A 12-year study evaluating the outcomes and predictors of mortality in critically ill cancer patients admitted with septic shock

Background

Though sepsis is common in patients with cancer, there are limited studies that evaluated sepsis and septic shock in this patient population. The objective of this study was to evaluate the outcomes and to identify predictors of mortality in cancer patients admitted to the intensive care unit (ICU) with septic shock.

Methods

This was a retrospective study conducted at a medical-surgical oncologic ICU of a comprehensive cancer center. Adult cancer patients admitted with septic shock between January 1, 2008 and December 31, 2019 were enrolled. Septic shock was defined as an ICU admission diagnosis of sepsis that required initiating vasopressors within 24 h of admission. Patient baseline characteristics, ICU length of stay and ICU and hospital mortality were recorded. Univariate analysis and logistic regression were performed to identify predictors associated with ICU and hospital mortality.

Results

During the study period, 1408 patients met the inclusion criteria. The mean age was 56.8 ± 16.1 (SD) years and mean Acute Physiology and Chronic Health Evaluation (APACHE) II was 23.0 ± 7.91 (SD). Among the enrolled patients, 67.8% had solid tumors while the remaining had hematological malignancies. Neutropenia and thrombocytopenia were reported in 19.3 and 39.5% of the patients, respectively, and mechanical ventilation was required for 42% of the patients. Positive cultures were reported in 836 (59.4%) patients, most commonly blood (33%) and respiratory (26.6%). Upon admission, about half the patients had acute kidney injury, while elevated total bilirubin and lactic acid levels were reported in 13.8 and 65.2% of the patients, respectively. The median ICU length of stay was 4 days (IQR 3–8), and ICU and hospital mortality were reported in 688 (48.9%) and 914 (64.9%) patients, respectively. Mechanical ventilation, APACHE II, thrombocytopenia, positive cultures, elevated bilirubin and lactic acid levels were significantly associated with both ICU and hospital mortality.

Conclusions

In a relatively large cohort of patients with solid and hematological malignancies admitted to the ICU with septic shock, hospital mortality was reported in about two-third of the patients. Mechanical ventilation, APACHE II, thrombocytopenia, positive cultures, elevated bilirubin and lactic acid levels were significant predictors of mortality.

The incidence and characteristics of ventilator-associated pneumonia in a regional nontertiary Australian intensive care unit: A retrospective clinical audit study

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation in the intensive care unit. The incidence, patient characteristics, and outcomes have not been described in a regional Australian setting.

OBJECTIVES

Τhe primary objective was to establish the incidence of VAP in a regional intensive care unit using predetermined diagnostic criteria. The secondary objective was to compare the agreement between criteria-based and physician-based diagnostic processes. The tertiary objectives were to compare patient characteristics and clinical outcomes of cases with and without VAP.

METHODS

A retrospective clinical audit was performed of adult patients admitted to Rockhampton Intensive Care Unit, Australia, between 2013 and 2016. We included all patients ventilated for ≥72 h and not diagnosed with a pneumonia before or during the first 72 h of ventilation.

RESULTS

A total of 170 cases met the inclusion criteria. The incidence of VAP as per the criteria-based diagnosis was 27.3 cases per 1000 ventilator days (95% confidence interval [CI]: 18.4-36.2) and as per the physician-based diagnosis was 25.8 cases per 1000 ventilator days (95% CI: 17.1-34.4). There was a moderate chance-corrected agreement between the criteria- and physician-based diagnosis. Very obese cases (body mass index [BMI] ≥40) were nearly four times more likely to develop VAP than cases with normal BMI (BMI <30) (odds ratio: 3.664; 95% CI: 1.394-9.634; p = 0.008). After controlling for sex, BMI category, comorbidities, and Acute Physiology and Chronic Health Evaluation II scores, there was a trend (p = 0.283) for higher adjusted mortality rate for cases with VAP (10.1%, 95% CI: 4.8-21.5) than for those without VAP (6.1%, 95% CI: 3.0-12.4). Cases with VAP had a higher total hospital cost ($123,223 AUD vs $66,425 AUD, p < 0.001), than cases without VAP.

CONCLUSIONS

This is the first study reporting incidence of VAP in an Australian regional intensive care unit setting. An increased length of stay and significantly higher hospital costs warrant research investigating reliable and valid clinical prediction rules to forecast those at risk of VAP.

