101
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Pather P, Doubrovsky A, Jack L, Coyer F. Incontinence-associated dermatitis: who is affected? J Wound Care 2021; 30:261-267. [PMID: 33856906 DOI: 10.12968/jowc.2021.30.4.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Intensive care unit (ICU) patients possess multiple risk factors for developing loss of skin integrity, particularly incontinence-associated dermatitis (IAD). IAD is an inflammatory skin condition resulting from repeated and prolonged contact with urine, faeces or both. This study aimed to measure the incidence and clinical characteristics of adult ICU patients with IAD. METHOD This was a prospective observational study conducted over three months in an adult ICU. Included patients were ≥18 years who experienced faecal incontinence during their intensive care admission. Patients were excluded if they had an ileostomy or colostomy, had IAD on admission, or were continent of urine and faeces. Skin inspections were performed every second day on all recruited patients by trained research nurses. Other data were collected from patient medical records. RESULTS A total of 37 patients took part in the study. Incidence of IAD was 35.1%; 13 patients who had incontinence developed IAD. The mean time to onset of IAD was 3.69 days, median 3 days (SD: 1.8, range: 2-8 days). Of the 13 patients who developed IAD, 12 (92.3%) patients were initially assessed as having category 1 IAD and one (7.7%) patient was initially assessed with category 2 IAD. Of the patients with category 1 IAD, one patient (7.7%) progressed to category 2 IAD severity. CONCLUSION A larger sample is recommended to fully explore ICU patient characteristics and IAD development. The incidence of IAD in ICU patients was high at 35%, indicating this condition requires due consideration in ICU patients.
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Affiliation(s)
- Priscilla Pather
- Queen Elizabeth ll Jubilee Hospital, Mater Health Services, Intensive Care, Australia
| | - Anna Doubrovsky
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Leanne Jack
- Post Graduate Study Area Coordinator Intensive Care Nursing and Emergency Nursing, School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Fiona Coyer
- Joint Appointment Royal Brisbane and Women's Hospital and School of Nursing, Queensland University of Technology Nursing, Brisbane, Australia.,Visiting Professor, Institute of Skin Integrity and Infection Prevention, University of Huddersfield, UK
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Stéphan S, Cohen F, Salviat F, Thevenin S, Devys JM, Cochereau I, Gabison E. Evaluation of the impact of intensive care support for COVID-19 on the ocular surface in a prospective cohort of 40 eyes. Ocul Surf 2021; 22:13-14. [PMID: 34174393 PMCID: PMC8220863 DOI: 10.1016/j.jtos.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/31/2021] [Accepted: 06/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Sophie Stéphan
- Hôpital Fondation Adolphe de Rothschild, Département d'Ophtalmologie, Paris, France.
| | - Florian Cohen
- Hôpital Fondation Adolphe de Rothschild, Département d'Ophtalmologie, Paris, France
| | - Flore Salviat
- Hôpital Fondation Adolphe de Rothschild, Service de Recherche Clinique, Paris, France
| | - Sophie Thevenin
- Hôpital Fondation Adolphe de Rothschild, Service de Recherche Clinique, Paris, France
| | - Jean-Michel Devys
- Hôpital Fondation Adolphe de Rothschild, Service d'Anesthésie et de Réanimation, Paris, France
| | - Isabelle Cochereau
- Hôpital Fondation Adolphe de Rothschild, Département d'Ophtalmologie, Paris, France
| | - Eric Gabison
- Hôpital Fondation Adolphe de Rothschild, Département d'Ophtalmologie, Paris, France
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103
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Ortiz G, Bastidas A, Garay-Fernández M, Lara A, Benavides M, Rocha E, Buitrago A, Díaz G, Ordóñez J, Reyes LF. Correlation and validity of imputed PaO2/FiO2 and SpO2/FiO2 in patients with invasive mechanical ventilation at 2600m above sea level. Med Intensiva 2021; 46:S0210-5691(21)00100-5. [PMID: 34167826 DOI: 10.1016/j.medin.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/09/2021] [Accepted: 05/04/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To establish the correlation and validity between PaO2/FiO2 obtained on arterial gases versus noninvasive methods (linear, nonlinear, logarithmic imputation of PaO2/FiO2 and SpO2/FiO2) in patients under mechanical ventilation living at high altitude. DESIGN Ambispective descriptive multicenter cohort study. SETTING Two intensive care units (ICU) from Colombia at 2600m a.s.l. PATIENTS OR PARTICIPANTS Consecutive critically ill patients older than 18 years with at least 24h of mechanical ventilation were included from June 2016 to June 2019. INTERVENTIONS None. VARIABLES Variables analyzed were demographic, physiological messures, laboratory findings, oxygenation index and clinical condition. Nonlinear, linear and logarithmic imputation formulas were used to calculate PaO2 from SpO2, and at the same time the SpO2/FiO2 by severe hypoxemia diagnosis. The intraclass correlation coefficient, area under the ROC curve, sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratio were calculated. RESULTS The correlation between PaO2/FiO2 obtained from arterial gases, PaO2/FiO2 derived from one of the proposed methods (linear, non-linear, and logarithmic formula), and SpO2/FiO2 measured by the intraclass correlation coefficient was high (greater than 0.77, p<0.001). The different imputation methods and SpO2/FiO2 have a similar diagnostic performance in patients with severe hypoxemia (PaO2/FiO2 <150). PaO2/FiO2 linear imputation AUC ROC 0,84 (IC 0.81-0.87, p<0.001), PaO2/FiO2 logarithmic imputation AUC ROC 0.84 (IC 0.80-0.87, p<0.001), PaO2/FiO2 non-linear imputation AUC ROC 0.82 (IC 0.79-0.85, p<0.001), SpO2/FiO2 oximetry AUC ROC 0.84 (IC 0.81-0.87, p<0.001). CONCLUSIONS At high altitude, the SaO2/FiO2 ratio and the imputed PaO2/FiO2 ratio have similar diagnostic performance in patients with severe hypoxemia ventilated by various pathological conditions.
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Affiliation(s)
- G Ortiz
- Pulmonary Medicine, Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Bastidas
- School of Medicine, Universidad de la Sabana, Clínica Universidad de La Sabana, Chía, Colombia.
| | - M Garay-Fernández
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Lara
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - M Benavides
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - E Rocha
- Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - A Buitrago
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - G Díaz
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - J Ordóñez
- Pulmonary Medicine Universidad El Bosque, Intensive Care Unit, Hospital Santa Clara Bogotá, Colombia
| | - L F Reyes
- School of Medicine, Universidad de la Sabana, Clínica Universidad de La Sabana, Chía, Colombia
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Man MY, Lam SM, Shum HP, Li KC, Lau S, Ip VHL, Yan WW. Prone positioning in non-intubated patients with coronavirus – A single-centre experience in Hong Kong. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211022914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction: Significant ventilator-associated pneumonia and mortality were found in COVID-19 patients who required mechanical ventilation which calls for non-invasive means in managing respiratory failure. Methods: We retrospectively reviewed patients admitted to the intensive care unit of Pamela Youde Nethersole Eastern Hospital in Hong Kong with severe acute respiratory syndrome coronavirus 2 infection from 28 November to 15 December 2020. Patients’ laboratory, respiratory parameters and outcome data were recorded and analysed. Results: Eleven received prone ventilation. The median age was 67 (inter-quartile range: 59–72) years, and median COVID-19 GRAM score was 151 (inter-quartile range: 133–181), representing a high-risk group. There were significant improvements 1 h after awake proning in SpO2 (95% vs 92%, p = 0.008), FiO2 (0.4 vs 0.5, p = 0.003), SpO2/FiO2 (240 vs 184, p = 0.005), respiratory rate (19 vs 26, p = 0.006) and respiratory rate – oxygenation index (13.22 vs 7.67, p = 0.003; Table 1). Although not reaching statistical significance, the median PaO2, PaCO2 and PaO2/FiO2 improved after proning. The overall intubation rate was 22% and intensive care unit mortality was 22%, which is in contrast to 65.5% and 27.6%, respectively, in the first three waves. Although did not reach statistical significance, those received prone ventilation tend to have a lower ICU mortality (9.1% vs 42.9%, p = 0.245) and hospital mortality (18.2% vs 42.9%, p = 0.326). Conclusion: Awake proning potentially minimizes complications from invasive ventilation and provides a low-cost low-risk treatment option in COVID-19 patients with respiratory failure. This is particularly important when healthcare resources are strained at times of a pandemic.
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Affiliation(s)
- Man-Yee Man
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Sin-Man Lam
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Hoi-Ping Shum
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Kin-Chio Li
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Swan Lau
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Vincent Hing-Lung Ip
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing-Wa Yan
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
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105
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Coyer F, Campbell J, Doubrovsky A. Efficacy of Incontinence-Associated Dermatitis Intervention for Patients in Intensive Care: An Open-Label Pilot Randomized Controlled Trial. Adv Skin Wound Care 2021; 33:375-382. [PMID: 32544117 DOI: 10.1097/01.asw.0000666904.35944.a3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the feasibility of an adequately powered trial testing a long-acting cyanoacrylate skin protectant to prevent incontinence-associated dermatitis in critically ill patients. METHODS This open-label pilot randomized controlled feasibility study was conducted in the adult ICU of an Australian quaternary referral hospital. Patients were allocated to either an intervention group or a control group (usual care). The intervention was the application of a skin protectant (a durable, ultra-thin, transparent, waterproof, no-removal barrier film). Data collected by trained research nurses included demographic and clinical variables, skin assessment, and incontinence-associated dermatitis presence and severity. Data were analyzed using descriptive and inferential statistics. RESULTS Of the 799 patients screened, 85% were eliminated because of a short ICU stay or other exclusion criteria. The mean proportion of patients not meeting any of the exclusion criteria was 22% on each screening day. Protocol fidelity was followed for 90% of intervention participant study days. Retention of participants was 86% (31 participants out of 36), 15 in the intervention group and 16 in the control group. Enrolled patients had a mean age of 59 years, 50% were obese, 67% were male, and 36% were smokers. Two patients (11%) in the intervention group developed incontinence-associated dermatitis, compared with three (17%) in the control group. CONCLUSIONS This study reports no significant findings between the two groups. Difficulty in recruitment and feasibility issues might be overcome with changes to inclusion criteria and study design.
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Affiliation(s)
- Fiona Coyer
- At the Queensland University of Technology in Brisbane, Queensland, Australia, Fiona Coyer, PhD, MSc, RN, is Professor of Nursing, Joint Appointment Intensive Care Services, Royal Brisbane and Women's Hospital and School of Nursing; Jill Campbell, PhD, RN, Grad Dip (Wound Care), is Visiting Fellow, School of Nursing; and Anna Doubrovsky, MPH, BSc (Hons), is Data Analyst and Research Assistant, School of Nursing. Acknowledgments: The authors thank the research nurses (Fiona Boch and Stacey Watts) and all patients who participated. The study was sponsored by 3M, which provided funding for research assistants, the investigational product, and training to two authors on the product application. The authors have disclosed no other financial relationships related to this article. Submitted May 20, 2019; accepted in revised form August 29, 2019
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Personalized Piperacillin Dosing for the Critically Ill: A Retrospective Analysis of Clinical Experience with Dosing Software and Therapeutic Drug Monitoring to Optimize Antimicrobial Dosing. Antibiotics (Basel) 2021; 10:antibiotics10060667. [PMID: 34205135 PMCID: PMC8227218 DOI: 10.3390/antibiotics10060667] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 12/29/2022] Open
Abstract
Optimization of antibiotic dosing is a treatment intervention that is likely to improve outcomes in severe infections. The aim of this retrospective study was to describe the therapeutic exposure of steady state piperacillin concentrations (cPIP) and clinical outcome in critically ill patients with sepsis or septic shock who received continuous infusion of piperacillin with dosing personalized through software-guided empiric dosing and therapeutic drug monitoring (TDM). Therapeutic drug exposure was defined as cPIP of 32–64 mg/L (2–4× the ‘MIC breakpoint’ of Pseudomonas aeruginosa). Of the 1544 patients screened, we included 179 patients (335 serum concentrations), of whom 89% achieved the minimum therapeutic exposure of >32 mg/L and 12% achieved potentially harmful cPIP > 96 mg/L within the first 48 h. Therapeutic exposure was achieved in 40% of the patients. Subsequent TDM-guided dose adjustments significantly enhanced therapeutic exposure to 65%, and significantly reduced cPIP > 96 mg/L to 5%. Mortality in patients with cPIP > 96 mg/L (13/21; 62%) (OR 5.257, 95% CI 1.867–14.802, p = 0.001) or 64–96 mg/L (30/76; 45%) (OR 2.696, 95% CI 1.301–5.586, p = 0.007) was significantly higher compared to patients with therapeutic exposure (17/72; 24%). Given the observed variability in critically ill patients, combining the application of dosing software and consecutive TDM increases therapeutic drug exposure of piperacillin in patients with sepsis and septic shock.
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107
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Govil D, Pal D. Can We Predict Outcome In Critically Ill Elderly Patients? Indian J Crit Care Med 2021; 25:615-616. [PMID: 34316137 PMCID: PMC8286403 DOI: 10.5005/jp-journals-10071-23886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Govil D, Pal D. Can We Predict Outcome in Critically Ill Elderly Patients? Indian J Crit Care Med 2021;25(6):615-616.
