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Statlender L, Shochat T, Robinson E, Fishman G, Hellerman-Itzhaki M, Bendavid I, Singer P, Kagan I. Urea to creatinine ratio as a predictor of persistent critical illness. J Crit Care 2024; 83:154834. [PMID: 38781812 DOI: 10.1016/j.jcrc.2024.154834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Persistent critical illness (PCI) is a syndrome in which the acute presenting problem has been stabilized, but the patient's clinical state does not allow ICU discharge. The burden associated with PCI is substantial. The most obvious marker of PCI is prolonged ICU length of stay (LOS), usually greater than 10 days. Urea to Creatinine ratio (UCr) has been suggested as an early marker of PCI development. METHODS A single-center retrospective study. Data of patients admitted to a general mixed medical-surgical ICU during Jan 1st 2018 till Dec 31st 2022 was extracted, including demographic data, baseline characteristics, daily urea and creatinine results, renal replacement therapy (RRT) provided, and outcome measures - length of stay, and mortality (ICU, and 90 days). Patients were defined as PCI patients if their LOS was >10 days. We used Fisher exact test or Chi-square to compare PCI and non-PCI patients. The association between UCr with PCI development was assessed by repeated measures linear model. Multivariate Cox regression was used for 1 year mortality assessment. RESULTS 2098 patients were included in the analysis. Patients who suffered from PCI were older, with higher admission prognostic scores. Their 90-day mortality was significantly higher than non-PCI patients (34.58% vs 12.18%, p < 0.0001). A significant difference in UCr was found only on the first admission day among all patients. This was not found when examining separately surgical, trauma, or transplantation patients. We did not find a difference in UCr in different KDIGO (Kidney Disease Improving Global Outcomes) stages. Elevated UCr and PCI were found to be significantly associated with 1 year mortality. CONCLUSION In this single center retrospective cohort study, UCr was not found to be associated with PCI development.
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Affiliation(s)
- Liran Statlender
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Centre, Petah Tikva, Israel
| | - Eyal Robinson
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Fishman
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Hellerman-Itzhaki
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itai Bendavid
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pierre Singer
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilya Kagan
- Department of General Intensive Care, Rabin Medical Centre, Beilinson Hospital, Petah Tikva, Israel; Institute for Nutrition Research, Felsenstein Medical Research Centre, Petah Tikva, Israel; School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Rodrigues AR, Oliveira A, Vieira T, Assis R, Lume C, Gonçalves-Pereira J, Fernandes SM. A prolonged intensive care unit stay defines a worse long-term prognosis - Insights from the critically ill mortality by age (Cimba) study. Aust Crit Care 2024; 37:734-739. [PMID: 38649316 DOI: 10.1016/j.aucc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/11/2024] [Accepted: 03/02/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Patients with critical illness often survive the intensive care unit (ICU) at a cost of prolonged length of stay (LOS) and slow recovery. This chronic critically ill disease may lead to long-term poor outcomes, especially in older or frail patients. OBJECTIVES The main goal of this study was to address the characteristics and outcomes of patients with prolonged ICU LOS. Mainly, short- and long-term admissions were compared to identify risk factors for persistent critical illness and to characterise the impact on ICU, hospital, and long-term mortality. METHODS Subanalysis of a retrospective, multicentric, observational study addressing the 2-year outcome of patients admitted to Portuguese ICUs (the Cimba study). Patients were segregated according to an ICU LOS of ≥14 days. RESULTS Data from 37 118 patients were analysed, featuring a median ICU LOS of 4 days (percentile: 25-75 2-9), and a mortality of 16.1% in the ICU, 24.0% in the hospital, and 38.7% after 2 years. A total of 5334 patients (14.4%) had an ICU LOS of ≥14 days (corresponding to 48.9% of all ICU patients/days). Patients with prolonged LOS were more often younger (52.8% vs 46.4%, were ≤65 years of age , p < 0.001), although more severe (Simplified Acute Physiology Score II: 49.1 ± 16.9 vs 41.8 ± 19.5, p < 0.001), and had higher ICU and hospital mortality (18.3% vs 15.7%, and 31.2 vs 22.8%, respectively). Prolonged ICU LOS was linked to an increased risk of dying during the 2-year follow-up (adjusted Cox proportional hazard: 1.65, p < 0.001). CONCLUSION Prolonged LOS is associated with a long-term impact on patient prognosis. More careful planning of care should incorporate these data.
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Affiliation(s)
- Ana Rita Rodrigues
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Department, Hospital St(a) Maria, Lisbon, Portugal
| | - André Oliveira
- Intensive Care Unit, Hospital de Vila Franca Xira, EPE, Portugal
| | - Tatiana Vieira
- Intensive Care Department, Hospital de São João, Porto, Portugal
| | - Rui Assis
- Intensive Care Unit, Centro Hospitalar Médio Tejo, Abrantes, Portugal
| | - Catarina Lume
- Intensive Care Unit, Hospital Nélio Mendonça, Funchal, Portugal
| | - João Gonçalves-Pereira
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Unit, Hospital de Vila Franca Xira, EPE, Portugal; Grupo Infeção e Desenvolvimento em Sépsis (GIS-ID), Porto, Portugal
| | - Susana M Fernandes
- Clinica Universitária de Medicina Intensiva, FMUL, Lisbon, Portugal; Intensive Care Department, Hospital St(a) Maria, Lisbon, Portugal; Grupo Infeção e Desenvolvimento em Sépsis (GIS-ID), Porto, Portugal.