The effects of intensive care unit-initiated transitional care interventions on elements of post-intensive care syndrome: A systematic review and meta-analysis

OBJECTIVE

The aim of the study was to assess the effectiveness of intensive care unit (ICU)-initiated transitional care interventions for patients and families on elements of post-intensive care syndrome (PICS) and/or PICS-family (PICS--F).

REVIEW METHOD USED

This is a systematic review and meta-analysis SOURCES: The authors searched in biomedical bibliographic databases including PubMed, Embase (OVID), CINAHL Plus (EBSCO), Web of Science, and the Cochrane Library and included studies written in English conducted up to October 8, 2020.

REVIEW METHODS

We included (non)randomised controlled trials focussing on ICU-initiated transitional care interventions for patients and families. Two authors conducted selection, quality assessment, and data extraction and synthesis independently. Outcomes were described using the three elements of PICS, which were categorised into (i) physical impairments (pulmonary, neuromuscular, and physical function), (ii) cognitive impairments (executive function, memory, attention, visuo-spatial and mental processing speed), and (iii) psychological health (anxiety, depression, acute stress disorder, post-traumatic stress disorder, and depression).

RESULTS

From the initially identified 5052 articles, five studies were included (i.e., two randomised controlled trials and three nonrandomised controlled trials) with varied transitional care interventions. Quality among the studies differs from moderate to high risk of bias. Evidence from the studies shows no significant differences in favour of transitional care interventions on physical or psychological aspects of PICS-(F). One study with a nurse-led structured follow-up program showed a significant difference in physical function at 3 months.

CONCLUSIONS

Our review revealed that there is a paucity of research about the effectiveness of transitional care interventions for ICU patients with PICS. All, except one of the identified studies, failed to show a significant effect on the elements of PICS. However, these results should be interpreted with caution owing to variety and scarcity of data.

PROSPERO REGISTRATION

CRD42020136589 (available via https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020136589).

Factors and Outcomes of Intensive Care Unit Readmission in Elderly Patients

INTRODUCTION

An increase in age has been observed among patients admitted to the intensive care unit (ICU). Age is a well-known risk factor for ICU readmission and mortality. However, clinical characteristics and risk factors of ICU readmission of elderly patients (≥65 years) have not been studied.

METHODS

This retrospective single-center cohort study was conducted in a total of 122-bed ICU of a tertiary care hospital in Seoul, Korea. A total of 85,413 patients were enrolled in this hospital between January 1, 2007, and December 31, 2017. The odds ratio of readmission and in-hospital mortality was calculated by logistic regression analysis.

RESULTS

Totally, 29,503 patients were included in the study group, of which 2,711 (9.2%) had ICU readmissions. Of the 2,711 readmitted patients, 472 patients were readmitted more than once (readmitted 2 or more times to the ICU, 17.4%). In the readmitted patient group, there were more males, higher sequential organ failure assessment (SOFA) scores, and hospitalized for medical reasons. Length of stay (LOS) in ICU and in-hospital were longer, and 28-day and in-hospital mortality was higher in readmitted patients than in nonreadmitted patients. Risk factors of ICU readmission included the ICU admission due to medical reason, SOFA score, presence of chronic heart disease, diabetes mellitus, chronic kidney disease, transplantation, use of mechanical ventilation, and initial ICU LOS. ICU readmission and age (over 85 years) were independent predictors of in-hospital mortality on multivariable analysis. The delayed ICU readmission group (>72 h) had higher in-hospital mortality than the early readmission group (≤72 h) (20.6 vs. 16.2%, p = 0.005).

CONCLUSIONS

ICU readmissions occurred in 9.2% of elderly patients and were associated with poor prognosis and higher mortality.

Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

Flow Index: a novel, non-invasive, continuous, quantitative method to evaluate patient inspiratory effort during pressure support ventilation

Background

The evaluation of patient effort is pivotal during pressure support ventilation, but a non-invasive, continuous, quantitative method to assess patient inspiratory effort is still lacking. We hypothesized that the concavity of the inspiratory flow-time waveform could be useful to estimate patient’s inspiratory effort. The purpose of this study was to assess whether the shape of the inspiratory flow, as quantified by a numeric indicator, could be associated with inspiratory effort during pressure support ventilation.

Methods

Twenty-four patients in pressure support ventilation were enrolled. A mathematical relationship describing the decay pattern of the inspiratory flow profile was developed. The parameter hypothesized to estimate effort was named Flow Index. Esophageal pressure, airway pressure, airflow, and volume waveforms were recorded at three support levels (maximum, minimum and baseline). The association between Flow Index and reference measures of patient effort (pressure time product and pressure generated by respiratory muscles) was evaluated using linear mixed effects models adjusted for tidal volume, respiratory rate and respiratory rate/tidal volume.