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Affiliation(s)
- Deepak Govil
- Institute of Critical Care and Anesthesia, Medanta: The Medicity, Gurugram, Haryana, India
| | - Divya Pal
- Institute of Critical Care and Anesthesia, Medanta: The Medicity, Gurugram, Haryana, India
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108
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Zheng S, Lyu J, Han D, Xu F, Li C, Yang R, Yao L, Wu Y, Tian G. Establishment of a prognostic model based on the Sequential Organ Failure Assessment score for patients with first-time acute myocardial infarction. J Int Med Res 2021; 49:3000605211011976. [PMID: 33951979 PMCID: PMC8113957 DOI: 10.1177/03000605211011976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to identify the prognostic factors of patients with
first-time acute myocardial infarction (AMI) and to establish a nomogram for
prognostic modeling. Methods We studied 985 patients with first-time AMI using data from the
Multi-parameter Intelligent Monitoring for Intensive Care database and
extracted their demographic data. Cox proportional hazards regression was
used to examine outcome-related variables. We also tested a new predictive
model that includes the Sequential Organ Failure Assessment (SOFA) score and
compared it with the SOFA-only model. Results An older age, higher SOFA score, and higher Acute Physiology III score were
risk factors for the prognosis of AMI. The risk of further cardiovascular
events was 1.54-fold higher in women than in men. Patients in the cardiac
surgery intensive care unit had a better prognosis than those in the
coronary heart disease intensive care unit. Pressurized drug use was a
protective factor and the risk of further cardiovascular events was
1.36-fold higher in nonusers. Conclusion The prognosis of AMI is affected by age, the SOFA score, the Acute Physiology
III score, sex, admission location, type of care unit, and vasopressin use.
Our new predictive model for AMI has better performance than the SOFA model
alone.
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Affiliation(s)
- Shuai Zheng
- Department of Geriatric Medicine, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China.,School of Public Health, Shannxi University of Chinese Medicine, Xianyang, Shaanxi Province, China
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Didi Han
- School of Public Health, Xi'an Jiaotong University Health Science Center, Shaanxi Province, China
| | - Fengshuo Xu
- School of Public Health, Xi'an Jiaotong University Health Science Center, Shaanxi Province, China
| | - Chengzhuo Li
- School of Public Health, Xi'an Jiaotong University Health Science Center, Shaanxi Province, China
| | - Rui Yang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Shaanxi Province, China
| | - Lu Yao
- Department of Geriatric Medicine, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yuntao Wu
- Department of Geriatric Medicine, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guoxiang Tian
- Department of Geriatric Medicine, Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
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Coyer F, Cook JL, Doubrovsky A, Campbell J, Vann A, McNamara G, Edward KL, Hartel G, Fulbrook P. Implementation and evaluation of multilayered pressure injury prevention strategies in an Australian intensive care unit setting. Aust Crit Care 2021; 35:143-152. [PMID: 33992515 DOI: 10.1016/j.aucc.2021.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pressure injuries are a ubiquitous, yet largely preventable, hospital acquired complication commonly seen in critically ill patients in the intensive care unit. OBJECTIVES The objectives of this study were to implement targeted evidence-based pressure injury prevention strategies and evaluate their effect through measurement of patient pressure injury observations. METHODS A prospective multiphased design was used in the intensive care unit of an Australian tertiary referral hospital using three study periods (period 1, weeks 1-18; period 2, weeks 19-28; and period 3, weeks 29-52). The interventions included staff-focused interventions and patient-focused interventions, with the latter defined in a work unit guideline. Weekly visual observations of critically ill patients' skin integrity were conducted by trained research nurses over 52 weeks from November 2015 to November 2016. The primary outcome measure was a pressure injury of any stage, identified at the weekly observation, and the effect of the intervention was evaluated through logistic regression. Reporting rigour has been demonstrated using the Standards for Quality Improvement Reporting Excellence checklist. RESULTS Over the whole study, 15.4% (95% confidence interval [CI] = 12.6, 18.2%, 97/631) of patients developed a pressure injury, with the majority of these injuries (73.2%, 95% CI = 64.4%, 82.0%, 71/97) caused by medical devices. After adjustment for covariates known to influence hospital-acquired pressure injury development, pressure injury rates for period 3 compared with period 1 were reduced (odds ratio = 0.41, 95% CI = 0.20-0.97, p = 0.0126). CONCLUSIONS We found the use of defined pressure injury prevention strategies targeted at both staff and patients reduced pressure injury prevalence.
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Affiliation(s)
- Fiona Coyer
- Joint Appointment Intensive Care Services, Royal Brisbane and Women's Hospital and School of Nursing, Queensland University of Technology, Australia; Institute of Skin Integrity and Infection Prevention, University of Huddersfield, UK; Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Queensland, 4029, Australia.
| | - Jane-Louise Cook
- School of Nursing, Queensland University of Technology, Australia.
| | - Anna Doubrovsky
- School of Nursing, Queensland University of Technology, Australia.
| | - Jill Campbell
- School of Nursing, Queensland University of Technology, Australia; Skin Integrity Services, Royal Brisbane and Women's Hospital, Australia.
| | - Amanda Vann
- Intensive Care Services, Royal Brisbane and Women's Hospital, Australia.
| | - Greg McNamara
- Intensive Care Services, Royal Brisbane and Women's Hospital, Australia.
| | - Karen-Leigh Edward
- Department of Health Professions, School of Health Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Australia; Human and Health Sciences, University of Huddersfield, UK.
| | - Gunter Hartel
- School of Nursing, Queensland University of Technology, Australia; QIMR Berghofer Medical Research Institute, Australia.
| | - Paul Fulbrook
- School of Nursing, Midwifery & Paramedicine, Australian Catholic University, Brisbane, Australia; Nursing Research & Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
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Sottile PD, Albers D, DeWitt PE, Russell S, Stroh JN, Kao DP, Adrian B, Levine ME, Mooney R, Larchick L, Kutner JS, Wynia MK, Glasheen JJ, Bennett TD. Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study. J Am Med Inform Assoc 2021; 28:2354-2365. [PMID: 33973011 PMCID: PMC8136054 DOI: 10.1093/jamia/ocab100] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/19/2021] [Accepted: 05/06/2021] [Indexed: 11/24/2022] Open
Abstract
Objective To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon sequential organ failure assessment (SOFA) for decision support for a Crisis Standards of Care team. Materials and Methods We developed, verified, and deployed a stacked generalization model to predict mortality using data available in the electronic health record (EHR) by combining 5 previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We verified the model with prospectively collected data from 12 hospitals in Colorado between March 2020 and July 2020. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results The prospective cohort included 27 296 encounters, of which 1358 (5.0%) were positive for SARS-CoV-2, 4494 (16.5%) required intensive care unit care, 1480 (5.4%) required mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94. In the subset of patients with COVID-19, the stacked model predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Discussion Stacked regression allows a flexible, updatable, live-implementable, ethically defensible predictive analytics tool for decision support that begins with validated models and includes only novel information that improves prediction. Conclusion We developed and validated an accurate in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model that improved upon SOFA.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Albers
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter E DeWitt
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Seth Russell
- Data Science to Patient Value Initiative, University of Colorado School of Medicine, Aurora, CO, USA
| | - J N Stroh
- Department of Bioengineering, University of Colorado-Denver College of Engineering, Design, and Computing, Denver, CO, USA
| | - David P Kao
- Divisions of Cardiology and Bioinformatics/Personalized Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bonnie Adrian
- UCHealth Clinical Informatics and University of Colorado College of Nursing, Aurora, CO, USA
| | - Matthew E Levine
- Department of Computational and Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | | | | | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Chief Medical Officer, University of Colorado Hospital/UCHealth, Aurora, CO, USA
| | - Matthew K Wynia
- Center for Bioethics and Humanities, University of Colorado and Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jeffrey J Glasheen
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine and Chief Quality Officer, UCHealth, Aurora, CO, USA
| | - Tellen D Bennett
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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111
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Sehgal IS, Basumatary NM, Dhooria S, Prasad KT, Muthu V, Aggarwal AN, Pal A, Desai M, Chaudhry D, Supe PD, Kurmi P, Choudhuri R, Shah C, Agarwal R. A Randomized Trial of Mycobacterium w in Severe Presumed Gram-Negative Sepsis. Chest 2021; 160:1282-1291. [PMID: 33852919 DOI: 10.1016/j.chest.2021.03.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Mycobacterium w, an immunomodulator, has been shown to resolve early organ failure in severe sepsis. RESEARCH QUESTION Does Mw improve survival in patients with severe presumed gram-negative sepsis? STUDY DESIGN AND METHODS This was a randomized, double-blind, placebo-controlled, parallel-group study conducted in ICUs of five tertiary care centers in India. We included consecutive patients (age ≥ 18 years) with presumed gram-negative sepsis in the study within 48 h of the first organ dysfunction. Patients in the treatment arm received 0.3 mL/d of Mw intradermally for 3 consecutive days, whereas the control arm received matching placebo. The primary outcome was 28-day all-cause mortality. The secondary outcomes were ventilator-free days, days receiving vasopressor therapy, ICU and hospital length of stay, nosocomial infection rate, antibiotic use duration, and delta Sequential Organ Failure Assessment (SOFA) score. RESULTS We included 202 patients with severe sepsis (101 Mw, 101 placebo). The use of Mw significantly reduced the mortality (9/101 vs 20/101; estimate difference, 0.11 [95% CI, 0.01-0.21]; P = .04). We found no difference in ventilator-free days, days receiving vasopressor drugs, ICU length of stay, and the hospital length of stay. The time to mortality (median, 13 days vs 8.5 days) was significantly longer in the Mw than in the placebo arm. The delta SOFA score, rate of nosocomial infections, and antibiotic use duration were similar in the two arms. We found Mw to reduce significantly the odds (OR, 0.37 [95% CI, 0.15-0.9]) of mortality after adjusting for culture-positive sepsis, baseline SOFA score, age, and sex. INTERPRETATION The use of Mw was associated with a significant reduction in mortality in patients with severe presumed gram-negative sepsis. Further studies are required to confirm our findings. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02330432; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nita M Basumatary
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arnab Pal
- Department of Biochemistry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Dhruva Chaudhry
- Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | | | | | | | - Chaitri Shah
- SBKS Medical Institute and Research Centre, Vadodara, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Van de Louw A, Rello J, Martin-Loeches I, Mokart D, Metaxa V, Benoit D, Barratt-Due A, Soares M, Pickkers P, Antonelli M, Demoule A, Schellongowski P, Kouatchet A, Mehta S, Balik M, Bauer PR, Lemiale V, Walter V, Azoulay E. Bacteremia in critically ill immunocompromised patients with acute hypoxic respiratory failure: A post-hoc analysis of a prospective multicenter multinational cohort. J Crit Care 2021; 64:114-119. [PMID: 33872917 DOI: 10.1016/j.jcrc.2021.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE The characteristics and impact of bacteremia have not been widely investigated in immunocompromised patients with acute respiratory failure (ARF). METHODS We performed a secondary analysis of a prospective cohort of immunocompromised patients with ARF (EFRAIM study). After exclusion of blood cultures positive for coagulase negative Staphylococci, we compared patients with (n = 236) and without (n = 1127) bacteremia. RESULTS The incidence of bacteremia was 17%. Bacterial pneumonia and extra-pulmonary ARDS were the main causes of ARF in bacteremic patients. Bacteremia involved gram negative rods (48%), gram positive cocci (40%) or were polymicrobial (10%). Bacteremic patients had more hematological malignancy, higher SOFA scores and increased organ support within 7 days. Bacteremia was associated with higher crude ICU mortality (40% versus 32%, p = 0.02), but neither hospital (49% versus 44%, p = 0.17) nor 90-day mortality (60% versus 56%, p = 0.25) were different from non-bacteremic patients. After propensity score matching based on baseline characteristics, the difference in ICU mortality lost statistical significance (p = 0.06), including in a sensitivity analysis restricted to patients with pneumonia. CONCLUSIONS We analyzed a large population of immunocompromised patients with ARF and an incidence of bacteremia of 17%. We could not demonstrate an impact of bacteremia on mortality after adjusting for baseline characteristics.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA.
| | - Jordi Rello
- Centro de Investigación Biomédica en Red en enfermedades respiratorias (Ciberes), Instituto Salud Carlos III, Barcelona, Spain; Infectious Area, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), Dublin, Ireland; Department of Respiratory Medicine, Hospital Clinic, IDIBAPS, CIBERes, Barcelona, Spain; Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, NHS Foundation Trust, London SE5 9RS, UK
| | - Dominique Benoit
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Programa de Pós-Graduação em Clínica Médica, Rio De Janeiro, Brazil
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Massimo Antonelli
- Department of Anesthesia, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alexandre Demoule
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | | | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Sinai Health System, University of Toronto, Toronto, ON, Canada
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, 1st Faculty of Medicine and General University Hospital, Charles University in Prague, Czech Republic
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Virginie Lemiale
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
| | - Vonn Walter
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA team, and Clinical Epidemiology, UMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Paris Diderot Sorbonne University, Paris, France
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Kashyap R, Sherani KM, Dutt T, Gnanapandithan K, Sagar M, Vallabhajosyula S, Vakil AP, Surani S. Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions. Open Respir Med J 2021; 15:1-6. [PMID: 34249175 PMCID: PMC8227444 DOI: 10.2174/1874306402115010001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/13/2020] [Accepted: 01/13/2021] [Indexed: 02/08/2023] Open
Abstract
The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.
