral for the surgery, e.g., for parathyroidectomy, vascular access surgery, nephrectomy or renal transplantation. As such, they are in an ideal position to contribute to, or coordinate, early preoperative medical optimization of the patient and also to provide advice during postoperative recovery and rehabilitation. In this article, we provide an overview of some of the key aspects of managing these patients successfully during the perioperative period. We propose the integration of cardiopulmonary exercise testing and cardiovascular optimization into the care of these high-risk patients and provide an overview of the importance of maintaining microvascular perfusion and the role of viscosity in preserving the capillary perfusion network.
Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in ... more Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in which bacterial toxins act as superantigens, activating very large numbers of T cells and generating an overwhelming immune-mediated cytokine avalanche that manifests clinically as fever, rash, shock, and rapidly progressive multiple organ failure, often in young, previously healthy patients. The syndrome can occur with any site of S. aureus infection, and so clinicians of all medical specialties should have a firm grasp of the presentation and management. In this article, we review the literature on the pathophysiology, clinical features, and treatment of this serious condition with emphasis on recent insights into pathophysiology and on information of relevance to the practicing clinician.
Toxic shock syndrome (TSS) is an acute, multi-system, toxin-mediated illness, often resulting in ... more Toxic shock syndrome (TSS) is an acute, multi-system, toxin-mediated illness, often resulting in multi-organ failure. It represents the most fulminant expression of a spectrum of diseases caused by toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes (group A streptococcus). The importance of Gram-positive organisms as pathogens is increasing, and TSS is likely to be underdiagnosed in patients with staphylococcal or group A streptococcal infection who present with shock. TSS results from the ability of bacterial toxins to act as superantigens, stimulating immune-cell expansion and rampant cytokine expression in a manner that bypasses normal MHC-restricted antigen processing. A repetitive cycle of cell stimulation and cytokine release results in a cytokine avalanche that causes tissue damage, disseminated intravascular coagulation, and organ dysfunction. Specific therapy focuses on early identification of the illness, source control, and administration on antimicrobial agents including drugs capable of suppressing toxin production (eg, clindamycin, linezolid). Intravenous immunoglobulin has the potential to neutralise superantigen and to mitigate subsequent tissue damage.
Published 5 July 2010, doi:10.1136/bmj.c3365 Cite this as: BMJ 2010;341:c3365 Clinical Review P... more Published 5 July 2010, doi:10.1136/bmj.c3365
Cite this as: BMJ 2010;341:c3365
Clinical Review
Perioperative acute kidney injury: risk factors, recognition, management, and outcomes
Emma Borthwick, specialist registrar1, Andrew Ferguson, consultant in intensive care medicine and anaesthesia2
1 Nephrology and Intensive Care Medicine, Belfast City Hospital, Belfast BT12 7BA, 2 Craigavon Area Hospital, Portadown BT63 5QQ
Correspondence to: A Ferguson fergua@yahoo.ca
doi:10.1136/bmj.b2370
Summary points
Perioperative acute kidney injury (AKI) is common but poorly recognised and managed
Perioperative AKI increases surgical mortality and morbidity and increases cost
An apparently successful surgical outcome may not mean a successful renal outcome
Careful and thoughtful preoperative assessment, including identifying patients with existing chronic kidney disease and stopping and avoiding nephrotoxic drugs, will reduce the incidence of perioperative AKI.
Management of AKI centres on optimising fluid status and blood pressure, treating sepsis, and removing nephrotoxic agents where possible
Patients with AKI are often complex to treat, and senior help should be sought at an early stage
Acute kidney injury (AKI), formerly known as "acute renal failure," is associated with increased morbidity, mortality, duration of hospital stay, and healthcare cost.w1 Despite this, published data on perioperative acute kidney injury, occurring between the time of admission for surgery and the time of discharge, are scarce outside the cardiovascular surgery setting. Regardless of the clinical setting, the diagnosis of AKI is often delayed, and treatment is suboptimal in a large proportion of cases.1 To improve diagnosis and treatment, clinicians need to understand the risks and triggers for perioperative AKI, the association of even small transient rises in creatinine concentration with risk of death,2 and what actions they need to take promptly on diagnosis. The term acute kidney injury reflects the importance of thinking of the condition as a spectrum or continuum of disease that may be recognised at an early stage, rather than as an "all or nothing" phenomenon as implied by the term acute renal failure. Recognising earlier stages of renal impairment allows for early appropriate action that may interrupt a process of functional decline.