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Likhvantsev VV, Berikashvili LB, Yadgarov MY, Yakovlev AA, Kuzovlev AN. The Tri-Steps Model of Critical Conditions in Intensive Care: Introducing a New Paradigm for Chronic Critical Illness. J Clin Med 2024; 13:3683. [PMID: 38999249 PMCID: PMC11242724 DOI: 10.3390/jcm13133683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/15/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The prevailing model for understanding chronic critical illness is a biphasic model, suggesting phases of acute and chronic critical conditions. A major challenge within this model is the difficulty in determining the timing of the process chronicity. It is likely that the triad of symptoms (inflammation, catabolism, and immunosuppression [ICIS]) could be associated with this particular point. We aimed to explore the impact of the symptom triad (inflammation, catabolism, immunosuppression) on the outcomes of patients hospitalized in intensive care units (ICUs). Methods: The eICU-CRD database with 200,859 ICU admissions was analyzed. Adult patients with the ICIS triad, identified by elevated CRP (>20 mg/L), reduced albumin (<30 g/L), and low lymphocyte counts (<0.8 × 109/L), were included. The cumulative risk of developing ICIS was assessed using the Nelson-Aalen estimator. Results: This retrospective cohort study included 894 patients (485 males, 54%), with 60 (6.7%) developing ICIS. The cumulative risk of ICIS by day 21 was 22.5%, with incidence peaks on days 2-3 and 10-12 after ICU admission. Patients with the ICIS triad had a 2.5-fold higher mortality risk (p = 0.009) and double the likelihood of using vasopressors (p = 0.008). The triad onset day did not significantly affect mortality (p = 0.104). Patients with ICIS also experienced extended hospital (p = 0.041) and ICU stays (p < 0.001). Conclusions: The symptom triad (inflammation, catabolism, immunosuppression) during hospitalization increases mortality risk by 2.5 times (p = 0.009) and reflects the chronicity of the critical condition. Identifying two incidence peaks allows the proposal of a new Tri-steps model of chronic critical illness with acute, extended, and chronic phases.
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Affiliation(s)
- Valery V Likhvantsev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Levan B Berikashvili
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Mikhail Ya Yadgarov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Alexey A Yakovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
| | - Artem N Kuzovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia
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Chadda KR, Puthucheary Z. Persistent inflammation, immunosuppression, and catabolism syndrome (PICS): a review of definitions, potential therapies, and research priorities. Br J Anaesth 2024; 132:507-518. [PMID: 38177003 PMCID: PMC10870139 DOI: 10.1016/j.bja.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 01/06/2024] Open
Abstract
Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) is a clinical endotype of chronic critical illness. PICS consists of a self-perpetuating cycle of ongoing organ dysfunction, inflammation, and catabolism resulting in sarcopenia, immunosuppression leading to recurrent infections, metabolic derangements, and changes in bone marrow function. There is heterogeneity regarding the definition of PICS. Currently, there are no licensed treatments specifically for PICS. However, findings can be extrapolated from studies in other conditions with similar features to repurpose drugs, and in animal models. Drugs that can restore immune homeostasis by stimulating lymphocyte production could have potential efficacy. Another treatment could be modifying myeloid-derived suppressor cell (MDSC) activation after day 14 when they are immunosuppressive. Drugs such as interleukin (IL)-1 and IL-6 receptor antagonists might reduce persistent inflammation, although they need to be given at specific time points to avoid adverse effects. Antioxidants could treat the oxidative stress caused by mitochondrial dysfunction in PICS. Possible anti-catabolic agents include testosterone, oxandrolone, IGF-1 (insulin-like growth factor-1), bortezomib, and MURF1 (muscle RING-finger protein-1) inhibitors. Nutritional support strategies that could slow PICS progression include ketogenic feeding and probiotics. The field would benefit from a consensus definition of PICS using biologically based cut-off values. Future research should focus on expanding knowledge on underlying pathophysiological mechanisms of PICS to identify and validate other potential endotypes of chronic critical illness and subsequent treatable traits. There is unlikely to be a universal treatment for PICS, and a multimodal, timely, and personalised therapeutic strategy will be needed to improve outcomes for this growing cohort of patients.
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Affiliation(s)
- Karan R Chadda
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK; Homerton College, University of Cambridge, Cambridge, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK; Adult Critical Care Unit, Royal London Hospital, London, UK
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Mancini B, Liu J, Samuelsen A, Howrylak JA, Schultz L, Bonavia AS. Comparing Long-Term Prognosis in Chronic Critically Ill Patients: A Case Series Study of Medical versus Surgical Sepsis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1617. [PMID: 37763735 PMCID: PMC10535459 DOI: 10.3390/medicina59091617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Chronic critical illness (CCI) is a syndrome characterized by persistent organ dysfunction that requires critical care therapy for ≥14 days. Sepsis and respiratory failure constitute the two primary causes of CCI. A better understanding of this patient population and their clinical course may help to risk-stratify them early during hospitalization. Our objective was to identify whether the source of sepsis (medical versus surgical) affected clinical trajectory and prognosis in patients developing CCI. Materials and Methods: We describe a cohort of patients having acute respiratory failure and sepsis and requiring critical care therapy in the medical (MICU) or surgical (SICU) critical care units for ≥14 days. Given the relative infrequency of CCI, we use a case series design to examine mortality, functional status, and place of residence (home versus non-home) at one year following their index hospitalization. Results: In medical patients developing CCI (n = 31), the severity of initial organ dysfunction, by SOFA score, was significantly associated with the development of CCI (p = 0.002). Surgical patients with CCI (n = 7) experienced significantly more ventilator-free days within the first 30 days following sepsis onset (p = 0.004), as well as less organ dysfunction at day 14 post-sepsis (p < 0.0001). However, one-year mortality, one-year functional status, and residency at home were not statistically different between cohorts. Moreover, 57% of surgical patients and 26% of medical patients who developed CCI were living at home for one year following their index hospitalization (p = 0.11). Conclusions: While surgical patients who develop sepsis-related CCI experience more favorable 30-day outcomes as compared with medical patients, long-term outcomes do not differ significantly between groups. This suggests that reversing established organ dysfunction and functional disability, regardless of etiology, is more challenging compared to preventing these complications at an earlier stage.