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Affiliation(s)
- Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Khalid M Sherani
- Department of Internal Medicine, Jamaica Hospital Medical Center, Jamaica, NY 11418, USA.,Corpus Christi Medical Center, Corpus Christi, TX 78411, USA
| | - Taru Dutt
- Department of Neurology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester MN, USA and Hennepin County Medical Center, Minneapolis, MN 55905, USA
| | - Karthik Gnanapandithan
- Department of Internal Medicine, Yale-New Haven Hospital and Yale University School of Medicine, New Haven, CT 06510, USA
| | - Malvika Sagar
- Department of Pediatrics, McLane Children's Hospital, Baylor Scott and White Health, Temple, TX 76502, USA
| | | | - Abhay P Vakil
- Department of Pediatrics, McLane Children's Hospital, Baylor Scott and White Health, Temple, TX 76502, USA.,Critical Care Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Salim Surani
- Corpus Christi Medical Center, Corpus Christi, TX 78411, USA.,Texas A&M University System Health Science Center, Bryan, TX 77807, USA
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114
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Vogels Y, Pouwels S, van Oers J, Ramnarain D. Characteristics and Risk Factors Associated With Mortality in Critically Ill Patients With COVID-19. Cureus 2021; 13:e14442. [PMID: 33996306 PMCID: PMC8114967 DOI: 10.7759/cureus.14442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose To describe clinical characteristics and outcomes of ICU patients with COVID-19 and to investigate differences between survivors and non-survivors. Methods Demographics, symptoms, laboratory values, comorbidities and outcomes were extracted retrospectively from the medical records of ICU patients with confirmed COVID-19 pneumonia from the Elisabeth-TweeSteden Hospital in Tilburg, the Netherlands from March until June 2020. Primary outcome was 28-day mortality and secondary outcomes were differences between survivors and non-survivors. Results Between March 1 and June 4, 2020, 114 patients with COVID-19 were admitted to the ICU. There were 83 (72.8%) survivors and 31 (27.2%) non-survivors. Non-survivors were significantly older (72.0 years [interquartile range, IQR 67.0-76.0] versus 65.0 years [IQR 58.0-73.0], P = 0.002), had a significantly higher Acute Physiology And Chronic Health Evaluation (APACHE) score (54 [IQR 45-72] versus 43 [IQR 36-53], P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (7 [IQR 4-7] versus 5 [IQR 3-6], P = 004). cTnT values were significantly higher in non-survivors due to more myocarditis (83.9% versus 40.8%, P < 0.001). A multivariate Cox regression model revealed SOFA score (hazard ratio, HR 1.337, 95% CI 1.131-1.582, P = 0.001) to be an independent predictor of 28-day mortality. Conclusion We demonstrated a 28-day mortality rate of 27.2% in our cohort. These patients were older and presented with a higher severity of illness and more organ failure.
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Affiliation(s)
- Yannick Vogels
- Intensive Care Medicine, Elisabeth-TweeSteden Hospital, Tilburg, NLD
| | - Sjaak Pouwels
- Intensive Care Medicine, Elisabeth-TweeSteden Hospital, Tilburg, NLD
| | - Jos van Oers
- Intensive Care Medicine, Elisabeth-TweeSteden Hospital, Tilburg, NLD
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115
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Methods and measures to quantify ICU patient heterogeneity. J Biomed Inform 2021; 117:103768. [PMID: 33839305 DOI: 10.1016/j.jbi.2021.103768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/21/2021] [Accepted: 03/29/2021] [Indexed: 11/22/2022]
Abstract
Patients in intensive care units are heterogeneous and the daily prediction of their days to discharge (DTD) a complex task that practitioners and computers are not always able to solve satisfactorily. In order to make more precise DTD predictors, it is necessary to have tools for the analysis of the heterogeneity of the patients. Unfortunately, the number of publications in this field is almost non-existent. In order to alleviate this lack of tools, we propose four methods and their corresponding measures to quantify the heterogeneity of intensive patients in the process of determining the DTD. These new methods and measures have been tested with patients admitted over four years to a tertiary hospital in Spain. The results deepen the understanding of the intensive patient and can serve as a basis for the construction of better DTD predictors.
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116
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McKeever L. Overview of Study Designs: A Deep Dive Into Research Quality Assessment. Nutr Clin Pract 2021; 36:569-585. [DOI: 10.1002/ncp.10647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Liam McKeever
- Department of Biostatistics, Epidemiology, and Informatics University of Pennsylvania Philadelphia Pennsylvania USA
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117
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Urinary Titin N-Fragment Evaluation in a Randomized Controlled Trial of Beta-Hydroxy-Beta-Methylbutyrate for Acute Mild Trauma in Older Adults. Nutrients 2021; 13:nu13030899. [PMID: 33802012 PMCID: PMC8001392 DOI: 10.3390/nu13030899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 11/17/2022] Open
Abstract
The effects of beta-hydroxy-beta-methylbutyrate (HMB) complex administration and the significance of titin, a biomarker of muscle injury, in elderly minor trauma patients in acute phase has not been established. In this single-center, randomized controlled study, trauma patients aged ≥ 70 years with an injury severity score < 16 were included. Titin values on days 1 and 3 were measured and the intervention group received HMB complex (2.4 g of HMB + 14 g of glutamine + 14 g of arginine) and the control group received glutamine complex (7.2 g of protein including 6 g of glutamine). The cross-sectional area of the rectus femoris (RFCSA) on ultrasound, grip strength, and the Barthel Index were assessed on the first day of rehabilitation and after 2 weeks. We analyzed 24 HMB and 25 control participants. Titin values on day 3 correlated with grip strength (r = -0.34, p = 0.03) and the Barthel Index (r = -0.39, p = 0.01) at follow-up. HMB complex supplementation had no effect on the RFCSA (2.41 vs. 2.45 cm2, p = 0.887), grip strength (13.3 vs. 13.1 kg, p = 0.946), or the Barthel Index (20.0 vs. 50.0, p = 0.404) at follow-up. Titin values might associate with subsequent physical function. Short-term HMB complex supplementation from acute phase did not ameliorate muscle injury.
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Fortini A, Faraone A, Meini S, Bettucchi M, Longo B, Valoriani B, Forni S. Validity of "Sepsis-3" criteria in identifying patients with community-onset sepsis in Internal Medicine wards; a prospective, multicenter study. Eur J Intern Med 2021; 85:92-97. [PMID: 33451890 DOI: 10.1016/j.ejim.2020.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Few data are available on the validity of "Sepsis-3" criteria in identifying patients with sepsis in internal medicine wards (IMWs). Real-life data about this topic and on the prevalence of sepsis in IMWs could be useful for improving hospital organization. OBJECTIVES To assess the validity of "Sepsis-3" criteria in identifying patients with community-onset sepsis in IMWs. Secondary objectives: to evaluate the prevalence of these patients in IMWs and to compare "Sepsis-3" and "Sepsis-1" criteria. METHODS Multicenter, prospective, observational, cohort study, carried out in 22 IMWs of Tuscany (Italy). All patients admitted to each of the study centers over a period of 21-31 days were evaluated within 48 hours; those with clinical signs of infection were enrolled. The main outcome was in-hospital mortality. RESULTS 2,839 patients were evaluated and 938 (33%) met the inclusion criteria. Patients with sepsis diagnosed according to "Sepsis-3" were 522, representing 55.6% of patients with infection and 18.4% of all patients hospitalized; they were older than those without sepsis (79.4±12.5 vs 74.6±15.2 years, p<0.001). In-hospital mortality was significantly higher in patients with sepsis compared to others (13.8% vs 4.6%; p<0.001). "Sepsis-3" criteria showed greater predictive validity for in-hospital mortality than "Sepsis-1" criteria (AUROC=0.71; 95%CI, 0.66-0.77 vs 0.60; 95%CI 0.54-0.66; p=0.0038). CONCLUSIONS "Sepsis-3" criteria are able to identify patients with community-onset sepsis in IMWs, whose prevalence and in-hospital mortality are remarkably high. Medical departments should adapt their organization to the needs for care of these complex patients.
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Affiliation(s)
- Alberto Fortini
- Internal Medicine, San Giovanni di Dio Hospital, Via di Torregalli 3, 50143 Firenze, Italy.
| | - Antonio Faraone
- Internal Medicine, San Giovanni di Dio Hospital, Via di Torregalli 3, 50143 Firenze, Italy
| | - Simone Meini
- Internal Medicine, Santa Maria Annunziata Hospital, Via Antella 58, 50012 Bagno a Ripol (Firenze), Italy; Internal Medicine, Felice Lotti Hospital, Via Roma, 147, 56025 Pontedera (Pisa), Italy
| | - Michael Bettucchi
- Internal Medicine, San Giovanni di Dio Hospital, Via di Torregalli 3, 50143 Firenze, Italy
| | - Benedetta Longo
- Internal Medicine, Felice Lotti Hospital, Via Roma, 147, 56025 Pontedera (Pisa), Italy
| | - Beatrice Valoriani
- Internal Medicine, Valdichiana Hospital, Località Nottola, 53045 Montepulciano (Siena), Italy
| | - Silvia Forni
- Regional Health Agency of Tuscany, Via Pietro Dazzi, 1, 50141 Firenze, Italy
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Mulatu HA, Bayisa T, Worku Y, Lazarus JJ, Woldeyes E, Bacha D, Taye B, Nigussie M, Gebeyehu H, Kebede A. Prevalence and outcome of sepsis and septic shock in intensive care units in Addis Ababa, Ethiopia: A prospective observational study. Afr J Emerg Med 2021; 11:188-195. [PMID: 33680740 PMCID: PMC7910175 DOI: 10.1016/j.afjem.2020.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/23/2020] [Accepted: 10/02/2020] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis and septic shock are the major causes of morbidity and mortality in Intensive care Units (ICUs) in low and middle-income countries. However, little is known about their prevalence and outcome in these settings. The study aimed to assess the prevalence and outcome of sepsis and septic shock in ICUs in Addis Ababa, Ethiopia. Methods A prospective observational study was conducted from March 2017 to February 2018 in four selected ICUs in Addis Ababa from a total of twelve hospitals having ICU services. There were 1145 total ICU admissions during the study period. All admissions into those ICUs with sepsis, severe sepsis, and septic shock using the Systemic Inflammatory Response Syndrome (SIRS) criteria (SEPSIS-2) during the study period were screened for sepsis or septic shock based on the new sepsis definition (SEPSIS-3). All patients with sepsis and septic shock during ICU admission were included and followed for 28 days of ICU admission. Data analysis was done using the Statistical Package for Social Sciences (SPSS) software version 20.0. Results A total of 275 patients were diagnosed with sepsis and septic shock. The overall prevalence of sepsis and septic shock was 26.5 per 100 ICU admissions. The most frequent source of sepsis was respiratory infection (53.1%). The median length of stay in the ICUs was 5 (IQR, 2–8) days. The most common bacterium isolate was Pseudomonas aeroginosa (34.5%). The ICU and 28-day mortality rate was 41.8% and 50.9% respectively. Male sex, modified Sequential Organ Failure Assessment score ≥10 on day 1 of ICU admission, and comorbidity of HIV or malignancy were the independent predictors of 28-day mortality. Conclusion Sepsis and septic shock are common among our ICU admissions, and are associated with a high mortality rate.
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Interleukin-37 as a biomarker of mortality risk in patients with sepsis. J Infect 2021; 82:346-354. [PMID: 33545167 DOI: 10.1016/j.jinf.2021.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/22/2021] [Accepted: 01/27/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Sepsis is a serious syndrome that is caused by an unbalanced inflammatory response to infection and can cause high mortality. The role of interleukin-37 (IL-37) in estimating the mortality in patients with sepsis remains unknown. This study aims to reveal the clinical application of IL-37 as a potentially novel biomarker to predict mortality risk in patients with sepsis. METHODS The serum IL-37 level in 114 adult septic patient serum samples on the day of intensive care unit (ICU) admission, 56 non-sepsis ICU patients, and 56 healthy volunteers were measured and analyzed, and the 28-day survival status and sequential organ failure assessment (SOFA) scores of the participants were compared. Furthermore, the area under the receiver operating characteristic curve (AUC) of IL-37, IL-6, and SOFA at ICU admission for 28-day survival was used to evaluate the ability of IL-37 in predicting the mortality of sepsis. RESULTS The serum IL-37 level at admission was elevated in patients with sepsis. Moreover, the concentration of IL-37 in patients with sepsis was significantly higher than that in non-sepsis ICU patients and the healthy control group. In addition, the concentration of serum IL-37 in non-surviving patients with sepsis was significantly higher than that in survivors. In patients with sepsis on the day of ICU admission, the AUC associated with 28-day mortality was 0.67 (p = 0.0022;95% confidence interval [95% CI], 0.57-0.77) for IL-37, 0.75 (p < 0.0001; 95% CI, 0.66-0.84) for SOFA, and 0.62 (p = 0.0342; 95% CI, 0.51-0.72) for IL-6. IL-37 and SOFA scores on the day of ICU admission of the patients with sepsis were found to be independent predictors of 28-day mortality, whereas IL-6 was not. The risk of mortality in patients with sepsis and high serum IL-37 concentration (≥107.05pg/ml) was 4.6 times that of patients with sepsis and low serum concentration. The AUC of IL-37 combined with SOFA-estimated 28-day mortality in patients with sepsis increased from 0.67 (p = 0.0022; 95% CI, 0.57-0.77) to 0.80 (p < 0.0001; 95% CI, 0.711-0.879). In addition, patients with sepsis and high serum IL-37 concentrations (≥107.05pg/ml) had poorer survival rate than those with low serum concentrations (<107.05pg/ml). CONCLUSION IL-37 concentrations at ICU admission are valuable for predicting the 28-day mortality risk of patients with sepsis, suggesting that IL-37 may be a novel biomarker. These findings can be used as a basis for guiding early clinical decision-making in treating patients with sepsis.