Results

Flow Index was different at the three pressure support levels and all group comparisons were statistically significant. In all tested models, Flow Index was independently associated with patient effort (p < 0.001). Flow Index prediction of inspiratory effort agreed with esophageal pressure-based methods.

Conclusions

Flow Index is associated with patient inspiratory effort during pressure support ventilation, and may provide potentially useful information for setting inspiratory support and monitoring patient-ventilator interactions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03624-3.

Why and how to open intensive care units to family visits during the pandemic

Since the lockdown because of the pandemic, family members have been prohibited from visiting their loved ones in hospital. While it is clearly complicated to implement protocols for the admission of family members, we believe precise strategic goals are essential and operational guidance is needed on how to achieve them. Even during the pandemic, we consider it a priority to share strategies adapted to every local setting to allow family members to enter intensive care units and all the other hospital wards.

The family in the intensive care unit in the face of a situational crisis

OBJECTIVE

To explore the experience of family members of a relative hospitalized in the intensive care unit and recognize their emotions and needs and describe the phases or milestones they go through and the strategies they use to cope with the situations that arise.

METHOD

Qualitative study developed under the grounded theory method proposed by Anselm Strauss and Juliet Corbin. During the period from July 2017 to July 2019, semi-structured interviews were conducted with 26 relatives of hospitalized patients in fifteen third-level private clinics in the city of Manizales and Medellín, Colombia. In the latter, 200 hours of participant observation were performed in ICUs of two private third-level clinics. The analysis procedure consisted of a microanalysis of the data and the process of open, axial, and selective coding of the information was continued.

RESULTS

We identified that the experience of relatives when they accompany their sick relative in the intensive care unit is represented in two categories: family disorganization which is characterized by generating a change and mismatch in family dynamics and, family reorganization in which a restoration of order is sought to cope with the situation.

CONCLUSIONS

The family in the intensive care unit develops a situational crisis characterized by intense, varied, and negative emotions and needs that wear down the relatives. Faced with this, family members undertake a reorganization process to restore the order of family dynamics to cope with the situation and overcome difficulties.

Influence of nutritional assistance on mortality by COVID-19 in critically ill patients

Background & aims

Evidence suggests the existence of an association between the institution of nutritional therapy and clinical outcomes in patients with critical COVID-19. Thus, the aim of this study was to evaluate the influence of nutritional assistance on COVID-19 mortality in patients admitted to intensive care units (ICU).

Methods

This is a subset of the cohort “Influence of nutritional therapy on clinical prognosis in patients with COVID-19: a multicenter retrospective cohort study”. Clinical and nutrition assistance information (type of assistance, evaluation of anthropometric status, and time of introduction of nutritional therapy) and presence of diabetes, hypertension and previous respiratory disease were collected from electronic medical records. To evaluate the association between the variables of interest and mortality, the hazard ratio was estimated.

Results

We evaluated 153 critically ill patients ≥18 years old, affected by COVID-19, with a rate of mortality of 77.8%. Among non survivors 58.8% were female, 52.9% aged <65 years, 66.4% had arterial hypertension, 46.2% diabetes mellitus and 81.5% had an early onset of nutritional support. Initiation of nutritional therapy after 48 h (HR: 2.57; 95% CI: 1.57–4.20) and the presence of obesity (HR: 1.55; 95% CI: 1.04–2.31) were associated with higher mortality, even after adjustment for potential confounders.

Conclusions

Our data suggests that the provision of early nutritional therapy should be prioritized, with greater attention directed to obese patients, and the nutritional assistance can contribute favorably to the clinical evolution and prognosis of critically ill patients with COVID-19.

Development of the nursing practice scale for end-of-life family conferences in critical care

OBJECTIVES

This study aimed to develop the Nursing Practice Scale for End-of-life Family conferences in critical care and to clarify the current status of nursing practice regarding family conferences.

RESEARCH METHODOLOGY/DESIGN

We conducted a cross-sectional, self-administered questionnaire survey with 955 critical care unit nurses in 97 hospitals. Content validity, factor validity and criterion-related validity, known-group validity, internal consistency and test-retest reliability were evaluated. Data were then analysed statistically.

SETTING

Adult intensive care units or high dependency units in Japan.