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Affiliation(s)
- Benjamin Mancini
- Penn State College of Medicine, 500 University Dr., Hershey, PA 17033, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY 10021, USA
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY 10021, USA
| | - Abigail Samuelsen
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Penn State Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA
| | - Judie A. Howrylak
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Penn State Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA
| | - Lisa Schultz
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Penn State Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA
| | - Anthony S. Bonavia
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Penn State Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA
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Palamim CVC, Boschiero MN, Marson FAL. Epidemiological profile and risk factors associated with death in patients receiving invasive mechanical ventilation in an adult intensive care unit from Brazil: a retrospective study. Front Med (Lausanne) 2023; 10:1064120. [PMID: 37181356 PMCID: PMC10166862 DOI: 10.3389/fmed.2023.1064120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/28/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Understanding the epidemiological profile and risk factors associated with invasive mechanical ventilation (IMV) is essential to manage the patients better and to improve health services. Therefore, our objective was to describe the epidemiological profile of adult patients in intensive care that required IMV in-hospital treatment. Also, to evaluate the risks associated with death and the influence of positive end-expiratory pressure (PEEP) and arterial oxygen pressure (PaO2) at admission in the clinical outcome. Methods We conducted an epidemiological study analyzing medical records of inpatients who received IMV from January 2016 to December 2019 prior to the Coronavirus Disease (COVID)-19 pandemic in Brazil. We considered the following characteristics in the statistical analysis: demographic data, diagnostic hypothesis, hospitalization data, and PEEP and PaO2 during IMV. We associated the patients' features with the risk of death using a multivariate binary logistic regression analysis. We adopted an alpha error of 0.05. Results We analyzed 1,443 medical records; out of those, 570 (39.5%) recorded the patients' deaths. The binary logistic regression was significant in predicting the patients' risk of death [X2(9) = 288.335; p < 0.001]. Among predictors, the most significant in relation to death risk were: age [elderly ≥65 years old; OR = 2.226 (95%CI = 1.728-2.867)]; male sex (OR = 0.754; 95%CI = 0.593-0.959); sepsis diagnosis (OR = 1.961; 95%CI = 1.481-2.595); need for elective surgery (OR = 0.469; 95%CI = 0.362-0.608); the presence of cerebrovascular accident (OR = 2.304; 95%CI = 1.502-3.534); time of hospital care (OR = 0.946; 95%CI = 0.935-0.956); hypoxemia at admission (OR = 1.635; 95%CI = 1.024-2.611), and PEEP >8 cmH2O at admission (OR = 2.153; 95%CI = 1.426-3.250). Conclusion The death rate of the studied intensive care unit was equivalent to that of other similar units. Regarding risk predictors, several demographic and clinical characteristics were associated with enhanced mortality in intensive care unit patients under mechanical ventilation, such as diabetes mellitus, systemic arterial hypertension, and older age. The PEEP >8 cmH2O at admission was also associated with increased mortality since this value is a marker of initially severe hypoxia.
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Affiliation(s)
- Camila Vantini Capasso Palamim
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, São Paulo, Brazil
- Laboratory of Human and Medical Genetics, Bragança Paulista, São Francisco University, São Paulo, Brazil
| | - Matheus Negri Boschiero
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, São Paulo, Brazil
- Laboratory of Human and Medical Genetics, Bragança Paulista, São Francisco University, São Paulo, Brazil
| | - Fernando Augusto Lima Marson
- Laboratory of Cell and Molecular Tumor Biology and Bioactive Compounds, São Francisco University, Bragança Paulista, São Paulo, Brazil
- Laboratory of Human and Medical Genetics, Bragança Paulista, São Francisco University, São Paulo, Brazil
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D'Alessandro VF, D'Alessandro-Gabazza CN, Yasuma T, Toda M, Takeshita A, Tomaru A, Tharavecharak S, Lasisi IO, Hess RY, Nishihama K, Fujimoto H, Kobayashi T, Cann I, Gabazza EC. Inhibition of a Microbiota-derived Peptide Ameliorates Established Acute Lung Injury. THE AMERICAN JOURNAL OF PATHOLOGY 2023:S0002-9440(23)00113-X. [PMID: 36965776 PMCID: PMC10035802 DOI: 10.1016/j.ajpath.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/20/2023] [Accepted: 03/07/2023] [Indexed: 03/25/2023]
Abstract
Acute lung injury is a clinical syndrome characterized by a diffuse lung inflammation that commonly evolves into acute respiratory distress syndrome and respiratory failure. The lung microbiota is involved in the pathogenesis of acute lung injury. Corisin, a proapoptotic peptide derived from the lung microbiota, plays a role in acute lung injury and acute exacerbation of pulmonary fibrosis. Preventive therapeutic intervention with a monoclonal anticorisin antibody inhibits acute lung injury in mice. However, whether inhibition of corisin with the antibody ameliorates established acute lung injury is unknown. Here, the therapeutic effectiveness of the anticorisin antibody in already established acute lung injury in mice was assessed. Lipopolysaccharide was used to induce acute lung injury in mice. After causing acute lung injury, the mice were treated with a neutralizing anticorisin antibody. Mice treated with the antibody showed significant improvement in lung radiological and histopathological findings, decreased lung infiltration of inflammatory cells, reduced markers of lung tissue damage, and inflammatory cytokines in bronchoalveolar lavage fluid compared to untreated mice. In addition, the mice treated with anticorisin antibody showed significantly increased expression of antiapoptotic proteins with decreased caspase-3 activation in the lungs compared to control mice treated with an irrelevant antibody. In conclusion, these observations suggest that the inhibition of corisin is a novel and promising approach for treating established acute lung injury.