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Touzani S, El Bouazzaoui A, Bouyarmane F, Faraj K, Houari N, Boukatta B, Kanjaa N. Factors Associated with Mortality in Severe Acute Cholangitis in a Moroccan Intensive Care Unit: A Retrospective Analysis of 140 Cases. Gastroenterol Res Pract 2021; 2021:4583493. [PMID: 33574838 PMCID: PMC7861946 DOI: 10.1155/2021/4583493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/14/2021] [Accepted: 01/22/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Severe acute cholangitis is a life-threatening biliary infection, leading to organ dysfunction, septic shock, and naturally death. Mortality has dropped significantly in the past years through improving resuscitation and biliary drainage techniques. The aim of our study is to analyze our daily practice and the factors associated with mortality. METHODS A retrospective study including severe acute cholangitis patients admitted to our unit from January 2009 to December 2018. Variables analyzed (univariate then multivariate analysis) were age, sex, history, origin, evolution time, bilirubin, etiology, organ dysfunction, qSOFA, SOFA, TOKYO, biliary drainage timing and technique, shock, antibiotherapy, and resuscitation. RESULTS 140 patients were included in this study. Average age was 61. Sex ratio M/F was 0.59. Lithiasis etiology was dominant (69%). SOFA average score upon admission was 8. Ceftriaxone + metronidazole was the empirical antibiotic used in 87%. Average time to biliary drainage was 1.58 ± 0.89 days. Endoscopic unblocking was the technique used in 76%. Mean duration of ICU stay was 6 days. Mortality rate was 28%. Statistically significant factors for mortality (p < 0.05) were history of taking anticoagulant treatment, use of catecholamines and mechanical ventilation during ICU stay, and delay in consultation and administration of antibiotic therapy. CONCLUSIONS Early recognition, antibiotics, resuscitation, and minimally invasive biliary drainage have improved patient outcomes although there is still progress to be made. Moreover, as multiple organ failure is often associated with mortality in severe acute cholangitis, predictive risk factors of organ failure should be more investigated.
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Affiliation(s)
- Soumaya Touzani
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Abderrahim El Bouazzaoui
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Fatima Bouyarmane
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Kaoutar Faraj
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Nawfal Houari
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Brahim Boukatta
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Nabil Kanjaa
- Anesthesiology and Intensive Care Department A4, Hassan II University Hospital, Sidi Mohammed Ben Abdellah University, Fez, Morocco
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Multicenter study of ceftolozane/tazobactam for treatment of Pseudomonas aeruginosa infections in critically ill patients. Int J Antimicrob Agents 2021; 57:106270. [PMID: 33347991 DOI: 10.1016/j.ijantimicag.2020.106270] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 12/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND This study aimed to assess the efficacy of ceftolozane-tazobactam (C/T) for treating infections due to Pseudomonas aeruginosa (P. aeruginosa) in critically ill patients. PATIENTS AND METHODS A multicenter, retrospective and observational study was conducted in critically ill patients receiving different C/T dosages and antibiotic combinations for P. aeruginosa infections. Demographic data, localisation and severity of infection, clinical and microbiological outcome, and mortality were evaluated. RESULTS Ninety-five patients received C/T for P. aeruginosa serious infections. The main infections were nosocomial pneumonia (56.2%), intra-abdominal infection (10.5%), tracheobronchitis (8.4%), and urinary tract infection (6.3%). Most infections were complicated with sepsis (49.5%) or septic shock (45.3%), and bacteraemia (10.5%). Forty-six episodes were treated with high-dose C/T (3 g every 8 hours) and 38 episodes were treated with standard dosage (1.5 g every 8 hours). Almost half (44.2%) of the patients were treated with C/T monotherapy, and the remaining group received combination therapy with other antibiotics. Sixty-eight (71.6%) patients presented a favourable clinical response. Microbiological eradication was documented in 42.1% (40/95) of the episodes. The global ICU mortality was 36.5%. Univariate analysis showed that 30-day mortality was significantly associated (P < 0.05) with Charlson Index at ICU admission and the need of life-supporting therapies. CONCLUSIONS C/T appeared to be an effective therapy for severe infections due to P. aeruginosa in critically ill patients. Mortality was mainly related to the severity of the infection. No benefit was observed with high-dose C/T or combination therapy with other antibiotics.
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Sottile PD, Albers D, DeWitt PE, Russell S, Stroh JN, Kao DP, Adrian B, Levine ME, Mooney R, Larchick L, Kutner JS, Wynia MK, Glasheen JJ, Bennett TD. Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 33469601 DOI: 10.1101/2021.01.14.21249793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background The SARS-CoV-2 virus has infected millions of people, overwhelming critical care resources in some regions. Many plans for rationing critical care resources during crises are based on the Sequential Organ Failure Assessment (SOFA) score. The COVID-19 pandemic created an emergent need to develop and validate a novel electronic health record (EHR)-computable tool to predict mortality. Research Questions To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon SOFA. Study Design and Methods We conducted a prospective cohort study of a regional health system with 12 hospitals in Colorado between March 2020 and July 2020. All patients >14 years old hospitalized during the study period without a do not resuscitate order were included. Patients were stratified by the diagnosis of COVID-19. From this cohort, we developed and validated a model using stacked generalization to predict mortality using data widely available in the EHR by combining five previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. Results We prospectively analyzed 27,296 encounters, of which 1,358 (5.0%) were positive for SARS-CoV-2, 4,494 (16.5%) included intensive care unit (ICU)-level care, 1,480 (5.4%) included invasive mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted overall mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted overall mortality with AUROC 0.94. In the subset of patients with COVID-19, we predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. Interpretation We developed and validated an accurate, in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model, that improved upon SOFA. Take Home Points Study Question: Can we improve upon the SOFA score for real-time mortality prediction during the COVID-19 pandemic by leveraging electronic health record (EHR) data?Results: We rapidly developed and implemented a novel yet SOFA-anchored mortality model across 12 hospitals and conducted a prospective cohort study of 27,296 adult hospitalizations, 1,358 (5.0%) of which were positive for SARS-CoV-2. The Charlson Comorbidity Index and SOFA scores predicted all-cause mortality with AUROCs of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94.Interpretation: A novel EHR-based mortality score can be rapidly implemented to better predict patient outcomes during an evolving pandemic.
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Lavillegrand JR, Garnier M, Spaeth A, Mario N, Hariri G, Pilon A, Berti E, Fieux F, Thietart S, Urbina T, Turpin M, Darrivere L, Fartoukh M, Verdonk F, Dumas G, Tedgui A, Guidet B, Maury E, Chantran Y, Voiriot G, Ait-Oufella H. Elevated plasma IL-6 and CRP levels are associated with adverse clinical outcomes and death in critically ill SARS-CoV-2 patients: inflammatory response of SARS-CoV-2 patients. Ann Intensive Care 2021; 11:9. [PMID: 33439360 PMCID: PMC7804215 DOI: 10.1186/s13613-020-00798-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/29/2020] [Indexed: 01/08/2023] Open
Abstract
Background SARS coronavirus 2 (SARS-CoV-2) is responsible for high morbidity and mortality worldwide, mostly due to the exacerbated inflammatory response observed in critically ill patients. However, little is known about the kinetics of the systemic immune response and its association with survival in SARS-CoV-2+ patients admitted in ICU. We aimed to compare the immuno-inflammatory features according to organ failure severity and in-ICU mortality. Methods Six-week multicentre study (N = 3) including SARS-CoV-2+ patients admitted in ICU. Analysis of plasma biomarkers at days 0 and 3–4 according to organ failure worsening (increase in SOFA score) and 60-day mortality. Results 101 patients were included. Patients had severe respiratory diseases with PaO2/FiO2 of 155 [111–251] mmHg), SAPS II of 37 [31–45] and SOFA score of 4 [3–7]. Eighty-three patients (83%) required endotracheal intubation/mechanical ventilation and among them, 64% were treated with prone position. IL-1β was barely detectable. Baseline IL-6 levels positively correlated with organ failure severity. Baseline IL-6 and CRP levels were significantly higher in patients in the worsening group than in the non-worsening group (278 [70–622] vs. 71 [29–153] pg/mL, P < 0.01; and 178 [100–295] vs. 100 [37–213] mg/L, P < 0.05, respectively). Baseline IL-6 and CRP levels were significantly higher in non-survivors compared to survivors but fibrinogen levels and lymphocyte counts were not different between groups. After adjustment on SOFA score and time from symptom onset to first dosage, IL-6 and CRP remained significantly associated with mortality. IL-6 changes between Day 0 and Day 3–4 were not different according to the outcome. A contrario, kinetics of CRP and lymphocyte count were different between survivors and non-survivors. Conclusions In SARS-CoV-2+ patients admitted in ICU, a systemic pro-inflammatory signature was associated with clinical worsening and 60-day mortality.
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Affiliation(s)
- Jean-Rémi Lavillegrand
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Marc Garnier
- Sorbonne Université, Paris, France.,Service D'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Agathe Spaeth
- Département de Biochimie, Hormonologie et Suivi Thérapeutique, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nathalie Mario
- Département de Biochimie, Hormonologie et Suivi Thérapeutique, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Geoffroy Hariri
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Antoine Pilon
- Département de Biochimie, Hormonologie et Suivi Thérapeutique, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Enora Berti
- Sorbonne Université, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Fabienne Fieux
- Service D'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sara Thietart
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Tomas Urbina
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Matthieu Turpin
- Sorbonne Université, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Darrivere
- Service D'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Sorbonne Université, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Franck Verdonk
- Service D'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Dumas
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France
| | - Alain Tedgui
- Inserm U970, Cardiovascular Research Center, Université de Paris, Paris, France
| | - Bertrand Guidet
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France.,Sorbonne Université, Paris, France
| | - Yannick Chantran
- Département D'Immunologie Biologique, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Voiriot
- Sorbonne Université, Paris, France.,Service de Médecine Intensive-Réanimation, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571, Paris cedex 12, France. .,Sorbonne Université, Paris, France. .,Inserm U970, Cardiovascular Research Center, Université de Paris, Paris, France.
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Factors associated with survival of patients with solid Cancer alive after intensive care unit discharge between 2005 and 2013. BMC Cancer 2021; 21:9. [PMID: 33402107 PMCID: PMC7786972 DOI: 10.1186/s12885-020-07706-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/01/2020] [Indexed: 12/24/2022] Open
Abstract
Background At intensive care unit (ICU) admission, the issue about prognosis of critically ill cancer patients is of clinical interest, especially after ICU discharge. Our objective was to assess the factors associated with 3- and 6-month survival of ICU cancer survivors. Methods Based on the French OutcomeRea™ database, we included solid cancer patients discharged alive, between December 2005 and November 2013, from the medical ICU of the university hospital in Grenoble, France. Patient characteristics and outcome at 3 and 6 months following ICU discharge were extracted from available database. Results Of the 361 cancer patients with unscheduled admissions, 253 (70%) were discharged alive from ICU. The main primary cancer sites were digestive (31%) and thoracic (26%). The 3- and 6-month mortality rates were 33 and 41%, respectively. Factors independently associated with 6-month mortality included ECOG performance status (ECOG-PS) of 3–4 (OR,3.74; 95%CI: 1.67–8.37), metastatic disease (OR,2.56; 95%CI: 1.34–4.90), admission for cancer progression (OR,2.31; 95%CI: 1.14–4.68), SAPS II of 45 to 58 (OR,4.19; 95%CI: 1.76–9.97), and treatment limitation decision at ICU admission (OR,4.00; 95%CI: 1.64–9.77). Interestingly, previous cancer chemotherapy prior to ICU admission was independently associated with lower 3-month mortality (OR, 0.38; 95%CI: 0.19–0.75). Among patients with an ECOG-PS 0–1 at admission, 70% (n = 66) and 61% (n = 57) displayed an ECOG-PS 0–2 at 3- and 6-months, respectively. At 3 months, 74 (55%) patients received anticancer treatment, 13 (8%) were given exclusive palliative care. Conclusions Factors associated with 6-month mortality are almost the same as those known to be associated with ICU mortality. We highlight that most patients recovered an ECOG-PS of 0–2 at 3 and 6 months, in particular those with a good ECOG-PS at ICU admission and could benefit from an anticancer treatment following ICU discharge. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-020-07706-3.
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Solmos S, LaFond C, Pohlman AS, Sala J, Mayampurath A. Characteristics of Critically Ill Adults With Sacrococcygeal Unavoidable Hospital-Acquired Pressure Injuries: A Retrospective, Matched, Case-Control Study. J Wound Ostomy Continence Nurs 2021; 48:11-19. [PMID: 33427805 DOI: 10.1097/won.0000000000000721] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To identify characteristics of critically ill adults with sacrococcygeal, unavoidable hospital-acquired pressure injuries (uHAPIs). DESIGN Retrospective, matched, case-control design. SUBJECTS/SETTING Patients admitted to adult intensive care units (ICUs) at an urban academic medical center from January 2014 through July 2016. METHODS Thirty-four patients without uHAPI were matched to 34 patients with sacrococcygeal uHAPI. Time points of interest included admission to the ICU, the week preceding the definitive assessment date, and hospital discharge status. Variables of interest included length of stay, any diagnosis of sepsis, severity of illness, degree of organ dysfunction/failure, supportive therapies in use (eg, mechanical ventilation), and pressure injury risk (Braden Scale score). RESULTS All 34 sacrococcygeal pressure injuries were classified as uHAPI using the pressure injury prevention inventory instrument. No statistically significant differences were noted between patients for severity of illness, degree of organ dysfunction/failure, or pressure injury risk at ICU admission. At 1 day prior to the definitive assessment date and at discharge, patients with uHAPI had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores (greater organ dysfunction/failure) and lower mean Braden Scale scores (greater pressure injury risk) than patients without uHAPI. Patients with uHAPI had significantly longer lengths of stay, more supportive therapies in use, were more often diagnosed with sepsis, and were more likely to die during hospitalization. CONCLUSION Sacrococcygeal uHAPI development was associated with progressive multiorgan dysfunction/failure, greater use of supportive therapies, sepsis diagnosis, and mortality. Additional research investigating the role of multiorgan dysfunction/failure and sepsis on uHAPI development is warranted.