RESULTS

Three factors with 39 items were extracted through item analysis and confirmatory factor analysis as hypothesised (Factor 1: Preparation, Factor 2: Discussion and Factor 3: Follow-up), and the mean score per item for each factor was 3.57, 3.73 and 3.75, respectively. Nurses who had any certification or had worked in critical care unit for >5 years had a significantly greater score than the others. The Cronbach's α were 0.86-0.96 and the intraclass correlation coefficients were 0.79-0.87.

CONCLUSION

The Nursing Practice Scale for End-of-life Family conferences in critical care is a valid and reliable scale. This study could effectively facilitate communication among patients, their families and healthcare providers.

Efficacy and safety of nintedanib for pulmonary fibrosis in severe pneumonia induced by COVID-19: An interventional study

Objectives

One of the most significant features of poor prognosis in COVID-19 is pulmonary fibrosis. Nintedanib is a new antifibrotic agent that interferes with processes of pulmonary fibrosis. This study aimed to investigate the efficacy and safety of nintedanib in COVID-19.

Methods

This was an interventional study in which adult patients with COVID-19 requiring mechanical ventilation were consecutively enrolled. The primary endpoint was 28-day mortality after the initiation of mechanical ventilation. The secondary endpoints were length of mechanical ventilation, volume of lung injury, and the incidence of gastrointestinal adverse events and acute liver failure.

Results

Thirty patients with COVID-19 underwent nintedanib therapy. We included 30 patients not receiving nintedanib as the historical control group. There were no significant differences in 28-day mortality between the groups (23.3% vs 20%, P = 0.834). Lengths of mechanical ventilation were significantly shorter in the nintedanib group (P = 0.046). Computed tomography volumetry showed that the percentages of high-attenuation areas were significantly lower in the nintedanib group at liberation from mechanical ventilation (38.7% vs 25.7%, P = 0.027). There were no significant differences in the adverse events.

Conclusions

The administration of nintedanib may offer potential benefits for minimizing lung injury in COVID-19.

Reduced quality of life in ICU survivors - the story behind the numbers: A mixed methods study

PURPOSE

To gain insight into the daily functioning of ICU survivors who reported a reduced quality of life (QoL) one year after ICU admission.

MATERIALS AND METHODS

A two-phase mixed method study design. QoL was assessed using the SF-36 questionnaire before admission and after one year (Phase 1). Participants reporting a reduced QoL were invited for an in-depth interview (Phase 2). Interview data were coded thematically using the PROMIS framework.

RESULTS

Of the 797 participants, 173 (22%) reported a reduced QoL, of which 19 purposively selected patients were interviewed. In line with their questionnaire scores, most participants described their QoL as reduced. They suffered from physical, mental and/or cognitive problems, impacting their daily life, restricting hobbies, work, and social activities. A new balance in life, including relationships, had to be found. Some interviewees experienced no changes in their QoL; they were grateful for being alive, set new life priorities, and were able to accept their life with its limitations.

CONCLUSIONS

Reduction in QoL is due to physical, mental, and cognitive health problems, restricting participants what they want to do. However, QoL was not only affected by the critical illness, but also by factors including independency, comorbidity, and life events. Registration: NCT03246334 (clinical trials.gov).

Severity of illness affecting the length of stay and outcomes in patients admitted to intensive care units, Iran, 2019

BACKGROUND

Length of stay (LOS) and patients' outcome are two important indicators in intensive care units (ICUs). The severity of illness influences these variables and could have a predictive value in clinical settings. The impact of severity of illness on the LOS and outcomes in patients admitted to ICUs was investigated in a selected hospital in Iran in 2019.

MATERIALS AND METHODS

This research was a descriptive longitudinal study. Data were prospectively collected on 150 patients. The sequential organ failure assessment (SOFA) score, LOS, and demographic variables of the patients were recorded. Abbreviated mental test and Barthel index measuring activities of daily living questionnaires were completed at the time of the discharge from ICU and 1 month later to show the patient outcomes. Data analysis was performed using Chi-square test, t-test, analysis of variance, Pearson's correlation, and linear and ordinal logistic regression with SPSS software version 16.

RESULTS

The mean of LOS was 11.21 ± 10.54 days. 24.7% of the patients were discharged from ICUs with optimal recovery, 49.3% with poor recovery, and 26% died in ICUs. One month after discharge, 67.6% of patients had optimal recovery, 24.3% had poor recovery, and 8.1% died. The SOFA score had a significant relation with LOS and patient outcomes in discharge and 1 month later. All the patients with SOFA score <5 survived, and all the patients with SOFA score more than 12 died.