In this article we recommend the introduction of systems to ensure that changes in creatinine concentration from baseline are urgently highlighted to the clinical team. We outline the risk factors for perioperative AKI and discuss how to recognise the condition, manage it, and improve outcomes, focusing on the non-specialist surgery setting and using evidence from randomised trials, retrospective studies, meta-analyses, and expert reviews, as well as the recommendations of recent guidelines.
Talks by Andrew Ferguson
Dr Andrew Ferguson 56 year old male with cardiogenic shock after AMI 42 year old female with hypo... more Dr Andrew Ferguson 56 year old male with cardiogenic shock after AMI 42 year old female with hypotension after amlodipine OD 82 year old nil orally with postoperative hypertension 66 year old male with aortic dissection 78 year old male with septic shock 45 year old female after subarachnoid haemorrhage agonists Na + /K + -ATPase antagonists PDE inhibitors Calcium sensitisers Ca 2+
Sepsis is the major killer in the general ICU. Sepsis is a common cause of hospital admission. Di... more Sepsis is the major killer in the general ICU. Sepsis is a common cause of hospital admission. Diagnosis is often delayed and common laboratory tests are non-specific. Biomarker panels offer the potential for more rapid diagnosis and for better risk stratification.
Seminars in Dialysis, 2011
Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems wo... more Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems worldwide. The prevalence of end-stage renal disease (ESRD) has increased by 20% since 2000 and stands at 1699 per million people
Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 2012
Purpose Obesity is widespread, yet it is often understood primarily as a disorder of body structu... more Purpose Obesity is widespread, yet it is often understood primarily as a disorder of body structure. This article provides anesthesiologists with a synopsis of recent research into the complex pathophysiology of obesity. It emphasizes the importance of this information for the perioperative planning and management of this patient group and for reviewing some of the major perioperative challenges. Principal findings Obesity is a multisystem chronic proinflammatory disorder associated with increased morbidity and mortality. Adipocytes are far more than storage vessels for lipids. They secrete a large number of physiologically active substances called adipokines that lead to inflammation, vascular and cardiac remodelling, airway inflammation, and altered microvascular flow patterns. They contribute to linked abnormalities, such as insulin resistance and the metabolic syndrome, and they attract and activate inflammatory cells such as macrophages. Author contributions Aiden Cullen and Andrew Ferguson were responsible for the conception and design of the manuscript. They contributed to the literature search and screening of the resulting papers, and they both contributed to the original draft. Andrew Ferguson further revised the article critically for important intellectual content.
Critical care medicine, Oct 5, 2018
To characterize current practice in fluid administration and deresuscitation (removal of fluid us... more To characterize current practice in fluid administration and deresuscitation (removal of fluid using diuretics or renal replacement therapy), the relationship between fluid balance, deresuscitative measures, and outcomes and to identify risk factors for positive fluid balance in critical illness. Retrospective cohort study. Ten ICUs in the United Kingdom and Canada. Adults receiving invasive mechanical ventilation for a minimum of 24 hours. None. Four-hundred patients were included. Positive cumulative fluid balance (fluid input greater than output) occurred in 87.3%: the largest contributions to fluid input were from medications and maintenance fluids rather than resuscitative IV fluids. In a multivariate logistic regression model, fluid balance on day 3 was an independent risk factor for 30-day mortality (odds ratio 1.26/L [95% CI, 1.07-1.46]), whereas negative fluid balance achieved in the context of deresuscitative measures was associated with lower mortality. Independent predic...
Arici M (Editor). Managing chronic kidney disease: a clinician’s guide. 2014 (in press).
Faber P, Siervo M (Editors) Nutrition in Critical Care, 2014: 53-66
Can J Anaesth 2012; 59: 974-96, Jul 2012
""""Purpose Obesity is widespread, yet it is often understood primarily as a disorder of body ... more """"Purpose
Obesity is widespread, yet it is often understood primarily as a disorder of body structure. This article provides anesthesiologists with a synopsis of recent research into the complex pathophysiology of obesity. It emphasizes the importance of this information for the perioperative planning and management of this patient group and for reviewing some of the major perioperative challenges.