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Affiliation(s)
- Susan Solmos
- Susan Solmos, MSN, RN, CWCN, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois
- Cynthia LaFond, PhD, RN, CCRN-K, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois; Rush University Medical Center, Chicago, Illinois
- Anne S. Pohlman, MSN, RN, CCRN, Section of Pulmonary/Critical Care, Department of Medicine, the University of Chicago, Chicago, Illinois
- Jennifer Sala, ADN, RN, Medical Intensive Care Unit, the University of Chicago Medicine, Chicago, Illinois
- Anoop Mayampurath, PhD, Department of Pediatrics, the University of Chicago, Chicago, Illinois; Center for Research Informatics, the University of Chicago, Chicago, Illinois
| | - Cynthia LaFond
- Susan Solmos, MSN, RN, CWCN, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois
- Cynthia LaFond, PhD, RN, CCRN-K, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois; Rush University Medical Center, Chicago, Illinois
- Anne S. Pohlman, MSN, RN, CCRN, Section of Pulmonary/Critical Care, Department of Medicine, the University of Chicago, Chicago, Illinois
- Jennifer Sala, ADN, RN, Medical Intensive Care Unit, the University of Chicago Medicine, Chicago, Illinois
- Anoop Mayampurath, PhD, Department of Pediatrics, the University of Chicago, Chicago, Illinois; Center for Research Informatics, the University of Chicago, Chicago, Illinois
| | - Anne S Pohlman
- Susan Solmos, MSN, RN, CWCN, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois
- Cynthia LaFond, PhD, RN, CCRN-K, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois; Rush University Medical Center, Chicago, Illinois
- Anne S. Pohlman, MSN, RN, CCRN, Section of Pulmonary/Critical Care, Department of Medicine, the University of Chicago, Chicago, Illinois
- Jennifer Sala, ADN, RN, Medical Intensive Care Unit, the University of Chicago Medicine, Chicago, Illinois
- Anoop Mayampurath, PhD, Department of Pediatrics, the University of Chicago, Chicago, Illinois; Center for Research Informatics, the University of Chicago, Chicago, Illinois
| | - Jennifer Sala
- Susan Solmos, MSN, RN, CWCN, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois
- Cynthia LaFond, PhD, RN, CCRN-K, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois; Rush University Medical Center, Chicago, Illinois
- Anne S. Pohlman, MSN, RN, CCRN, Section of Pulmonary/Critical Care, Department of Medicine, the University of Chicago, Chicago, Illinois
- Jennifer Sala, ADN, RN, Medical Intensive Care Unit, the University of Chicago Medicine, Chicago, Illinois
- Anoop Mayampurath, PhD, Department of Pediatrics, the University of Chicago, Chicago, Illinois; Center for Research Informatics, the University of Chicago, Chicago, Illinois
| | - Anoop Mayampurath
- Susan Solmos, MSN, RN, CWCN, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois
- Cynthia LaFond, PhD, RN, CCRN-K, Center for Nursing Professional Practice and Research, the University of Chicago Medicine, Chicago, Illinois; Rush University Medical Center, Chicago, Illinois
- Anne S. Pohlman, MSN, RN, CCRN, Section of Pulmonary/Critical Care, Department of Medicine, the University of Chicago, Chicago, Illinois
- Jennifer Sala, ADN, RN, Medical Intensive Care Unit, the University of Chicago Medicine, Chicago, Illinois
- Anoop Mayampurath, PhD, Department of Pediatrics, the University of Chicago, Chicago, Illinois; Center for Research Informatics, the University of Chicago, Chicago, Illinois
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Kannaujia A, Srivastava U, Dwivedi Y, Verma S, Ambasta S, Lalramthara I. Sequential organ failure assessment score for predicting outcome of severely ill obstetric patients admitted to intensive care unit. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.4103/joacc.joacc_15_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ramos Hernández C, Botana Rial M, Pazos Area LA, Núñez Fernández M, Pérez Fernández S, Rubianes González M, Crespo Casal M, Fernández Villar A. [Lung Ultrasound to Predict Unfavorable Progress in Patients Hospitalized for COVID-19]. Arch Bronconeumol 2021; 57:47-54. [PMID: 34629648 PMCID: PMC7505546 DOI: 10.1016/j.arbres.2020.07.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/28/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Thoracic ultrasound has been shown to be useful in the diagnosis of COVID-19 pulmonary involvement. Several scores for quantifying the degree of involvement have been described, although there is no evidence to show that they have any capacity for predicting unfavorable progress. METHODOLOGY Prospective cohort study of patients hospitalized for COVID-19. The sample was stratified according to clinical course, and patients requiring invasive or non-invasive respiratory support were classified as having unfavorable progress. Biomarkers were analyzed at admission and on the same day that thoracic ultrasound was performed. Prognostic scales were also determined at admission. The ultrasound score was obtained in 8 or 14 areas, depending on the patient's ability to sit. RESULTS We included 44 patients, 13 (29,5%) of whom subsequently needed ventilatory support. Eight areas were explored in all patients and 14 areas in 35 (79.5%). The most affected areas were the posterior lower lobes. Significant differences were found between the 2 groups on the SOFA and quick SOFA multidimensional scales, and PCR and LDH on the same day as thoracic ultrasound, and the ultrasound scores. The best area under the ROC curve (AUC) was obtained with the 14-area score, with a result of 0.88 (95% CI: 0.75-0.99). Its sensitivity and specificity for a cut-off score of 13.5 were 100% and 61.5%, respectively. CONCLUSIONS The use of scores to quantify lung involvement measured by thoracic ultrasound provides useful information, facilitating risk stratification in patients hospitalized with COVID-19.
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Affiliation(s)
- Cristina Ramos Hernández
- Departamento de Neumología, Hospital Álvaro Cunqueiro; Neumo Vigo I+i. Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
| | - Maribel Botana Rial
- Departamento de Neumología, Hospital Álvaro Cunqueiro; Neumo Vigo I+i. Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
| | - Luis Alberto Pazos Area
- Departamento de Neumología, Hospital Álvaro Cunqueiro; Neumo Vigo I+i. Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
| | - Marta Núñez Fernández
- Departamento de Neumología, Hospital Álvaro Cunqueiro; Neumo Vigo I+i. Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
| | | | | | | | - Alberto Fernández Villar
- Departamento de Neumología, Hospital Álvaro Cunqueiro; Neumo Vigo I+i. Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, España
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Sehgal IS, Agarwal R, Dhooria S, Prasad KT, Muthu V, Aggarwal AN. Etiology and Outcomes of ARDS in the Elderly Population in an Intensive Care Unit in North India. Indian J Crit Care Med 2021; 25:648-654. [PMID: 34316144 PMCID: PMC8286392 DOI: 10.5005/jp-journals-10071-23878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background Whether age would impact the outcomes in subjects with acute respiratory distress syndrome (ARDS) remains unclear. Herein, we study the effect of age as a predictor of mortality in ARDS. Materials and methods We categorized consecutive subjects with ARDS as either ARDSelderly (age >65 years) or ARDSnonelderly (age ≤65 years) admitted to the respiratory intensive care unit (ICU) of a tertiary care hospital in North India between January 2007 and December 2019. We compared the baseline clinical and demographic characteristics, lung mechanics, and mortality between the two groups. We also analyzed the factors predicting ICU survival using multivariate logistic regression analysis. Results We included 625 patients (ARDSelderly, 140 [22.4%] and ARDSnonelderly, 485 [77.6%]) with a mean (standard deviation) age (56.3% males) of 40.6 (17.8) years. The ARDSelderly were more likely (p = 0.0001) to have the presence of any comorbid illness compared to ARDSnonelderly. The elderly subjects had significantly higher pulmonary ARDS than the younger group. The severity of ARDS was however, similarly distributed between the two study arms. There were 224 (35.8%) deaths, and the mortality was significantly higher (p = 0.012) in the ARDSelderly than the to ARDSnonelderly (ARDSelderly vs ARDSnonelderly, 45 vs 33.2%). On multivariate logistic regression analysis, the baseline sequential organ failure assessment scores, presence of pulmonary ARDS, and the development of new organ dysfunction were the independent predictors of mortality. Conclusion The outcomes in subjects with ARDS are dependent on the severity of illness at admission and the etiology of ARDS rather than the age alone. How to cite this article Sehgal IS, Agarwal R, Dhooria S, Prasad KT, Muthu V, Aggarwal AN. Etiology and Outcomes of ARDS in the Elderly Population in an Intensive Care Unit in North India. Indian J Crit Care Med 2021;25(6):648–654.
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Affiliation(s)
- Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Debureaux PE, Darmon M, Bige N, Moreau AS, Mokart D, Morel G, Lacan C, Perez P, Pene F, Kouatchet A, Picard M, Murgier M, Wallet F, Mayaux J, Canet E, Azoulay E, Valade S. Sinusoidal Obstruction Syndrome in Critically Ill Patients in the Era of Defibrotide: A Retrospective Multicenter Study. Transplant Cell Ther 2020; 27:338.e1-338.e7. [PMID: 33836884 DOI: 10.1016/j.jtct.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
Sinusoidal obstruction syndrome (SOS) is a life-threatening liver complication of high- dose chemotherapy. Defibrotide is the only available therapeutic option approved for SOS. The prognosis of SOS in patients requiring intensive care unit (ICU) admission remains unknown. The primary objective of this study was to assess the outcome of SOS patients in ICU. This retrospective study was conducted between 2007 and 2019 in 13 French ICUs. Seventy-one critically ill adult patients with SOS defined according to European Society for Blood and Marrow Transplantation criteria and treated with defibrotide were included. The main reasons for ICU admission were respiratory failure and acute kidney injury. Mechanical ventilation, vasopressors, and renal replacement therapy were required in 59%, 52%, and 49% of patients, respectively. Twenty-three percent of patients experienced a bleeding event during defibrotide treatment. Hospital mortality was 54%, mainly related to multiorgan failure. Older age (hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.00 to 1.04), mechanical ventilation (HR, 1.99; 95% CI, 1.00 to 3.99), renal replacement therapy (HR, 2.55; 95% CI, 1.32 to 4.91) were independent predictors of hospital mortality. Defibrotide prophylaxis (HR, 0.35; 95% CI, 0.13 to 0.92) was associated with better outcomes. Critically ill patients with SOS have a high mortality rate in the ICU, especially if organ support is required. Additional studies assessing the impact of defibrotide prophylaxis are warranted.
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Affiliation(s)
| | - Michael Darmon
- Medical Intensive Care Unit, Saint Louis Hospital, Paris, France
| | - Naïke Bige
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Paris, France
| | | | - Djamel Mokart
- Intensive Care Unit, Institut Paoli-Calmettes, Marseille, France
| | - Guillaume Morel
- Intensive Medicine-Resuscitation Department, Strasbourg University Hospital, Strasbourg, France
| | - Claire Lacan
- Intensive Medicine-Resuscitation Department, Strasbourg University Hospital, Strasbourg, France
| | - Pierre Perez
- Medical Intensive Care Unit, Brabois University Hospital, Nancy, France
| | - Frédéric Pene
- Medical Intensive Care Unit, Cochin Hospital, AP-HP, University of Paris, Paris, France
| | - Achille Kouatchet
- Medical Intensive Care Unit, Angers Teaching Hospital, Angers, France
| | - Muriel Picard
- Intensive Care Unit, IUCT Oncopole, Toulouse, France
| | - Martin Murgier
- Medical-Surgical Intensive Care Unit, Saint-Priest-en-Jarez Hospital, Saint-Etienne, France
| | - Florent Wallet
- Medical Intensive Care Unit, Lyon Sud Teaching Hospital, Pierre Bénite, France
| | - Julien Mayaux
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Saint Louis Hospital, Paris, France
| | - Sandrine Valade
- Medical Intensive Care Unit, Saint Louis Hospital, Paris, France
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131
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Corrêa TD, Cordioli RL, Campos Guerra JC, Caldin da Silva B, dos Reis Rodrigues R, de Souza GM, Midega TD, Campos NS, Carneiro BV, Campos FND, Guimarães HP, de Matos GFJ, de Aranda VF, Rolim Ferraz LJ. Coagulation profile of COVID-19 patients admitted to the ICU: An exploratory study. PLoS One 2020; 15:e0243604. [PMID: 33320874 PMCID: PMC7737963 DOI: 10.1371/journal.pone.0243604] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Coagulation abnormalities in COVID-19 patients have not been addressed in depth. OBJECTIVE To perform a longitudinal evaluation of coagulation profile of patients admitted to the ICU with COVID-19. METHODS Conventional coagulation tests, rotational thromboelastometry (ROTEM), platelet function, fibrinolysis, antithrombin, protein C and S were measured at days 0, 1, 3, 7 and 14. Based on median total maximum SOFA score, patients were divided in two groups: SOFA ≤ 10 and SOFA > 10. RESULTS Thirty patients were studied. Some conventional coagulation tests, as aPTT, PT and INR remained unchanged during the study period, while alterations on others coagulation laboratory tests were detected. Fibrinogen levels were increased in both groups. ROTEM maximum clot firmness increased in both groups from Day 0 to Day 14. Moreover, ROTEM-FIBTEM maximum clot firmness was high in both groups, with a slight decrease from day 0 to day 14 in group SOFA ≤ 10 and a slight increase during the same period in group SOFA > 10. Fibrinolysis was low and decreased over time in all groups, with the most pronounced decrease observed in INTEM maximum lysis in group SOFA > 10. Also, D-dimer plasma levels were higher than normal reference range in both groups and free protein S plasma levels were low in both groups at baseline and increased over time, Finally, patients in group SOFA > 10 had lower plasminogen levels and Protein C than patients with SOFA <10, which may represent less fibrinolysis activity during a state of hypercoagulability. CONCLUSION COVID-19 patients have a pronounced hypercoagulability state, characterized by impaired endogenous anticoagulation and decreased fibrinolysis. The magnitude of coagulation abnormalities seems to correlate with the severity of organ dysfunction. The hypercoagulability state of COVID-19 patients was not only detected by ROTEM but it much more complex, where changes were observed on the fibrinolytic and endogenous anticoagulation system.