CONCLUSIONS

The severity of illness had a significant relation with LOS and patient outcomes in the time of the discharge from ICU and 1 month later. It seems that the initial SOFA score of 12 and higher can be suggested as a cutoff point for poor prognosis in ICU patients.

Anti-infectious decontamination strategies in Dutch intensive care units: A survey study on contemporary practice and heterogeneity

PURPOSE

Despite increasing evidence and updated national guidelines, practice of anti-infectious strategies appears to vary in the Netherlands. This study aimed to determine the variation of current practices of anti-infectious strategies in Dutch ICUs.

MATERIALS AND METHODS

In 2018 and 2019 an online survey of all Dutch ICUs was conducted with detailed questions on their anti-infectious strategies.

RESULTS

89% (63 of 71) of the Dutch ICUs responded to the online survey. The remaining ICUs were contacted by telephone. 47 (66%) of the Dutch ICUs used SDD, 14 (20%) used SOD and 10 (14%) used neither SDD nor SOD. Within these strategies considerable heterogeneity was observed in the start criteria of SDD/SOD, the regimen adjustments based on microbiological surveillance and the monitoring of the interventions.

CONCLUSIONS

The proportion of Dutch ICUs applying SDD or SOD increased over time. Considerable heterogeneity in the regimens was reported. The impact of the observed differences within SDD and SOD practices on clinical outcome remains to be explored.

Psychological impact of COVID-19 pandemic in Western frontline healthcare professionals. A systematic review

The aim of this study was to assess the psychological impact among healthcare workers who stand in the frontline of the SARS-CoV-2 crisis and to compare it with the rest of healthcare professionals, by means of a systematic review of Western publications. The systematic review was carried out in PubMed, Scopus and Web of Science databases and 12 descriptive studies were reviewed. The European and American quantitative studies reported moderate and high levels of stress, anxiety, depression, sleep disturbance and burnout, with diverse coping strategies and more frequent and intense symptoms among women and nurses, without conclusive results by age. In the first line of assistance the psychological impact was greater than in the rest of the health professionals and in the Asian area. It is necessary to go deeper into the emotional experiences and professional needs for emotional support in order to design effective interventions for protection and help.

Psychological impact of COVID-19 pandemic in Western frontline healthcare professionals. A systematic review

The aim of this study was to assess the psychological impact among healthcare workers who stand in the frontline of the SARS-CoV-2 crisis and to compare it with the rest of healthcare professionals, by means of a systematic review of Western publications. The systematic review was carried out in PubMed, Scopus and Web of Science databases and 12 descriptive studies were reviewed. The European and American quantitative studies reported moderate and high levels of stress, anxiety, depression, sleep disturbance and burnout, with diverse coping strategies and more frequent and intense symptoms among women and nurses, without conclusive results by age. In the first line of assistance the psychological impact was greater than in the rest of the health professionals and in the Asian area. It is necessary to go deeper into the emotional experiences and professional needs for emotional support in order to design effective interventions for protection and help.

Performance of prognostic markers in pediatric sepsis

OBJECTIVE

To evaluate the prognostic performance of the Pediatric Index of Mortality 2 (PIM2), ferritin, lactate, C-reactive protein (CRP), and leukocytes, alone and in combination, in pediatric patients with sepsis admitted to the pediatric intensive care unit (PICU).

METHODS

A retrospective study was conducted in a PICU in Brazil. All patients aged 6 months to 18 years admitted with a diagnosis of sepsis were eligible for inclusion. Those with ferritin and C-reactive protein measured within 48h and lactate and leukocytes within 24h of admission were included in the prognostic performance analysis.

RESULTS

Of 350 eligible patients with sepsis, 294 had undergone all measurements required for analysis and were included in the study. PIM2, ferritin, lactate, and CRP had good discriminatory power for mortality, with PIM2 and ferritin being superior to CRP. The cutoff values for PIM2 (> 14%), ferritin (> 135ng/mL), lactate (> 1.7mmol/L), and CRP (> 6.7mg/mL) were associated with mortality. The combination of ferritin, lactate, and CRP had a positive predictive value of 43% for mortality, similar to that of PIM2 alone (38.6%). The combined use of the three biomarkers plus PIM2 increased the positive predictive value to 76% and accuracy to 0.945.

CONCLUSIONS

PIM2, ferritin, lactate, and CRP alone showed good prognostic performance for mortality in pediatric patients older than 6 months with sepsis. When combined, they were able to predict death in three-fourths of the patients with sepsis. Total leukocyte count was not useful as a prognostic marker.