Principal findings
Obesity is a multisystem chronic pro-inflammatory disorder associated with increased morbidity and mortality. Adipocytes are far more than storage vessels for lipids. They secrete a large number of physiologically active substances called adipokines that lead to inflammation, vascular and cardiac remodelling, airway inflammation, and altered microvascular flow patterns. They contribute to linked abnormalities, such as insulin resistance and the metabolic syndrome, and they attract and activate inflammatory cells such as macrophages. These changes can lead ultimately to organ dysfunction, especially cardiovascular and pulmonary issues. In the respiratory system, anesthesiologists should be familiar not just with screening tools for obstructive sleep apnea but also with obesity hypoventilation syndrome, which is less well appreciated and carries a significant outcome disadvantage. Perioperative management is challenging. It is centred around cardiorespiratory and metabolic optimization, minimizing adverse effects of both pain and systemic opioids, effective use of regional anesthesia, and an emphasis on mobilization and nutrition − given the prevalence of micronutrient deficiencies in the severely obese. There is a risk of incorrect drug dosing in obesity, which requires an understanding of the appropriate dosing weights for perioperative medications.
Conclusion
The literature clearly highlights the complexity of severe obesity as a multisystem disease, and anesthesiologists caring for these patients perioperatively must have a sound understanding of the changes in order to offer the highest quality care to these patients.""""
Anesthesia & Analgesia, Jan 1, 2011
Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems wo... more Dialysis-dependent chronic kidney disease (CKD) is an expanding problem for healthcare systems worldwide. The prevalence of end-stage renal disease (ESRD) has increased by 20% since 2000 and stands at 1699 per million people in the USA. ESRD is associated with an increased risk of cardiovascular comorbidity, increased severity of cardiovascular disease, and an adjusted all-cause mortality rate that is 6.4–7.8-fold higher than the general population. These patients may present electively or emergently for surgery related to, or remote from, the CKD. In any perioperative setting, the patient with hemodialysis-dependent CKD represents a significant clinical challenge, and successful management of these patients requires effective cooperation and communication between nephrology, anesthesia, and surgical staff. The ESRD patient’s nephrologist will have the best knowledge of their medical history, comorbidities, and future management goals and may have been the clinician who instigated the referral for the surgery, e.g., for parathyroidectomy, vascular access surgery, nephrectomy or renal transplantation. As such, they are in an ideal position to contribute to, or coordinate, early preoperative medical optimization of the patient and also to provide advice during postoperative recovery and rehabilitation. In this article, we provide an overview of some of the key aspects of managing these patients successfully during the perioperative period. We propose the integration of cardiopulmonary exercise testing and cardiovascular optimization into the care of these high-risk patients and provide an overview of the importance of maintaining microvascular perfusion and the role of viscosity in preserving the capillary perfusion network.
Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in ... more Staphylococcal toxic shock syndrome is a rare complication of Staphylococcus aureus infection in which bacterial toxins act as superantigens, activating very large numbers of T cells and generating an overwhelming immune-mediated cytokine avalanche that manifests clinically as fever, rash, shock, and rapidly progressive multiple organ failure, often in young, previously healthy patients. The syndrome can occur with any site of S. aureus infection, and so clinicians of all medical specialties should have a firm grasp of the presentation and management. In this article, we review the literature on the pathophysiology, clinical features, and treatment of this serious condition with emphasis on recent insights into pathophysiology and on information of relevance to the practicing clinician.
Toxic shock syndrome (TSS) is an acute, multi-system, toxin-mediated illness, often resulting in ... more Toxic shock syndrome (TSS) is an acute, multi-system, toxin-mediated illness, often resulting in multi-organ failure. It represents the most fulminant expression of a spectrum of diseases caused by toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes (group A streptococcus). The importance of Gram-positive organisms as pathogens is increasing, and TSS is likely to be underdiagnosed in patients with staphylococcal or group A streptococcal infection who present with shock. TSS results from the ability of bacterial toxins to act as superantigens, stimulating immune-cell expansion and rampant cytokine expression in a manner that bypasses normal MHC-restricted antigen processing. A repetitive cycle of cell stimulation and cytokine release results in a cytokine avalanche that causes tissue damage, disseminated intravascular coagulation, and organ dysfunction. Specific therapy focuses on early identification of the illness, source control, and administration on antimicrobial agents including drugs capable of suppressing toxin production (eg, clindamycin, linezolid). Intravenous immunoglobulin has the potential to neutralise superantigen and to mitigate subsequent tissue damage.