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Affiliation(s)
- Thiago Domingos Corrêa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ricardo Luiz Cordioli
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Bruno Caldin da Silva
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Hélio Penna Guimarães
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Abstract
Maternal mortality misses the morbidity associated with pregnancy and delivery. Maternal Near Miss is an alternate measure that reflects maternal morbidity and in areas with low maternal mortality improves comparability. Maternal Near Miss is a proxy indicator of the quality of healthcare services and helps in understanding health system failures with relation to obstetric care and addressing them. But regional variations in availability of resources have led to a dozen different adapted versions of WHO Maternal Near Miss criteria. This creates confusion and reduces comparability, nationally and internationally. A review of articles defining maternal near miss was conducted using a PubMed search to compare and assess the various definitions of MNM. The present article summarises the available criteria and discusses the advantages and drawbacks of WHO MNM criteria as compared to others. The objective is to impress the need to have comprehensive criteria that can be applied in different settings and ensure comparability.Impact statementWhat is already known on this subject? Many different definitions and criteria to diagnose Maternal Near Miss are available. They are diverse, thereby reducing comparability both nationally and internationally.What do the results of this study add? This article summarises the differences in the available definitions and classifying criteria. It also highlights the difficulty in usage of the criteria in different settings.What are the implications of these findings for clinical practice and/or further research? This calls for researchers working in areas of maternal health to further simplify the definitions and criteria used for identification of Maternal Near Miss to improve comparability and uniformity.
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Affiliation(s)
- Mohan Kumar M
- All India Institute of Medical Sciences, Raipur, India
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133
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Kawamoto E, Ito-Masui A, Esumi R, Imai H, Shimaoka M. How ICU Patient Severity Affects Communicative Interactions Between Healthcare Professionals: A Study Utilizing Wearable Sociometric Badges. Front Med (Lausanne) 2020; 7:606987. [PMID: 33344484 PMCID: PMC7744931 DOI: 10.3389/fmed.2020.606987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/10/2020] [Indexed: 11/13/2022] Open
Abstract
Numerous factors affecting the interactions between healthcare professionals in the workplace demand a comprehensive understanding if the quality of patient healthcare is to be improved. Our previous cross-sectional analysis showed that patient severity scores [i.e., Acute Physiology and Chronic Health Evaluation (APACHE) II] in the 24 h following admission positively correlated with the length of the face-to-face interactions among ICU healthcare professionals. The present study aims to address how the relationships between patient severity and interaction lengths can change over a period of time during both admission and treatment in the ICU. We retrospectively analyzed data prospectively collected between 19 February to 17 March 2016 from an open ICU in a University Hospital in Japan. We used wearable sensors to collect a spatiotemporal distribution dataset documenting the face-to-face interactions between ICU healthcare professionals, which involved 76 ICU staff members, each of whom worked for 160 h, on average, during the 4-week period of data collection. We studied the longitudinal relationships among these interactions, which occurred at the patient bedside, vis-à-vis the severity of the patient's condition [i.e., the Sequential Organ Failure Assessment (SOFA) score] assessed every 24 h. On Day 1, during which a total of 117 patients stayed in the ICU, we found statistically significant positive associations between the interaction lengths and their SOFA scores, as shown by the Spearman's correlation coefficient value (R) of 0.447 (p < 0.01). During the course of our observation from Day 1 to Day 10, the number of patients (N) who stayed in the ICU gradually decreased (N = 117, Day1; N = 10, Day 10), as they either were discharged or died. The statistically significant positive associations of the interaction lengths with the SOFA scores disappeared from Days 2 to 6, but re-emerged on Day 7 (R = 0.620, p < 0.05) and Day 8 (R = 0.625, p < 0.05), then disappearing again on Days 9 and 10. Whereas all 6 SOFA sub-scores correlated well with the interaction lengths on Day 1, only a few of the sub-scores (coagulation, cardiovascular, and central nervous system scores) did so; specifically, those on Days 7 and 8. The results suggest that patient severity may play an important role in affecting the interactions between ICU healthcare professionals in a time-related manner on ICU Day 1 and on Days 7/8.
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Affiliation(s)
- Eiji Kawamoto
- Departments of Molecular and Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan.,Departments of Emergency and Disaster Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Asami Ito-Masui
- Departments of Molecular and Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan.,Departments of Emergency and Disaster Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryo Esumi
- Departments of Molecular and Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan.,Departments of Emergency and Disaster Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroshi Imai
- Departments of Emergency and Disaster Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Motomu Shimaoka
- Departments of Molecular and Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan
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134
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Nutritional therapy among burn injured patients in the critical care setting: An international multicenter observational study on “best achievable” practices. Clin Nutr 2020; 39:3813-3820. [DOI: 10.1016/j.clnu.2020.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/31/2020] [Accepted: 04/10/2020] [Indexed: 12/20/2022]
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135
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Promotion of Regular Oesophageal Motility to Prevent Regurgitation and Enhance Nutrition Intake in Long-Stay ICU Patients. A Multicenter, Phase II, Sham-Controlled, Randomized Trial: The PROPEL Study. Crit Care Med 2020; 48:e219-e226. [PMID: 31904685 DOI: 10.1097/ccm.0000000000004176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To evaluate the effect of esophageal stimulation on nutritional adequacy in critically ill patients at risk for enteral feeding intolerance. DESIGN A multicenter randomized sham-controlled clinical trial. SETTING Twelve ICUs in Canada. PATIENTS We included mechanically ventilated ICU patients who were given moderate-to-high doses of opioids and expected to remain alive and ventilated for an additional 48 hours and who were receiving enteral nutrition or expected to start imminently. INTERVENTIONS Patients were randomly assigned 1:1 to esophageal stimulation via an esophageal stimulating catheter (E-Motion Tube; E-Motion Medical, Tel Aviv, Israel) or sham treatment. All patients were fed via these catheters using a standardized feeding protocol. MEASUREMENTS AND MAIN RESULTS The co-primary outcomes were proportion of caloric and protein prescription received enterally over the initial 7 days following randomization. Among 159 patients randomized, the modified intention-to-treat analysis included 155 patients: 73 patients in the active treatment group and 82 in the sham treatment group. Over the 7-day study period, the percent of prescribed caloric intake (± SE) received by the enteral route was 64% ± 2 in the active group and 65% ± 2 in sham patients for calories (difference, -1; 95% CI, -8 to 6; p = 0.74). For protein, it was 57% ± 3 in the active group and 60% ± 3 in the sham group (difference, -3; 95% CI, -10 to 3; p = 0.30). Compared to the sham group, there were more serious adverse events reported in the active treatment group (13 vs 6; p = 0.053). Clinically important arrhythmias were detected by Holter monitoring in 36 out of 70 (51%) in the active group versus 22 out of 76 (29%) in the sham group (p = 0.006). CONCLUSIONS Esophageal stimulation via a special feeding catheter did not improve nutritional adequacy and was associated with increase risk of harm in critically ill patients.
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Stoppe C, Hill A, Day AG, Kristof AS, Hundeshagen G, Kneser U, Beier J, Lumenta D, Kim BS, Plock J, Collins DP, Gille J, Jiang X, Heyland DK. The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation. Burns 2020; 47:765-775. [PMID: 33288334 DOI: 10.1016/j.burns.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/25/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency. METHODS This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care. RESULTS In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used. CONCLUSIONS POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted. STUDY TYPE Prospective cohort study, level of evidence: II.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH, Aachen, Germany; CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Aileen Hill
- Department of Intensive Care Medicine, University Hospital RWTH, Aachen, Germany; CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Andrew G Day
- KGH Research Institute, Kingston Health Sciences Centre, Kingston, Ontario
| | - Arnold S Kristof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Faculty of Medicine, Departments of Medicine and Critical Care, Montreal, Canada
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center. BG Trauma Center Ludwigshafen; University of Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center. BG Trauma Center Ludwigshafen; University of Heidelberg, Germany
| | - Justus Beier
- Department of Plastic, Hand and Burn Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - David Lumenta
- Research Unit for Tissue Regeneration, Repair and Reconstruction, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jan Plock
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Declan P Collins
- Department of Burns and Plastic Surgery, Chelsea and Westminster Hospital, London, United Kingdom
| | - Jochen Gille
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy. Burn Unit. St. Georg Hospital GmbH Leipzig, 04129 Leipzig, Germany
| | - Xuran Jiang
- Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada.
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137
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Brandtner A, Tymoszuk P, Nairz M, Lehner GF, Fritsche G, Vales A, Falkner A, Schennach H, Theurl I, Joannidis M, Weiss G, Pfeifhofer-Obermair C. Linkage of alterations in systemic iron homeostasis to patients' outcome in sepsis: a prospective study. J Intensive Care 2020; 8:76. [PMID: 33014378 PMCID: PMC7528491 DOI: 10.1186/s40560-020-00495-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/22/2020] [Indexed: 12/16/2022] Open
Abstract
Background Sepsis, a dysregulated host response following infection, is associated with massive immune activation and high mortality rates. There is still a need to define further risk factors and laboratory parameters predicting the clinical course. Iron metabolism is regulated by both, the body’s iron status and the immune response. Iron itself is required for erythropoiesis but also for many cellular and metabolic functions. Moreover, iron availability is a critical determinant in infections because it is an essential nutrient for most microbes but also impacts on immune function and intravascular oxidative stress. Herein, we used a prospective study design to investigate the putative impact of serum iron parameters on the outcome of sepsis. Methods Serum markers of iron metabolism were measured in a prospective cohort of 61 patients (37 males, 24 females) with sepsis defined by Sepsis-3 criteria in a medical intensive care unit (ICU) and compared between survivors and non-survivors. Regulation of iron parameters in patients stratified by focus of infection and co-medication as well as association of the markers with sepsis severity scores and survival were investigated with linear and logistic regression corrected for sex and age effects. Results Positive correlations of increased serum iron and ferritin concentrations upon ICU admission with the severity of organ failure (SOFA score) and with mortality were observed. Moreover, high TF-Sat, elevated ferritin and serum iron levels and low transferrin concentrations were associated with reduced survival. A logistic regression model consisting of SOFA and transferrin saturation (SOFA–TF-Sat) had the best predictive power for survival in septic ICU patients. Of note, administration of blood transfusions prior to ICU admission resulted in increased TF-Sat and reduced survival of septic patients. Conclusions Our study could show an important impact of serum iron parameters on the outcome of sepsis. Furthermore, we identified transferrin saturation as a stand-alone predictor of sepsis survival and as a parameter of iron metabolism which may in a combined model improve the prediction power of the SOFA score. Trial registration The study was carried out in accordance with the recommendations of the Declaration of Helsinki on biomedical research. The study was approved by the institutional ethics review board of the Medical University Innsbruck (study AN2013-0006).
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Affiliation(s)
- Anna Brandtner
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Piotr Tymoszuk
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria
| | - Manfred Nairz
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria
| | - Georg F Lehner
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Gernot Fritsche
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria
| | - Anja Vales
- Central Institute for Blood Transfusion and Immunology, Innsbruck, Austria
| | - Andreas Falkner
- Central Institute for Blood Transfusion and Immunology, Innsbruck, Austria
| | - Harald Schennach
- Central Institute for Blood Transfusion and Immunology, Innsbruck, Austria
| | - Igor Theurl
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Medical University of Innsbruck, Anichstr. 35, Innsbruck, Austria.,Christian Doppler Laboratory for Iron Metabolism and Anemia Research, Medical University of Innsbruck, Innsbruck, Austria
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138
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Tsai SY, Lio CF, Shih SC, Lin CJ, Chen YT, Yu CM, Sun FJ, Kuo CF, Jia X. The predisposing factors of AKI for prophylactic strategies in burn care. PeerJ 2020; 8:e9984. [PMID: 33072437 PMCID: PMC7537615 DOI: 10.7717/peerj.9984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 08/27/2020] [Indexed: 01/22/2023] Open
Abstract
Background Acute kidney injury (AKI) is one of the most severe complications of burn injury. AKI with severe burn injury causes high mortality. This study aims to investigate the incidence of and predisposing factors for AKI in burn patients. Methods This is a single-center, retrospective, descriptive criterion standard study conducted from June 27, 2015, to March 8, 2016. We used Kidney Disease Improving Global Outcomes criteria to define and select patients with AKI. The study was conducted by recruiting in hospital patients who suffered from the flammable cornstarch-based powder explosion and were treated under primary care procedures. A total of 49 patients who suffered from flammable dust explosion-related burn injury were enrolled and admitted on June 27, 2015. The patients with more than 20% total body surface area of burn were transferred to the intensive care unit. Patients received fluid resuscitation in the first 24 hours based on the Parkland formula. The primary measurements were the incidence of and predisposing factors for AKI in these patients. Demographic characteristics, laboratory data, and inpatient outcomes were also evaluated. The incidence of AKI in this cohort was 61.2% (n = 30). The mortality rate was 2.0% (n = 1) during a 59-day follow-up period. The multivariate analysis revealed inhalation injury (adjusted OR = 22.0; 95% CI [1.4–358.2]) and meeting ≥3 American Burn Association (ABA) sepsis criteria (adjusted OR = 13.7; 95% CI [1.7–110.5]) as independent risk factors for early advanced AKI. Conclusions The incidence rate of AKI was higher in this cohort than in previous studies, possibly due to the flammable dust explosion-related burn injury. However, the mortality was lower than that expected. In clinical practice, indicators of inflammation, including ABA sepsis criteria may help in predicting the risk of AKI in patients with burn injury.