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Affiliation(s)
- Valeria Fridman D'Alessandro
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Corina N D'Alessandro-Gabazza
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan;; Center for Intractable Diseases, Mie University, Edobashi 2-174, Tsu, Mie 514-8507, Japan; Carl R. Woese Institute for Genomic Biology (Microbiome Metabolic Engineering), University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Taro Yasuma
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan;; Department of Diabetes and Endocrinology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Masaaki Toda
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Atsuro Takeshita
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan;; Department of Diabetes and Endocrinology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Atsushi Tomaru
- Department of Pulmonary and Critical care Medicine, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Suphachai Tharavecharak
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Isaiah O Lasisi
- School of Molecular and Cellular Biology, the University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Rebecca Y Hess
- School of Molecular and Cellular Biology, the University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Kota Nishihama
- Department of Diabetes and Endocrinology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Hajime Fujimoto
- Department of Pulmonary and Critical care Medicine, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Tetsu Kobayashi
- Department of Pulmonary and Critical care Medicine, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan
| | - Isaac Cann
- School of Molecular and Cellular Biology, the University of Illinois at Urbana-Champaign, Urbana, IL, United States; Department of Animal Science, the University of Illinois at Urbana-Champaign, Urbana, IL, United States; Department of Microbiology, the University of Illinois at Urbana-Champaign, Urbana, IL, United States; Division of Nutritional Sciences, the University of Illinois at Urbana-Champaign, Urbana, IL, United States; Center for East Asian & Pacific Studies, the University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Esteban C Gabazza
- Department of Immunology, Mie University Faculty and Graduate School of Medicine, Edobashi 2-174, Tsu, Mie 514-8507, Japan;; Center for Intractable Diseases, Mie University, Edobashi 2-174, Tsu, Mie 514-8507, Japan; Carl R. Woese Institute for Genomic Biology (Microbiome Metabolic Engineering), University of Illinois at Urbana-Champaign, Urbana, IL, United States.
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Bergman ZR, Tignanelli CJ, Gould R, Pendleton KM, Chipman JG, Lusczek E, Beilman G. Factors Associated with Mortality in Patients with COVID-19 Receiving Prolonged Ventilatory Support. Surg Infect (Larchmt) 2022; 23:893-901. [PMID: 36383156 PMCID: PMC9784594 DOI: 10.1089/sur.2022.195] [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: 11/17/2022] Open
Abstract
Background: Since its emergence in early 2020, coronavirus disease 2019 (COVID-19)-associated pneumonia has caused a global strain on intensive care unit (ICU) resources with many intubated patients requiring prolonged ventilatory support. Outcomes for patients with COVID-19 who receive prolonged intubation (>21 days) and possible predictors of mortality in this group are not well established. Patients and Methods: Data were prospectively collected from adult patients with COVID-19 requiring mechanical ventilation from March 2020 through December 2021 across a system of 11 hospitals. The primary end point was in-hospital mortality. Factors associated with mortality were evaluated using univariable and multivariable logistic regression analyses. Results: Six hundred six patients were placed on mechanical ventilation for COVID-19 pneumonia during the study period, with in-hospital mortality of 40.3% (n = 244). Increased age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.09), increased creatinine (OR, 1.40; 95% CI, 1.08-1.82), and receiving corticosteroids (OR, 2.68; 95% CI, 1.20-5.98) were associated with mortality. Intubations lasting longer than 21 days (n = 140) had a lower in-hospital mortality of 25.7% (n = 36; p < 0.001). Increasing Elixhauser comorbidity index (OR, 1.12; 95% CI, 1.04-1.19) and receiving corticosteroids (OR, 1.92; 95% CI, 1.06-3.47) were associated with need for prolonged ventilation. In this group, increased age (OR, 1.06; 95% CI, 1.01-1.08) and non-English speaking (OR, 3.74; 95% CI, 1.13-12.3) were associated with mortality. Conclusions: In-hospital mortality in mechanically ventilated patients with COVID-19 pneumonia occurs primarily in the first 21 days after intubation, possibly related to the early active inflammatory process. In patients on prolonged mechanical ventilation, increased age and being non-English speaking were associated with mortality.
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Affiliation(s)
- Zachary R. Bergman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,Address correspondence to: Dr. Zachary Bergman, Department of Surgery, University of Minnesota, 420 East Delaware Street, Mayo Mail Code 195, Minneapolis, MN 55455, USA
| | | | - Robert Gould
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jeffrey G. Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Greg Beilman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.,M Health Fairview Health System Management, Minneapolis, Minnesota, USA
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Mortality Risk Factors in Patients Admitted with the Primary Diagnosis of Tracheostomy Complications: An Analysis of 8026 Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159031. [PMID: 35897404 PMCID: PMC9332357 DOI: 10.3390/ijerph19159031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/16/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022]
Abstract
Background: Tracheostomy is a procedure commonly conducted in patients undergoing emergency admission and requires prolonged mechanical ventilation. In the present study, the aim was to determine the prevalence and risk factors of mortality among emergently admitted patients with tracheostomy complications, during the years 2005−2014. Methods: This was a retrospective cohort study. Demographics and clinical data were obtained from the National Inpatient Sample, 2005−2014, to evaluate elderly (65+ years) and non-elderly adult patients (18−64 years) with tracheostomy complications (ICD-9 code, 519) who underwent emergency admission. A multivariable logistic regression model with backward elimination was used to identify the association between predictors and in-hospital mortality. Results: A total of 4711 non-elderly and 3315 elderly patients were included. Females included 44.5% of the non-elderly patients and 47.6% of the elderly patients. In total, 181 (3.8%) non-elderly patients died, of which 48.1% were female, and 163 (4.9%) elderly patients died, of which 48.5% were female. The mean (SD) age of the non-elderly patients was 50 years and for elderly patients was 74 years. The mean age at the time of death of non-elderly patients was 53 years and for elderly patients was 75 years. The odds ratio (95% confidence interval, p-value) of some of the pertinent risk factors for mortality showed by the final regression model were older age (OR = 1.007, 95% CI: 1.001−1.013, p < 0.02), longer hospital length of stay (OR = 1.008, 95% CI: 1.001−1.016, p < 0.18), cardiac disease (OR = 3.21, 95% CI: 2.48−4.15, p < 0.001), and liver disease (OR = 2.61, 95% CI: 1.73−3.93, p < 0.001). Conclusion: Age, hospital length of stay, and several comorbidities have been shown to be significant risk factors in in-hospital mortality in patients admitted emergently with the primary diagnosis of tracheostomy complications. Each year of age increased the risk of mortality by 0.7% and each additional day in the hospital increased it by 0.8%.