Published 5 July 2010, doi:10.1136/bmj.c3365 Cite this as: BMJ 2010;341:c3365 Clinical Review P... more Published 5 July 2010, doi:10.1136/bmj.c3365
Cite this as: BMJ 2010;341:c3365
Clinical Review
Perioperative acute kidney injury: risk factors, recognition, management, and outcomes
Emma Borthwick, specialist registrar1, Andrew Ferguson, consultant in intensive care medicine and anaesthesia2
1 Nephrology and Intensive Care Medicine, Belfast City Hospital, Belfast BT12 7BA, 2 Craigavon Area Hospital, Portadown BT63 5QQ
Correspondence to: A Ferguson fergua@yahoo.ca
doi:10.1136/bmj.b2370
Summary points
Perioperative acute kidney injury (AKI) is common but poorly recognised and managed
Perioperative AKI increases surgical mortality and morbidity and increases cost
An apparently successful surgical outcome may not mean a successful renal outcome
Careful and thoughtful preoperative assessment, including identifying patients with existing chronic kidney disease and stopping and avoiding nephrotoxic drugs, will reduce the incidence of perioperative AKI.
Management of AKI centres on optimising fluid status and blood pressure, treating sepsis, and removing nephrotoxic agents where possible
Patients with AKI are often complex to treat, and senior help should be sought at an early stage
Acute kidney injury (AKI), formerly known as "acute renal failure," is associated with increased morbidity, mortality, duration of hospital stay, and healthcare cost.w1 Despite this, published data on perioperative acute kidney injury, occurring between the time of admission for surgery and the time of discharge, are scarce outside the cardiovascular surgery setting. Regardless of the clinical setting, the diagnosis of AKI is often delayed, and treatment is suboptimal in a large proportion of cases.1 To improve diagnosis and treatment, clinicians need to understand the risks and triggers for perioperative AKI, the association of even small transient rises in creatinine concentration with risk of death,2 and what actions they need to take promptly on diagnosis. The term acute kidney injury reflects the importance of thinking of the condition as a spectrum or continuum of disease that may be recognised at an early stage, rather than as an "all or nothing" phenomenon as implied by the term acute renal failure. Recognising earlier stages of renal impairment allows for early appropriate action that may interrupt a process of functional decline.
In this article we recommend the introduction of systems to ensure that changes in creatinine concentration from baseline are urgently highlighted to the clinical team. We outline the risk factors for perioperative AKI and discuss how to recognise the condition, manage it, and improve outcomes, focusing on the non-specialist surgery setting and using evidence from randomised trials, retrospective studies, meta-analyses, and expert reviews, as well as the recommendations of recent guidelines.
Dr Andrew Ferguson 56 year old male with cardiogenic shock after AMI 42 year old female with hypo... more Dr Andrew Ferguson 56 year old male with cardiogenic shock after AMI 42 year old female with hypotension after amlodipine OD 82 year old nil orally with postoperative hypertension 66 year old male with aortic dissection 78 year old male with septic shock 45 year old female after subarachnoid haemorrhage agonists Na + /K + -ATPase antagonists PDE inhibitors Calcium sensitisers Ca 2+
Sepsis is the major killer in the general ICU. Sepsis is a common cause of hospital admission. Di... more Sepsis is the major killer in the general ICU. Sepsis is a common cause of hospital admission. Diagnosis is often delayed and common laboratory tests are non-specific. Biomarker panels offer the potential for more rapid diagnosis and for better risk stratification.
Perioperative AKI is a common phenomenon with appreciable morbidity and mortality risk. There are... more Perioperative AKI is a common phenomenon with appreciable morbidity and mortality risk. There are multiple contributors, and the main diagnostic tool, creatinine, is flawed. There are a number of new renal injury biomarkers that offer the potential for earlier intervention in AKI, and these are summarised. The role of fluid overload in the development and maintenance of AKI is explored, along with the impact of intra-abdominal hypertension.
Pulmonary hypertension is an important contributor to poor outcome. Although much attention is gi... more Pulmonary hypertension is an important contributor to poor outcome. Although much attention is given to acute pulmonary hypertension in the setting of acute lung injury or pulmonary embolus, many patients over the age of 60 years have PH chronically, and this baseline abnormality can significantly impact on their ICU course and management. This presentation provides an overview of the aetiology, diagnosis, and therapeutic options availbale to the intensivist.