[Preparing for a pandemic]

Der am 16. März 2020 in Bayern aufgrund der COVID(„corona virus disease“)-19-Pandemie ausgerufene Katastrophenfall stellte alle Kliniken vor völlig neue und schwierige Herausforderungen. Entsprechend den Vorgaben der Allgemeinverfügung wurden im Klinikum Kempten Pandemiebeauftragte benannt und eine klinische Einsatzleitung etabliert. Es galt, zu jedem Zeitpunkt einen relevanten Anteil der Mitarbeiterinnen und Mitarbeiter im Dienstfrei zu halten, und so eine konstante Reserve bei zu erwartenden infektionsbedingten Ausfällen innerhalb der Belegschaft zur Verfügung zu haben. Flankiert wurden diese strukturellen Veränderungen durch gegenseitige Unterweisungen und dem kurzfristigen Schaffen eines Fortbildungsprogramms zum Thema COVID-19 und den damit in Verbindung stehenden unterschiedlichsten Aspekten. Innerhalb kürzester Zeit wurden Algorithmen entworfen und festgelegt, wie mit Patientinnen und Patienten in den unterschiedlichsten Konstellationen bei Vorstellung im Klinikum bzw. in der Zentralen Notaufnahme umzugehen sei. Das operative Programm wurde auf unaufschiebbare Operationen, z. B. extrauterine Gravidität oder Adnextorsion, und die onkologischen Diagnosen ohne Möglichkeit einer primär systemischen Therapie beschränkt. Im Falle des Mammakarzinoms aber wurde in allen Fällen, in denen eine primär systemische Therapie (PST), sei diese zytotoxischer oder endokrinologischer Art, möglich und indiziert erschien, eine solche begonnen. Ab dem 01. April 2020 standen mehr als 50 % der belegbaren Betten im Klinikum Kempten leer. Auch die Auslastung der Intensivstation war so reduziert worden, dass jederzeit auch höhere Zahlen beatmungspflichtiger Patientinnen und Patienten hätten versorgt werden können.

Diabesity Associates with Poor COVID-19 Outcomes among Hospitalized Patients

Background

Although numerous studies have investigated obesity's negative effect on coronavirus disease 2019 (COVID-19) outcomes, only a limited number focused on this association in diabetic patients. In this study, we analyzed the association between obesity and COVID-19 outcome (death, intensive care unit [ICU] admission, mechanical ventilation needs, quick Sequential Organ Failure Assessment [qSOFA] score, and confusion, urea, respiratory rate, blood pressure [CURB-65] scores) for hospitalized diabetic patients.

Methods

In this prospective hospital-based registry of patients with COVID-19 in East Azerbaijan, Iran, 368 consecutive diabetic patients with COVID-19 were followed from admission until discharge or death. Self-reported weight and height were used to calculate body mass index (kg/m²) upon admission. Our primary endpoint was analyzing obesity and COVID-19 mortality association. Assessing the associations among obesity and disease severity, ICU admission, and mechanical ventilation was our secondary endpoint.

Results

We analyzed data from 317 patients and found no significant difference between obese and non-obese patients regarding frequency of death, invasive mechanical ventilation, ICU admission, CURB-65, or qSOFA scores (P>0.05). After adjusting for confounding factors, obese diabetic COVID-19 patients were 2.72 times more likely to die than non-obese patients. Moreover, ventilator dependence (adjusted odds ratio [aOR], 1.87; 95% confidence interval [CI], 1.03-4.76) and ICU admission (aOR, 2.41; 95% CI, 1.11-5.68) odds were significantly higher for obese patients than non-obese patients.

Conclusion

The results of the present study indicated that obesity worsens health outcomes for diabetic COVID-19 patients.

Survival rate in patients with ICU-acquired infections and its related factors in Iran's hospitals

BACKGROUND

Hospital-acquired infections (HAIs) are a well-known cause of morbidity and mortality in hospitalized patients. This study aimed at investigating the survival rate in patients with ICU-acquired infections (ICU-AIs) and its related factors in Iran's hospitals.

METHODS

Data were obtained from the Iranian Nosocomial Infections Surveillance (INIS), which registers all necessary information on the main types of infection from different units of each included hospital. One thousand one hundred thirty-four duplicate cases were removed from the analysis using the variables of name, father's name, age, hospital code, infection code, and bedridden date. From 2016 to 2019, 32,998 patients diagnosed with ICU-AI from about 547 hospitals. All patients were followed up to February 29, 2020.