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Viglianti EM, Carlton EF, McPeake J, Wang XQ, Seelye S, Iwashyna TJ. Acquisition of new medical devices among the persistently critically ill: A retrospective cohort study in the Veterans Affairs. Medicine (Baltimore) 2022; 101:e29821. [PMID: 35801748 PMCID: PMC9259166 DOI: 10.1097/md.0000000000029821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/20/2022] [Accepted: 05/31/2022] [Indexed: 01/04/2023] Open
Abstract
Patients who develop persistent critical illness remain in the ICU predominately because they develop new late-onset organ failure(s), which may render them at risk of acquiring a new medical device. The epidemiology and short-term outcomes of patients with persistent critical illness who acquire a new medical device are unknown. We retrospectively studied a cohort admitted to the Veterans Affairs (VA) ICUs from 2014 to 2019. Persistent critical illness was defined as an ICU length of stay of at least 14 days. Receipt of new devices was defined as acquisition of a new tracheostomy, feeding tube (including gastrostomy and jejunostomy tubes), implantable cardiac device, or ostomy. Logistic regression models were fit to identify patient factors associated with the acquisition of each new medical device. Among hospitalized survivors, 90-day posthospitalization discharge location and mortality were identified. From 2014 to 2019, there were 13,184 ICU hospitalizations in the VA which developed persistent critical illness. In total, 30.4% of patients (N = 3998/13,184) acquired at least 1 medical device during their persistent critical illness period. Patients with an initial higher severity of illness and prolonged hospital stay preICU admission had higher odds of acquiring each medical device. Among patients who survived their hospitalization, discharge location and mortality did not significantly differ among those who acquired a new medical device as compared to those who did not. Less than one-third of patients with persistent critical illness acquire a new medical device and no significant difference in short-term outcomes was identified. Future work is needed to understand if the acquisition of new medical devices is contributing to the development of persistent critical illness.
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Affiliation(s)
- Elizabeth M. Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management Research, HSR&D Center for Innovation, Ann Arbor, MI, USA
| | - Erin F. Carlton
- Department of Pediatrics Division of Pediatric Critical Care, University of Michigan, Ann Arbor, MI, USA
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Joanne McPeake
- University of Glasgow, School of Medicine, Dentistry and Nursing, Scotland, UK
- NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Intensive Care Unit, Scotland, UK
| | - Xiao Qing Wang
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Seelye
- Veterans Affairs Center for Clinical Management Research, HSR&D Center for Innovation, Ann Arbor, MI, USA
| | - Theodore J. Iwashyna
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management Research, HSR&D Center for Innovation, Ann Arbor, MI, USA
- Institute for Social Research, Ann Arbor, MI, USA
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Ballesteros MÁ, Sánchez‐Arguiano MJ, Chico‐Fernández M, Barea‐Mendoza JA, Serviá‐Goixart L, Sánchez‐Casado M, García Sáez I, Pino‐Sánchez FI, Antonio Llompart‐Pou J, Miñambres E. Chronic critical illness in polytrauma. Results of the Spanish trauma in ICU registry. Acta Anaesthesiol Scand 2022; 66:722-730. [PMID: 35332519 DOI: 10.1111/aas.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/11/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Chronic critical illness after trauma injury has not been fully evaluated, and there is little evidence in this regard. We aim to describe the prevalence and risk factors of chronic critical illness (CCI) in trauma patients admitted to the intensive care unit. MATERIAL AND METHODS Retrospective observational multicenter study (Spanish Registry of Trauma in ICU (RETRAUCI)). Period March 2015 to December 2019. Trauma patients admitted to the ICU, who survived the first 48 h, were included. Chronic critical illness (CCI) was considered as the need for mechanical ventilation for a period greater than 14 days and/or placement of a tracheostomy. The main outcomes measures were prevalence and risk factors of CCI after trauma. RESULTS 1290/9213 (14%) patients developed CCI. These patients were older (51.2 ± 19.4 vs 49 ± 18.9); p < .01) and predominantly male (79.9%). They presented a higher proportion of infectious complications (81.3% vs 12.7%; p < .01) and multiple organ dysfunction syndrome (MODS) (27.02% vs 5.19%; p < .01). CCI patients required longer stays in the ICU and had higher ICU and overall in-hospital mortality. Age, injury severity score, head injury, infectious complications, and development of MODS were independent predictors of CCI. CONCLUSION CCI in trauma is a prevalent entity in our series. Early identification could facilitate specific interventions to change the trajectory of this process.
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Affiliation(s)
| | | | - Mario Chico‐Fernández
- UCI de Trauma y Emergencias Servicio de Medicina Intensiva, Hospital Universitario Madrid Spain
| | | | - Luis Serviá‐Goixart
- Servicio de Medicina Intensiva Hospital Universitario Arnau de Vilanova Lleida Spain
| | | | - Iker García Sáez
- Servicio de Medicina Intensiva Hospital Universitario Donostia Donostia‐San Sebastian Spain
| | | | - Juan Antonio Llompart‐Pou
- Servei de Medicina Intensiva Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa) Palma Spain
| | - Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care University Hospital Marqués de Valdecilla‐IDIVAL School of Medicine University of Cantabria Santander Spain
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Roedl K, Jarczak D, Boenisch O, de Heer G, Burdelski C, Frings D, Sensen B, Nierhaus A, Kluge S, Wichmann D. Chronic Critical Illness in Patients with COVID-19: Characteristics and Outcome of Prolonged Intensive Care Therapy. J Clin Med 2022; 11:jcm11041049. [PMID: 35207322 PMCID: PMC8876562 DOI: 10.3390/jcm11041049] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/12/2022] [Accepted: 02/15/2022] [Indexed: 01/27/2023] Open
Abstract
The spread of SARS-CoV-2 caused a worldwide healthcare threat. High critical care admission rates related to Coronavirus Disease 2019 (COVID-19) respiratory failure were observed. Medical advances helped increase the number of patients surviving the acute critical illness. However, some patients require prolonged critical care. Data on the outcome of patients with a chronic critical illness (CCI) are scarce. Single-center retrospective study including all adult critically ill patients with confirmed COVID-19 treated at the Department of Intensive Care Medicine at the University Medical Center Hamburg-Eppendorf, Germany, between 1 March 2020 and 8 August 2021. We identified 304 critically ill patients with COVID-19 during the study period. Of those, 55% (n = 167) had an ICU stay ≥21 days and were defined as chronic critical illness, and 45% (n = 137) had an ICU stay <21 days. Age, sex and BMI were distributed equally between both groups. Patients with CCI had a higher median SAPS II (CCI: 39.5 vs. no-CCI: 38 points, p = 0.140) and SOFA score (10 vs. 6, p < 0.001) on admission. Seventy-three per cent (n = 223) of patients required invasive mechanical ventilation (MV) (86% vs. 58%; p < 0.001). The median duration of MV was 30 (17–49) days and 7 (4–12) days in patients with and without CCI, respectively (p < 0.001). The regression analysis identified ARDS (OR 3.238, 95% CI 1.827–5.740, p < 0.001) and referral from another ICU (OR 2.097, 95% CI 1.203–3.654, p = 0.009) as factors significantly associated with new-onset of CCI. Overall, we observed an ICU mortality of 38% (n = 115) in the study cohort. In patients with CCI we observed an ICU mortality of 28% (n = 46) compared to 50% (n = 69) in patients without CCI (p < 0.001). The 90-day mortality was 28% (n = 46) compared to 50% (n = 70), respectively (p < 0.001). More than half of critically ill patients with COVID-19 suffer from CCI. Short and long-term survival rates in patients with CCI were high compared to patients without CCI, and prolonged therapy should not be withheld when resources permit prolonged therapy.