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Affiliation(s)
- Shin-Yi Tsai
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan.,Graduate Institute of Biomedical Sciences; Graduate Institute of Long- Term Care, Mackay Medical College, New Taipei City, Taiwan.,Department of Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, MD, United States of America
| | - Chon-Fu Lio
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shou-Chuan Shih
- Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Cheng-Jui Lin
- Department of Nephrology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yu-Tien Chen
- Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chia-Meng Yu
- Department of Plastic Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chien-Feng Kuo
- Institute of Infectious Disease, Mackay Memorial Hospital, Taipei, Taiwan
| | - Xiaofeng Jia
- Biomedical Engineering, Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, United States of America.,Department of Neurosurgery, Orthopaedics, Anatomy & Neurobiology, University of Maryland at Baltimore, Baltimore, MD, United States of America
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139
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Olinder J, Ehinger D, Liljenborg E, Herwald H, Rydén C. Plasma Levels of Hepcidin and Reticulocyte Haemoglobin during Septic Shock. J Innate Immun 2020; 12:448-460. [PMID: 32950976 DOI: 10.1159/000508561] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/03/2020] [Indexed: 12/13/2022] Open
Abstract
Septic shock, a serious consequence of disseminated infection that has a high mortality, is due to a dysregulated, severe immune response triggered by the infection. Acute phase reactants play key roles in sepsis, for example, hepcidin regulating iron metabolism. Reticulocyte haemoglobin (Ret-He) depends on available iron in blood, indirectly regulated by hepcidin. This study aimed at exploring rapid changes in hepcidin and Ret-He in patients with septic shock receiving adequate antibiotic treatment. Fifteen patients, included within an hour of admission to the intensive care unit, were evaluated by microbiological tests and cultures, Sequential Organ Failure Assessment score, and plasma levels of hepcidin, Ret-He, heparin-binding protein (HBP), leucocytes, C-reactive protein, procalcitonin (PCT), and lactate. Samples were taken every morning for 7 consecutive days. Maximal levels of hepcidin (median 61 nmol/L; reference 1-12 nmol/L) were seen at the time of inclusion, then declining steadily similar to PCT and lactate levels. Ret-He values decreased transiently in response to increased hepcidin, normalization occurred at 96 h upon decrease of hepcidin levels. Maximal levels of HBP were noted 24 h after inclusion. In conclusion, hepcidin promptly declined within the first 24 h in patients with septic shock receiving adequate antibiotic treatment in contrast to Ret-He and HBP.
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Affiliation(s)
- Jon Olinder
- Department of Infectious Diseases, Helsingborg Hospital, Helsingborg, Sweden, .,Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden,
| | - Daniel Ehinger
- Department of Pathology, University and Regional Laboratories, Region Skåne, Helsingborg, Sweden
| | - Erik Liljenborg
- Department of Orthopaedic Surgery, County Hospital Halland, Halmstad, Sweden
| | - Heiko Herwald
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Cecilia Rydén
- Department of Infectious Diseases, Helsingborg Hospital, Helsingborg, Sweden.,Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
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Van de Louw A, Twomey K, Habecker N, Rakszawski K. Prevalence of acute liver dysfunction and impact on outcome in critically ill patients with hematological malignancies: a single-center retrospective cohort study. Ann Hematol 2020; 100:229-237. [PMID: 32918593 DOI: 10.1007/s00277-020-04197-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/20/2020] [Indexed: 12/20/2022]
Abstract
Patients with hematological malignancies (HM) often require ICU admission, and acute respiratory or renal failure are then independent risk factors for mortality. Data are scarce on acute liver dysfunction (ALD), despite HM patients cumulating risk factors. The objective of this retrospective cohort study was to assess the prevalence of ALD in critically ill HM patients and its impact on outcome. Data of all patients with HM admitted to the medical ICU between 2008 and 2018 were extracted from electronic medical records. ALD was defined by ALT > 165 U/L, AST > 230 U/L, or total bilirubin > 4 mg/dL. Univariate and multivariate logistic regressions were used to analyze hospital mortality. Charts of survivors with ALD were reviewed to assess impact of ALD on subsequent anti-cancer treatment. We included 971 patients (60% male), age 64 (54-72) years, of whom 196 (20%) developed ALD. ALD patients were younger, more frequently had liver cirrhosis or acute leukemia, and had increased severity of illness and vital organ support needs. ALD was associated with hospital mortality in univariate (OR 4.14, 95% CI 2.95-5.80, p < 0.001) and multivariate analysis (OR 1.86, 95% CI 1.07-3.24, p = 0.03). Hospital mortality was 46% in ALD patients; among 106 survivors, a third of patients requiring therapy received it as previously planned, and half of the patients were alive at 1 year. In summary, in a large population of critically ill patients with hematological malignancies, 20% developed ALD, which was an independent risk factor for hospital mortality and occasionally altered further anti-cancer treatment.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State Health Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA.
| | - Kathleen Twomey
- Division of Pulmonary and Critical Care Medicine, Penn State Health Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Nicholas Habecker
- Division of Pulmonary and Critical Care Medicine, Penn State Health Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Kevin Rakszawski
- Division of Hematology and Oncology, Penn State Health Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
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Huimin S, Jing W, Chang HU, Chang L, Jianguo LI. [Effects of cholestasis and hypoxic hepatitis on prognosis of ICU patients: a retrospective study based on MIMIC Ⅲ database]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:771-777. [PMID: 32895209 DOI: 10.12122/j.issn.1673-4254.2020.06.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Abnormalities of liver-related indices are common in ICU patients, but the effects of cholestasis and hypoxic hepatitis in critically ill patients remains unclarified. The purpose of this study was to investigate the effects of cholestasis and hypoxic liver dysfunction on the prognosis of ICU patients. METHODS A retrospective study was conducted based on the data of patients admitted to the ICU for the first time between 2001 and 2011 archived in the MIMIC-Ⅲ database. The patients were divided into cholestasis, hypoxic hepatitis and control groups, and their 28-day case fatality rate as the primary outcome was compared among the groups. RESULTS A total of 5852 ICU patients were included in the analysis. The incidence of cholestasis and hypoxic liver dysfunction was 31.9% (1869/5852) and 17.9% (1046/5852), respectively. There was no significant difference in 28-day case fatality rate between cholestasis group and the control group. Compared with the control group, the patients with hypoxic hepatitis had a significantly higher 28-day case fatality rate (46% vs 35%, P < 0.01), a higher hospital case fatality rate (40% vs 31%, P < 0.01), and a higher ICU case fatality rate (35.7% vs 22.2%, P < 0.01). Logistic regression analysis showed that lactic acid (LAC), aspartate transaminase (AST), and international standard ratio (INR) were independent risk factors for 28-day case fatality rate. CONCLUSIONS The incidence of cholestatic liver dysfunction is higher than that of hypoxic hepatitis, but it does not increase the 28-day case fatality rate of the ICU patients, suggesting that cholestatic liver dysfunction may be the early adaptation of the liver to critical diseases.
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Affiliation(s)
- Song Huimin
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - Wang Jing
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - H U Chang
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - Liu Chang
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - L I Jianguo
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
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142
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Impact of different consensus definition criteria on sepsis diagnosis in a cohort of critically ill patients-Insights from a new mathematical probabilistic approach to mortality-based validation of sepsis criteria. PLoS One 2020; 15:e0238548. [PMID: 32898161 PMCID: PMC7478755 DOI: 10.1371/journal.pone.0238548] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/18/2020] [Indexed: 12/16/2022] Open
Abstract
Background Sepsis-3 definition uses SOFA score to discriminate sepsis from uncomplicated infection, replacing SIRS criteria that were criticized for being inaccurate. Eligibility of sepsis-3 criteria for sepsis diagnosis and the applied validation methodology using mortality as endpoint are topic of ongoing debate. We assessed the impact of different criteria on sepsis diagnosis in our ICU and devised a mathematical approach for mortality-based validation of sepsis criteria. As infectious status is often unclear at clinical deterioration, we integrated non-infected patients into analysis. Methods Suspected infection, SOFA and SIRS were captured for an ICU cohort of a university center over one year. For raw scores (SIRS/SOFA) and sepsis criteria (SIRS≥2/SOFA≥2/SOFA_change≥2) frequencies and associations with in-hospital mortality were assessed. Using a mathematical approach, we estimated the correlation between sepsis and in-hospital mortality serving as reference for evaluation of observed mortality correlations of sepsis criteria. Results Of 791 patients, 369 (47%) were infected and 422 (53%) non-infected, with an in-hospital mortality of 39% and 15%. SIRS≥2 indicated sepsis in 90% of infected patients, SOFA≥2 in 99% and SOFA_change≥2 in 77%. In non-infected patients, SIRS, SOFA and SOFA_change were ≥2 in 78%, 88% and 58%. In AUROC analyses neither SOFA nor SIRS displayed superior mortality discrimination in infected compared to non-infected patients. The mathematically estimated correlation of sepsis and in-hospital mortality was 0.10 in infected and 0 in non-infected patients. Among sepsis criteria, solely SIRS≥2 agreed with expected correlations in both subgroups (infected: r = 0.19; non-infected: r = 0.02). Conclusions SOFA≥2 yielded a more liberal sepsis diagnosis than SIRS≥2. None of the criteria showed an infection specific occurrence that would be essential for reliable sepsis detection. However, SIRS≥2 matched the mortality association pattern of a valid sepsis criterion, whereas SOFA-based criteria did not. With this study, we establish a mathematical approach to mortality-based evaluation of sepsis criteria.
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Abstract
The syndrome of critical illness is a complex physiological stressor that can be triggered by diverse pathologies. It is widely believed that organ dysfunction and death result from bioenergetic failure caused by inadequate cellular oxygen supply. Teleologically, life has evolved to survive in the face of stressors by undergoing a suite of adaptive changes. Adaptation not only comprises alterations in systemic physiology but also involves molecular reprogramming within cells. The concept of cellular adaptation in critically ill patients is a matter of contention in part because medical interventions mask underlying physiology, creating the artificial construct of "chronic critical illness," without which death would be imminent. Thus far, the intensive care armamentarium has not targeted cellular metabolism to preserve a temporary equilibrium but instead attempts to normalize global oxygen and substrate delivery. Here, we review adaptations to hypoxia that have been demonstrated in cellular models and in human conditions associated with hypoxia, including the hypobaric hypoxia of high altitude, the intrauterine low-oxygen environment, and adult myocardial hibernation. Common features include upregulation of glycolytic ATP production, enhancement of respiratory efficiency, downregulation of mitochondrial density, and suppression of energy-consuming processes. We argue that these innate cellular adaptations to hypoxia represent potential avenues for intervention that have thus far remained untapped by intensive care medicine.
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Affiliation(s)
- Helen T McKenna
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.,Royal Free Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | - Andrew J Murray
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Daniel S Martin
- Royal Free Intensive Care Unit, Royal Free Hospital, London, United Kingdom.,Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
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144
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Clinical characteristics and outcomes of critically ill patients with novel coronavirus infectious disease (COVID-19) in China: a retrospective multicenter study. Intensive Care Med 2020; 46:1863-1872. [PMID: 32816098 PMCID: PMC7439240 DOI: 10.1007/s00134-020-06211-2] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/04/2020] [Indexed: 12/21/2022]
Abstract
Purpose An ongoing outbreak of coronavirus disease 2019 (COVID-19) emerged in Wuhan since December 2019 and spread globally. However, information about critically ill patients with COVID-19 is still limited. We aimed to describe the clinical characteristics and outcomes of critically ill patients with COVID-19 and figure out the risk factors of mortality. Methods We extracted data retrospectively regarding 733 critically ill adult patients with laboratory-confirmed COVID-19 from 19 hospitals in China through January 1 to February 29, 2020. Demographic data, symptoms, laboratory values, comorbidities, treatments, and clinical outcomes were collected. The primary outcome was 28-day mortality. Data were compared between survivors and non-survivors. Results Of the 733 patients included in the study, the median (IQR) age was 65 (56–73) years and 256 (34.9%) were female. Among these patients, the median (IQR) APACHE II score was 10 (7 to 14) and 28-day mortality was 53.8%. Respiratory failure was the most common organ failure (597 [81.5%]), followed by shock (20%), thrombocytopenia (18.8%), central nervous system (8.6%) and renal dysfunction (8%). Multivariate Cox regression analysis showed that older age, malignancies, high APACHE II score, high d-dimer level, low PaO2/FiO2 level, high creatinine level, high hscTnI level and low albumin level were independent risk factors of 28-day mortality in critically ill patients with COVID-19. Conclusion In this case series of critically ill patients with COVID-19 who were admitted into the ICU, more than half patients died at day 28. The higher percentage of organ failure in these patients indicated a significant demand for critical care resources. Electronic supplementary material The online version of this article (10.1007/s00134-020-06211-2) contains supplementary material, which is available to authorized users.
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Garg D, Tyagi A, Kumar M. Intraabdominal pressure and its relation with organ dysfunction in patients scheduled for elective cesarean section: Effect of supine vs left lateral tilt position. Acta Obstet Gynecol Scand 2020; 100:101-108. [PMID: 32726457 DOI: 10.1111/aogs.13965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/12/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intraabdominal pressure (IAP) is related to clinical outcome of patients. It is measured as intravesical pressure through a Foley catheter in the supine position. During pregnancy, there are data showing elevated IAP and also a suggestion that it may be a false increase due to pressure on the urinary bladder by the gravid uterus in the supine position. Additionally, it is not known whether the elevated IAP during pregnancy is merely a physiological change or is associated with impairment of organ functions. We thus aimed to establish a normal value of IAP in supine (IAPsupine ) as well as 10° left lateral (IAPlateral-tilt ) positions, and their association with organ functions as well as certain maternal risk characteristics. MATERIAL AND METHODS This prospective cross-sectional cohort study included 100 consenting parturients with term gestation posted for elective cesarean section under single-shot subarachnoid block. IAP was measured via an indwelling Foley catheter with a transducer connected to it, as per the recommended technique. Organ dysfunction was defined as Sequential Organ Failure Assessment (SOFA) subscore ≥1 for the particular system. TRIAL REGISTRATION ctri.gov.in (CTRI/2017/11/010527). RESULTS The IAPsupine was significantly higher than IAPlateral-tilt (13.8 ± 2.4 vs 12 ± 2.3 mm Hg) (P < .001). The incidence of intraabdominal hypertension as per conventional definition, that is, IAP ≥12 mm Hg, was also higher in the supine position (77% vs 55%) (P < .001). None of the patients had dysfunction of the cardiovascular, renal or central nervous system. The incidence of respiratory, hepatic and hematologic dysfunction was 2%, 15% and 32%, respectively. Receiver operating characteristic analysis showed insignificant association of IAPsupine and IAPlateral-tilt with various organ dysfunctions (P > .05). There was a significant correlation of intraabdominal hypertension when considering IAPsupine or IAPlateral-tilt , with obesity (P = .004 and .000, respectively), as well as preeclampsia (P = .006 and .000, respectively). CONCLUSIONS In nonlaboring patients undergoing elective cesarean section, IAP is significantly higher in the supine vs 10° left lateral position. In neither position is IAP significantly associated with organ dysfunction. Thus, the usual recommendation of a supine position for measuring IAP to diagnose intraabdominal hypertension, formulated consequent to its pathological effects on organ functions, may not be applicable to pregnant patients and needs urgent validation studies.