RESULTS

The median age of patients with ICU-AIs was 61 (IQR = 46) years. 45.5, 20.69, 17.63, 12.08, and 4.09% of infections were observed in general, surgical, internal, neonatal and pediatric ICUs, respectively. Acinetobacter (16.52%), E.coli (12.01%), and Klebsiella (9.93%) were the major types of microorganisms. From total, 40.76% of infected patients (13,449 patients) died. The 1, 3, 6-months and overall survival rate was 70, 25.72, 8.21 1.48% in ICU-AI patients, respectively. The overall survival rate was 5.12, 1.34, 0.0, 51.65, and 31.08% for surgical, general, internal, neonatal and pediatric ICU, respectively. Hazard ratio shows a significant relationship between age, hospitalization-infection length, infection type, and microorganism and risk of death in patients with ICU-AI.

CONCLUSIONS

Based on the results, it seems that the nosocomial infections surveillance system should be more intelligent. This intelligence should act differently based on related factors such as the age of patients, hospitalization-infection length, infection type, microorganism and type of ward. In other words, this system should be able to dynamically provide the necessary and timely warnings based on the factors affecting the survival rate of infection due to the identification, intervention and measures to prevent the spread of HAIs based on a risk severity system.

Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit

OBJECTIVES

To evaluate values and experience with facilitating end-of-life care among intensive care professionals (registered nurses, medical practitioners and social workers) to determine perceived education and support needs.

RESEARCH DESIGN

Using a cross-sectional study design, 96 professionals completed a survey on knowledge, preparedness, patient and family preferences, organisational culture, resources, palliative values, emotional support, and care planning in providing end-of-life care.

SETTING

General adult intensive care unit at a tertiary referral hospital.

RESULTS

Compared to registered nurses, medical practitioners reported lower emotional and instrumental support after a death, including colleagues asking if OK (p = 0.02), lower availability of counselling services (p = 0.01), perceived insufficient time to spend with families (p = 0.01), less in-service education for end-of-life topics (p = 0.002) and symptom management (p = 0.02). Registered nurses reported lower scores related to knowing what to say to the family in end-of-life care scenarios (p = 0.01).

CONCLUSION

Findings inform strategies for practice development to prepare and support healthcare professionals to provide end-of-life care in the intensive care setting. Professionals reporting similar palliative care values and inclusion of patient and family preferences in care planning is an important foundation for planning interprofessional education and support with opportunities for professionals to share experiences and strengths.

Novel criteria to classify ARDS severity using a machine learning approach

Background

Usually, arterial oxygenation in patients with the acute respiratory distress syndrome (ARDS) improves substantially by increasing the level of positive end-expiratory pressure (PEEP). Herein, we are proposing a novel variable [PaO₂/(FiO₂xPEEP) or P/FP_E] for PEEP ≥ 5 to address Berlin’s definition gap for ARDS severity by using machine learning (ML) approaches.

Methods

We examined P/FP_E values delimiting the boundaries of mild, moderate, and severe ARDS. We applied ML to predict ARDS severity after onset over time by comparing current Berlin PaO₂/FiO₂ criteria with P/FP_E under three different scenarios. We extracted clinical data from the first 3 ICU days after ARDS onset (N = 2738, 1519, and 1341 patients, respectively) from MIMIC-III database according to Berlin criteria for severity. Then, we used the multicenter database eICU (2014–2015) and extracted data from the first 3 ICU days after ARDS onset (N = 5153, 2981, and 2326 patients, respectively). Disease progression in each database was tracked along those 3 ICU days to assess ARDS severity. Three robust ML classification techniques were implemented using Python 3.7 (LightGBM, RF, and XGBoost) for predicting ARDS severity over time.

Results

P/FP_E ratio outperformed PaO₂/FiO₂ ratio in all ML models for predicting ARDS severity after onset over time (MIMIC-III: AUC 0.711–0.788 and CORR 0.376–0.566; eICU: AUC 0.734–0.873 and CORR 0.511–0.745).

Conclusions

The novel P/FP_E ratio to assess ARDS severity after onset over time is markedly better than current PaO₂/FiO₂ criteria. The use of P/FP_E could help to manage ARDS patients with a more precise therapeutic regimen for each ARDS category of severity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03566-w.

The family in preventing delirium in the intensive care unit: Scoping review

INTRODUCTION

Delirium is cognitive impairment related to negative inpatient outcomes in the Intensive Care Unit (ICU), family interventions have been shown to be effective in reducing the incidence of this condition.