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13
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Rationale and design of a mechanistic clinical trial of JAK inhibition to prevent ventilator-induced diaphragm dysfunction. Respir Med 2021; 189:106620. [PMID: 34655959 DOI: 10.1016/j.rmed.2021.106620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Ventilator-induced diaphragm dysfunction (VIDD) is an important phenomenon that has been repeatedly demonstrated in experimental and clinical models of mechanical ventilation. Even a few hours of MV initiates signaling cascades that result in, first, reduced specific force, and later, atrophy of diaphragm muscle fibers. This severe, progressive weakness of the critical ventilatory muscle results in increased duration of MV and thus increased MV-associated complications/deaths. A drug that could prevent VIDD would likely have a major positive impact on intensive care unit outcomes. We identified the JAK/STAT pathway as important in VIDD and then demonstrated that JAK inhibition prevents VIDD in rats. We subsequently developed a clinical model of VIDD demonstrating reduced contractile force of isolated diaphragm fibers harvested after ∼7 vs ∼1 h of MV during a thoracic surgical procedure. MATERIALS AND METHODS The NIH-funded clinical trial that has been initiated is a prospective, placebo controlled trial: subjects undergoing esophagectomy are randomized to receive 6 preoperative doses of the FDA-approved JAK inhibitor Tofacitinib (commonly used for rheumatoid arthritis) vs. placebo. The primary outcome variable will be the difference in the reduction that occurs in force generation of diaphragm single muscle fibers (normalized to their cross-sectional area), in the Tofacitinib vs. placebo subjects, over 6 h of MV. DISCUSSION This trial represents a first-in-human, mechanistic clinical trial of a drug to prevent VIDD. It will provide proof-of-concept in human subjects whether JAK inhibition prevents clinical VIDD, and if successful, will support an ICU-based clinical trial that would determine whether JAK inhibition impacts clinical outcome variables such as duration of MV and mortality.
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Chronic Critical Illness and PICS Nutritional Strategies. J Clin Med 2021; 10:jcm10112294. [PMID: 34070395 PMCID: PMC8197535 DOI: 10.3390/jcm10112294] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 12/26/2022] Open
Abstract
The nutritional hallmark of chronic critical illness (CCI) after sepsis is persistent inflammation, immunosuppression, and catabolism syndrome (PICS), which results in global resistance to the anabolic effect of nutritional supplements. This ultimately leaves these patients in a downward phenotypic spiral characterized by cachexia with profound weakness, decreased capacity for rehabilitation, and immunosuppression with the propensity for sepsis recidivism. The persistent catabolism is driven by a pathologic low-grade inflammation with the inability to return to homeostasis and by ongoing increased energy expenditure. Better critical care support systems and advances in technology have led to increased intensive care unit (ICU) survival, but CCI due to PICS with poor long-term outcomes has emerged as a frequent phenotype among ICU sepsis survivors. Unfortunately, therapies to mitigate or reverse PICS-CCI are limited, and recent evidence supports that these patients fail to respond to early ICU evidence-based nutrition protocols. A lack of randomized controlled trials has limited strong recommendations for nutrition adjuncts in these patients. However, based on experience in other conditions characterized by a similar phenotype, immunonutrients aimed at counteracting inflammation, immunosuppression, and catabolism may be important for improving outcomes in PICS-CCI patients. This manuscript intends to review several immunonutrients as adjunctive therapies in treating PICS-CCI.
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Howard AF, Crowe S, Choroszewski L, Kovatch J, J. Haynes A, Ford J, Beck S, Haljan GJ. Sources of Distress for Residents With Chronic Critical Illness and Ventilator Dependence in Long-Term Care. QUALITATIVE HEALTH RESEARCH 2021; 31:550-563. [PMID: 33292054 PMCID: PMC7802046 DOI: 10.1177/1049732320976373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Limited understanding of the psychological challenges experienced by individuals with chronic critical illness hampers efforts to deliver quality care. We used an interpretive description approach to explore sources of distress for individuals with chronic critical illness in residential care, wherein we interviewed six residents, 11 family members, and 21 staff. Rather than discuss physical symptoms, sources of distress for residents were connected to feeling as though they were a patient receiving medical care as opposed to an individual living in their home. The tension between medical care and the unmet need for a sense of home was related to care beyond the physical being overlooked, being dependent on others but feeling neglected, frustration with limited choice and participation in decision making, and feeling sad and alone. Efforts to refine health care for individuals with chronic critical illness must foster a sense of home while ensuring individuals feel safe and supported to make decisions.