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Affiliation(s)
- Devansh Garg
- Department of Anesthesiology & Critical Care, University College of Medical Sciences & GTB Hospital, New Delhi, India
| | - Asha Tyagi
- Department of Anesthesiology & Critical Care, University College of Medical Sciences & GTB Hospital, New Delhi, India
| | - Mahendra Kumar
- Department of Anesthesiology & Critical Care, University College of Medical Sciences & GTB Hospital, New Delhi, India
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Pawar RD, Shih JA, Balaji L, Grossestreuer AV, Patel PV, Hansen CK, Donnino MW, Moskowitz A. Variation in SOFA (Sequential Organ Failure Assessment) Score Performance in Different Infectious States. J Intensive Care Med 2020; 36:1217-1222. [PMID: 32799718 DOI: 10.1177/0885066620944879] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION In this study, we investigated whether the Sequential Organ Failure Assessment (SOFA) score performance differs based on the type of infection among patients admitted to the intensive care unit (ICU) with infection. MATERIALS AND METHODS Single-center, retrospective study of adult ICU patients admitted with infection between January 2008 and April 2018 at an urban tertiary care center. Patients were uniquely classified into different infection types based on International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes. Infection types included were pneumonia, meningitis, bacteremia, cellulitis, cholangitis/cholecystitis, intestinal and diarrheal disease, endocarditis, urinary tract infection (UTI), and peritonitis. The SOFA score performance and mortality in relation to SOFA score were compared across infection types. RESULTS A total of 12 283 patients were included. Of these, 50.6% were female and the median age was 70 years (interquartile range: 57-82). The most common infection types were pneumonia (32.2%) and UTI (31.0%). Overall, 1703 (13.9%) patients died prior to hospital discharge. The median baseline SOFA score (within 24 hours of ICU admission) for the cohort was 5 (3-8). Patients with peritonitis had the highest median SOFA score, 7 (4-9), and patients with cellulitis and UTI had the lowest median SOFA score, 4 (2-7). The SOFA score discrimination to predict mortality was highest among patients with endocarditis (area under the receiver operating characteristic [AUC]: 0.79, 95% CI: 0.69-0.90) and lowest for patients with isolated bacteremia (AUC: 0.59, 95% CI: 0.49-0.70). Observed mortality by quartile of SOFA score differed substantially across infection types. CONCLUSIONS Type of infection is an important consideration when interpreting the SOFA score. This is relevant as SOFA emerges as an important tool in the definition and prognostication of sepsis.
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Affiliation(s)
- Rahul D Pawar
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jenny A Shih
- Department of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lakshman Balaji
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Anne V Grossestreuer
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Parth V Patel
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christopher K Hansen
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael W Donnino
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ari Moskowitz
- Center for Resuscitation Science, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Sanchez-Pinto LN, Stroup EK, Pendergrast T, Pinto N, Luo Y. Derivation and Validation of Novel Phenotypes of Multiple Organ Dysfunction Syndrome in Critically Ill Children. JAMA Netw Open 2020; 3:e209271. [PMID: 32780121 PMCID: PMC7420303 DOI: 10.1001/jamanetworkopen.2020.9271] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Multiple organ dysfunction syndrome (MODS) is a dynamic and heterogeneous process associated with high morbidity and mortality in critically ill children. OBJECTIVE To determine whether data-driven phenotypes of MODS based on the trajectories of 6 organ dysfunctions have prognostic and therapeutic relevance in critically ill children. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 20 827 pediatric intensive care encounters among 14 285 children admitted to 2 large academic pediatric intensive care units (PICUs) between January 2010 and August 2016. Patients were excluded if they were older than 21 years or had undergone cardiac surgery. The 6 subscores of the pediatric Sequential Organ Failure Assessment (pSOFA) score were calculated for the first 3 days, including the subscores for respiratory, cardiovascular, coagulation, hepatic, neurologic, and renal dysfunctions. MODS was defined as a pSOFA subscore of at least 2 in at least 2 organs. Encounters were split in a 80:20 ratio for derivation and validation, respectively. The trajectories of the 6 subscores were used to derive a set of data-driven phenotypes of MODS using subgraph-augmented nonnegative matrix factorization in the derivation set. Data analysis was conducted from March to October 2019. EXPOSURES The primary exposure was phenotype membership. In the subset of patients with vasoactive-dependent shock, the interaction between hydrocortisone and phenotype membership and its association with outcomes were examined in a matched cohort. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included persistent MODS on day 7, and vasoactive-free, ventilator-free, and hospital-free days. Regression analysis was used to adjust for age, severity of illness, immunocompromised status, and study site. RESULTS There were 14 285 patients with 20 827 encounters (median [interquartile range] age 5.2 years [1.5-12.7] years; 11 409 [54.8%; 95% CI, 54.1%-55.5%] male patients). Of these, 5297 encounters (25.4%; 95% CI, 24.8%-26.0%) were with patients who had MODS, of which 5054 (95.4%) met the subgraph count threshold and were included in the analysis. Subgraph augmented nonnegative matrix factorization uncovered 4 data-driven phenotypes of MODS, characterized by a combination of neurologic, respiratory, coagulation, and cardiovascular dysfunction, as follows: phenotype 1, severe, persistent encephalopathy (1019 patients [19.2%]); phenotype 2, moderate, resolving hypoxemia (1828 patients [34.5%]); phenotype 3, severe, persistent hypoxemia and shock (1012 patients [19.1%]); and phenotype 4, moderate, persistent thrombocytopenia and shock (1195 patients [22.6%]). These phenotypes were reproducible in a validation set of encounters, had distinct clinical characteristics, and were independently associated with outcomes. For example, using phenotype 2 as reference, the adjusted hazard ratios (aHRs) for death by 28 days were as follows: phenotype 1, aHR of 3.0 (IQR, 2.1-4.3); phenotype 3, aHR of 2.8 (IQR, 2.0-4.1); and phenotype 4, aHR of 1.8 (IQR, 1.2-2.6). Interaction analysis in a matched cohort of patients with vasoactive-dependent shock revealed that hydrocortisone had differential treatment association with vasoactive-free days across phenotypes. For example, patients in phenotype 3 who received hydrocortisone had more vasoactive-free days than those who did not (23 days vs 18 days; P for interaction < .001), whereas patients in other phenotypes who received hydrocortisone either had no difference or had less vasoactive-free days. CONCLUSIONS AND RELEVANCE In this study, data-driven phenotyping in critically ill children with MODS uncovered 4 distinct and reproducible phenotypes with prognostic relevance and possible therapeutic relevance. Further validation and characterization of these phenotypes is warranted.
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Affiliation(s)
- L. Nelson Sanchez-Pinto
- Critical Care, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Critical Care Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Emily K. Stroup
- Driskill Graduate Program, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Tricia Pendergrast
- Division of Critical Care Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Neethi Pinto
- Section of Critical Care, Department of Pediatrics, The University of Chicago, Chicago, Illinois
| | - Yuan Luo
- Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Lalitha AV, Satish JK, Reddy M, Ghosh S, George J, Pujari C. Sequential Organ Failure Assessment Score As a Predictor of Outcome in Sepsis in Pediatric Intensive Care Unit. J Pediatr Intensive Care 2020; 10:110-117. [PMID: 33884211 DOI: 10.1055/s-0040-1714705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/06/2020] [Indexed: 01/08/2023] Open
Abstract
Sequential organ failure assessment (SOFA) score is used as a predictor of outcome of sepsis in the pediatric intensive care unit. The aim of the study is to determine the application of SOFA scores as a predictor of outcome in children admitted to the pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective observational study. The study took place at the multidisciplinary pediatric intensive care unit (PICU), tertiary care hospital, South India. The patients included are children, aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to a single center PICU in India from November 2017 to November 2019. Data collected included the demographic, clinical, laboratory, and outcome-related variables. Severity of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3) using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within 24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days 1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock during the study period. The overall mortality rate was 42 of 240 patients (17.5%). The majority (59%) required mechanical ventilation, while only 19% required renal replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with mortality. All three severity of illness scores were higher among nonsurvivors as compared with survivors ( p < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3 (AUC 0.87) demonstrated significantly higher discriminative power for in-hospital mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]), and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions (vasoactive infusion score), and PICU length of stay were all significantly increased ( p < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio of mortality was elevated at 8.65 (95% CI: 3.48-21.52) on day 1 and 16.77 (95% confidence interval or CI: 4.7-59.89) on day 3 ( p < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1-SF3) and in-hospital mortality (chi-square for linear trend, p < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to 50%. Similar association was-observed between ΔSOFA of ≥2 and-longer duration of inotropic support ( p = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15-0.35; p = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both days 1 and 3, have a greater discriminative power for predicting in-hospital mortality than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days 1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining not only mortality risk but also duration of inotropic support as well.
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Affiliation(s)
- A V Lalitha
- Department of Pediatric Intensive Care, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
| | - J K Satish
- Department of Pediatric Intensive Care, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
| | - Mounika Reddy
- Department of Pediatric Intensive Care, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
| | - Santu Ghosh
- Department of Pediatric Intensive Care, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
| | - Jiny George
- Department of Pediatrics, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
| | - Chandrakanth Pujari
- Department of Pediatric Intensive Care, St Johns Medical College and Hospital, Bengaluru, Karnataka, India
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Yoshida T, Uchino S, Sasabuchi Y. Clinical course after identification of new-onset atrial fibrillation in critically ill patients: The AFTER-ICU study. J Crit Care 2020; 59:136-142. [PMID: 32674000 DOI: 10.1016/j.jcrc.2020.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/12/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Epidemiological information is lacking after identification of new-onset atrial fibrillation (AF) in critically ill patients. This study aimed to describe the clinical course after the identification of new-onset AF. MATERIALS AND METHODS This prospective cohort study enrolled adult patients with new-onset AF in 32 Japanese ICUs during 2017-2018. We collected data on patient comorbidities, physiological information before and at the AF onset, interventions for AF, cardiac rhythm transition, adverse events and in-hospital death and stroke. RESULTS We included 423 new-onset AF patients. At the AF onset, mean arterial pressure decreased and the heart rate increased. Eighty-four patients (20%) spontaneously restored sinus rhythm and 328 patients (78%) received various pharmacological interventions (rate-control drugs, 67%; rhythm-control drugs, 34%). Anticoagulants were administered in 173 patients (40%) and 13 patients (3%) experienced bleeding complications. Twenty-four patients (6%) were still in AF at 168 h after the onset (sustained AF 4%; recurrent AF 2%). The overall hospital mortality was 26% and the incidence of in-hospital stroke was 4.5%. CONCLUSIONS Although the proportion of patients with AF continued to decrease with various treatments, these patients had high risk of death. Further research to assess the management of new-onset AF in critically ill patients is warranted.
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Affiliation(s)
- Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan.
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
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Association Between Doppler Snuffbox Resistive Index and Tissue Perfusion in Septic Patients. Shock 2020; 54:723-730. [PMID: 32941387 DOI: 10.1097/shk.0000000000001547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Peripheral vascular disorders leading to tissue hypoperfusion play a central role in the pathophysiology of organ failure in septic shock. The Doppler snuffbox resistive index (SBRI) can be an accurate parameter to evaluate the status of peripheral vasculature at the bedside. We evaluated whether the SBRI is related to lactate levels or the peripheral perfusion index (PI) and its ability to predict lactate clearance in septic patients. METHODS We conducted a prospective observational study in a tertiary general and teaching hospital in China. From July 2019 to December 2019, all consecutive adult patients with septic shock who required intensive care unit admission were included. At the same time, 20 stable postoperative patients were studied as a control group. We recorded the hemodynamic parameters, including the SBRI and PI, which were measured simultaneously after patient recruitment. RESULTS We evaluated 44 patients with septic shock in the study group and 20 stable postoperative patients in the control group. Patients with septic shock had higher Sequential Organ Failure Assessment scores, procalcitonin levels, cardiac index (CI) and lactate levels than patients in the control group. The SBRI was correlated with the PI and lactate level. The CI was not correlated with lactate level in the patients examined. Based on lactate clearance in the first 6 h, the septic shock patients were divided into two groups: one with lactate clearance ≥20% (n = 28) and the other with lactate clearance <20% (n = 16). The CI was not significantly different between the two groups. The SBRI of the lactate clearance <20% group was higher than that of the lactate clearance ≥20% group and the control group. The PI of the lactate clearance <20% group was lower than that of the lactate clearance ≥20% group and the control group. The SBRI cutoff value for predicting 6-h lactate clearance after resuscitation was ≥1.09, with a sensitivity of 68.8% and a specificity of 85.7%. The PI cutoff value for predicting 6-h lactate clearance after resuscitation was ≤0.99, with a sensitivity of 64.3% and a specificity of 81.2%. The SBRI was significantly better than the PI for predicting 6-h lactate clearance after resuscitation (area under the curve: 0.805 vs. 0.703, P < 0.05). CONCLUSIONS The Doppler SBRI is correlated with tissue perfusion parameters in critically ill patients. An abnormal SBRI may be better than the PI for predicting poor lactate clearance in septic patients. Further investigations are required to determine whether correcting an abnormal SBRI and PI may improve the success rate of septic shock resuscitation.
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