OBJECTIVE

To identify strategies that include the family in the prevention of delirium in the adult intensive care unit that can be integrated into ABCDEF.

INCLUSION CRITERIA

Studies describing actions and interventions involving caregivers and family members in the ICU for the prevention of delirium, conducted in the last five years, available in full text, in English and Spanish, Portuguese and in adults.

METHODS

A scope review was conducted using the keywords "Critical Care, Delirium, Family, Primary Prevention" in 11 databases (PubMed, Virtual Health Library, Cochrane Library, TRIP Data base, EBSCO, Ovid Nursing, Springer, Scopus, Dialnet, Scielo, Lilacs) and other sources (Open Gray, Google Scholar), between August - October 2019; 8 studies were considered relevant and were analysed.

RESULTS

The results were described in 3 categories: flexibility vs. restriction of visits in the ICU, Reorientation as a prevention strategy and post-ICU syndrome in the family.

CONCLUSION

Extended visits, development of family-mediated activities, and redirection are non-pharmacological strategies that reduce the incidence of delirium in the ICU and offer multiple benefits to the patient and family/caregiver.

Higher 1-year mortality in women admitted to intensive care units after cardiac arrest: A nationwide overview from the Netherlands between 2010 and 2018

PURPOSE

We study sex differences in 1-year mortality of out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients admitted to the intensive care unit (ICU).

DATA

A retrospective cohort analysis of OHCA and IHCA patients registered in the NICE registry in the Netherlands. The primary and secondary outcomes were 1-year and hospital mortality, respectively.

RESULTS

We included 19,440 OHCA patients (5977 women, 30.7%) and 13,461 IHCA patients (4889 women, 36.3%). For OHCA, 1-year mortality was 63.9% in women and 52.6% in men (Hazard Ratio [HR] 1.28, 95% Confidence Interval [95% CI] 1.23-1.34). For IHCA, 1-year mortality was 60.0% in women and 57.0% in men (HR 1.09, 95% CI 1.04-1.14). In OHCA, hospital mortality was 57.4% in women and 46.5% in men (Odds Ratio [OR] 1.42, 95% CI 1.33-1.52). In IHCA, hospital mortality was 52.0% in women and 48.2% in men (OR 1.11, 95% CI 1.03-1.20).

CONCLUSION

Women admitted to the ICU after cardiac arrest have a higher mortality rate than men. After left-truncation, we found that this sex difference persisted for OHCA. For IHCA we found that the effect of sex was mainly present in the initial phase after the cardiac arrest.

Incidence, Risk Factors, and Attributable Mortality of Catheter-Related Bloodstream Infections in the Intensive Care Unit After Suspected Catheters Infection: A Retrospective 10-year Cohort Study

INTRODUCTION

Catheter management strategies for suspected catheter-related bloodstream infection (CRBSI) remain a major challenge in intensive care units (ICUs). The objective of this study was to determine the incidence, risk factors, and mortality attributable to CRBSIs in those patients.

METHODS

A population-based surveillance on suspected CRBSI was conducted from 2009 to 2018 in a tertiary care hospital in China. We used the results of catheter tip culture to identify patients with suspected CRBSIs. Demographics, systemic inflammatory response syndrome (SIRS) criteria, interventions, and microorganism culture results were analysed and compared between patients with and without confirmed CRBSIs. Univariate and multivariate analyses identified the risk factors for CRBSIs, and attributable mortality was evaluated with a time-varying Cox proportional hazard model.

RESULTS

In total, 686 patients with 795 episodes of suspected CRBSIs were included; 19.2% (153/795) episodes were confirmed as CRBSIs, and 17.4% (119/686) patients died within 30 days. The multifactor model shows that CRBSIs were associated with fever, hypotension, acute respiratory distress syndrome, hyperglycaemia and the use of continuous renal replacement therapy. The AUC was 77.0% (95% CI 73.3%-80.7%). The population attributable mortality fraction of CRBSI in patients was 18.2%, and mortality rate did not differ significantly between patients with and without CRBSIs (95% CI 0.464-1.279, P = 0.312).

CONCLUSIONS

This initial model based on the SIRS criteria is relatively better at identifying patients with CRBSI but only in domains of the sensitivity. There were no significant differences in attributable mortality due to CRBSI and other causes in patients with suspected CRBSI, which prompt catheter removal and re-insertion of new catheter may not benefit patients with suspected CRBSIs.

TRIAL REGISTRATION

China Clinical Trials Registration number; ChiCTR1900022175.