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Affiliation(s)
- A. Fuchsia Howard
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Crowe
- Fraser Health Authority, Surrey, British Columbia, Canada
| | | | - Joe Kovatch
- Fraser Health Authority, Surrey, British Columbia, Canada
| | | | - Joan Ford
- Patient Partner, Vancouver, British Columbia, Canada
| | - Scott Beck
- The University of British Columbia, Vancouver, British Columbia, Canada
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Yildirim S, Durmaz Y, Şan Y, Taşkıran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021; 25:519-523. [PMID: 34177170 PMCID: PMC8196383 DOI: 10.5005/jp-journals-10071-23804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU. Materials and methods This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses. Results During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001). Conclusion CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost. How to cite this article Yildirim S, Durmaz Y, Şan Y, Taşkiran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021;25(5):519–523.
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Affiliation(s)
- Süleyman Yildirim
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Yusuf Durmaz
- Department of Intensive Care Unit, Hakkari Public Hospital, Hakkari, Turkey
| | - Yosun Şan
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - İmren Taşkıran
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Burcu A Cinleti
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
| | - Cenk Kirakli
- Department of Intensive Care Unit, University of Health Sciences, Turkey, Dr Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, İzmir, Turkey
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Darden DB, Moore FA, Brakenridge SC, Navarro EB, Anton SD, Leeuwenburgh C, Moldawer LL, Mohr AM, Efron PA, Mankowski RT. The Effect of Aging Physiology on Critical Care. Crit Care Clin 2021; 37:135-150. [PMID: 33190766 PMCID: PMC8194285 DOI: 10.1016/j.ccc.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Older patients experience a decline in their physiologic reserves as well as chronic low-grade inflammation named "inflammaging." Both of these contribute significantly to aging-related factors that alter the acute, subacute, and chronic response of these patients to critical illness, such as sepsis. Unfortunately, this altered response to stressors can lead to chronic critical illness followed by dismal outcomes and death. The primary goal of this review is to briefly highlight age-specific changes in physiologic systems majorly affected in critical illness, especially because it pertains to sepsis and trauma, which can lead to chronic critical illness and describe implications in clinical management.
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Affiliation(s)
- Dijoia B Darden
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Scott C Brakenridge
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Eduardo B Navarro
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Stephen D Anton
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL 32611, USA
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL 32611, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610, USA
| | - Robert T Mankowski
- Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Road, Gainesville, FL 32611, USA.
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Outcome Predictive Value of Serum Ferritin in ICU Patients with Long ICU Stay. ACTA ACUST UNITED AC 2020; 57:medicina57010001. [PMID: 33375016 PMCID: PMC7822040 DOI: 10.3390/medicina57010001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 12/24/2022]
Abstract
Background and Objectives: The simplified interpretation of serum ferritin levels, according to which low ferritin levels indicate iron deficiency and high levels indicate hemochromatosis is obsolete, as in the presence of inflammation serum ferritin levels, no longer correlate with iron stores. However, further data are needed to interpret serum ferritin levels correctly in patients with ongoing inflammation. Our study aimed to assess serum iron and ferritin dynamics in patients with long ICU stay and the possible correlations with organ dysfunction progression and outcome. Materials and Methods: We conducted a prospective study in a university hospital intensive care unit (ICU) over six months. All patients with an ICU length-of-stay of more than seven days were enrolled. Collected data included: demographics, Sequential Organ Failure Assessment (SOFA) score, admission, weekly serum iron and ferritin levels, ICU length-of-stay and outcome. Interactions between organ dysfunction progression and serum iron and ferritin levels changes were investigated. Outcome predictive value of serum ferritin was assessed. Results: Seventy-two patients with a mean ICU length-of-stay of 15 (4.4) days were enrolled in the study. The average age of patients was 62 (16.8) years. There were no significant differences between survivors (39 patients, 54%) and nonsurvivors (33 patients, 46%) regarding demographics, serum iron and ferritin levels and SOFA score on ICU admission. Over time, serum iron levels remained normal or low, while serum ferritin levels statedly increased in all patients. Serum ferritin increase was higher in nonsurvivors than survivors. There was a significant positive correlation between SOFA score and serum ferritin (r = 0.7, 95%CI for r = 0.64 to 0.76, p < 0.01). The predictive outcome accuracy of serum ferritin was similar to the SOFA score. Conclusions: In patients with prolonged ICU stay, serum ferritin dynamics reflects organ dysfunction progression and parallels SOFA score in terms of outcome predictive accuracy.
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Abstract
OBJECTIVES Tracheostomy utilization has dramatically increased recently. Large gaps exist between expected and actual outcomes resulting in significant decisional conflict and regret. We determined 1-year patient outcomes and healthcare utilization following tracheostomy to aid in decision-making and resource allocation. DESIGN Retrospective cohort study. SETTING All California hospital discharges from 2012 to 2013 with follow-up through 2014. PATIENTS Nonsurgical patients who received a tracheostomy for acute respiratory failure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Our primary outcome was 30-day, 90-day, and 1-year mortality. We also determined hospitals readmissions rates and healthcare utilization in the first year following tracheostomy. We identified 8,343 tracheostomies during the study period. One-year mortality following tracheostomy was high, 46.5%. Older adults (≥ 65 yr) had significantly higher mortality compared with younger patients (< 65 yr) (54.7% vs 36.5%; p < 0.0001). Median survival for older adults was 175 days (95% CI, 150-202 d) compared with greater than 1 year for younger adults (adjusted hazard ratio, 1.25; 95% CI, 1.14-1.36). Within 1 year of tracheostomy, 60.3% of patients required hospital readmission. Older adults were more likely to be readmitted in the first year after tracheostomy compared with younger adults (66.1% vs 55.2%; adjusted hazard ratio, 1.19; 95% CI, 1.09-1.29). Total short-term acute care hospital costs (index and readmissions) in the first year after tracheostomy were high (mean, $215,369; SD, $160,874). CONCLUSIONS Long-term outcomes following tracheostomy are extremely poor with high mortality, morbidity, and healthcare resource utilization especially among older patients. Some subsets of younger patients may have better outcomes compared with the general tracheostomy population. Short-term acute care costs were extremely high in the first year following tracheostomy. If extended to the entire U.S. population, total short-term acute care hospital costs approach $11 billion dollars per year for tracheostomy-related to acute respiratory failure. These findings may aid families and surrogates in the decision-making process.
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Roedl K, Amann D, Eichler L, Fuhrmann V, Kluge S, Müller J. The chronic ICU patient: Is intensive care worthwhile for patients with very prolonged ICU-stay (≥ 90 days)? Eur J Intern Med 2019; 69:71-76. [PMID: 31494021 DOI: 10.1016/j.ejim.2019.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Due to medical advances, an increasing number of patients are surviving the acute critical illness. However, some patients require a prolonged critical care treatment. Data on outcome and functional status of patients with an ICU-stay ≥90 days are scarce. METHODS Single-center retrospective study including all adult patients with ICU stay ≥90 days treated at the department of intensive care medicine at the university medical center Hamburg-Eppendorf, Germany, between January 1st 2008 and December 31st 2016. RESULTS Out of 65,249 patients, we identified 96 (0.1%) patients with a very prolonged ICU stay. Median age was 61 (49.8-67) years, 30 (31%) patients were female. Patients were admitted to ICU due to abdominal (28%) reasons, followed by sepsis (23%) and transplantation (15%). Fourteen patients received organ-transplantation: 9 received liver-, 4 lung- and 1 heart-transplantation. All patients needed mechanical ventilation (MV), median duration was 74.1 (55-95.1) days. Sixty-Three (66%) patients survived the ICU-stay and 1-Year survival rate was 28%. Overall eight (8%) patients had a favourable outcome after 1-Year. Severity of illness (SOFA, SAPS II) on admission were comparable. Length of MV, use of renal replacement therapy (both p < .01) and maximum lactate (5.3 vs 11.5 mmol/l; p < .001) were significantly higher in ICU non-survivors. ICU-stay was significantly longer in ICU non-survivors (137 vs 107 days; p < .05). Cox-regression-model revealed age (HR 1.02, 95% CI 1.00-1.04, p < .05) and surgical admission (HR 0.50, 95% CI 0.28-0.90, p < .05) as independent predictors of 1-year mortality. CONCLUSIONS Only a small number of patients requires a very prolonged ICU stay. Two-third of patients survive the ICU stay and about one-third 1-Year. However, about 10% of patients have a remarkable recovery with a favourable overall outcome after 1-Year.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Dorothee Amann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Lars Eichler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jakob Müller
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Anaesthesia, Tabea Hospital, Hamburg, Germany.
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Zhang F, Gu Y, Wu L. Skin-stretching device promotes the treatment effect of vacuum sealing drainage technique on phases III and IV stress-induced injuries in aged patients with chronic critical illness: A retrospective study of 70 patients. Medicine (Baltimore) 2019; 98:e18027. [PMID: 31764820 PMCID: PMC6882589 DOI: 10.1097/md.0000000000018027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Stress-induced injury is a common complication associated with patients with chronic critical illness (CCI). Skin-stretching device (SSD) and vacuum sealing drainage (VSD) technique are 2 approaches that can facilitate wound healing.In the present study, the effect of the concatenated application of the 2 techniques on the phases III and IV stress-induced injuries in aged patients with CCI was assessed. About 70 patients with CCI with stress-induced injuries were selected from February 2015 to October 2017. The treatment outcomes of the combined method and VSD method were assessed by comparing their clinicopathologic parameters.The results showed that the combined treatment shortened the average healing duration of wounds. Moreover, the total area of pressure sores, incidence of bleeding, bacteria amount, 28-day cure rate, peripheral C-reactive protein (CRP) level, and the hospitalization duration were all significantly improved in patients treated with SSD and VSD. The overall effective rate (97.14%) of patients treated with VSD and SSD was significantly higher than that (77.14%) in patients treated with VSD.The present study showed that the combined application of VSD and SSD improved the treatment outcomes of phases III and IV stress-induced injuries in aged patients with CCI.
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Affiliation(s)
- Fulian Zhang
- Department of Intensive Care Unit, Hangzhou First People's Hospital
- Department of Intensive Care Unit, Hangzhou Geriatric Hospital, Hangzhou, China
| | - Yuecheng Gu
- Department of Intensive Care Unit, Hangzhou First People's Hospital
- Department of Intensive Care Unit, Hangzhou Geriatric Hospital, Hangzhou, China
| | - Linjun Wu
- Department of Intensive Care Unit, Hangzhou First People's Hospital
- Department of Intensive Care Unit, Hangzhou Geriatric Hospital, Hangzhou, China
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22
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Ingraham NE, Tignanelli CJ, Menk J, Chipman JG. Pre- and Peri-Operative Factors Associated with Chronic Critical Illness in Liver Transplant Recipients. Surg Infect (Larchmt) 2019; 21:246-254. [PMID: 31618109 DOI: 10.1089/sur.2019.192] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Chronic critical illness (CCI) is a new and increasing entity that accounts for substantial cost despite its low incidence. We hypothesized that patients with end-stage liver failure undergoing liver transplant would be at high risk for developing CCI. With limited liver donors it is essential to understand pre- and peritransplant predictors of CCI. Methods: To accomplish this we performed a retrospective cohort study at a large academic transplant center of all adult liver transplant patients from 2011 to 2017. We defined CCI as the need for mechanical ventilation for seven days or more post-transplant. Recipients who had re-transplantation during their index admission, acute rejection, or who died during transplant surgery were excluded. Logistic regression was performed using the Akaike information criterion (AIC) and the likelihood ratio test. Results: We identified 382 transplant recipients. Forty-five (11.8%) developed CCI. Univariable analysis identified 16 pre-transplant factors associated with post-transplant CCI. Subsequent multivariable logistic regression identified eight independent factors associated with CCI in liver transplant recipients including previous liver transplant, acute renal failure, frailty, lower albumin level, higher international normalized ratio, need for mechanical ventilation, and higher systolic pulmonary artery pressure. Pre-transplant factors associated with protection against CCI included higher Model for End-Stage Liver Disease (MELD) score. Conclusion: The incidence of CCI post-liver transplant is similar to the general population admitted to the intensive care unit. Pre-transplant factors associated with CCI can help identify at-risk patients, and furthermore, promote further research and interventions with the goal to decrease the incidence of CCI in the liver transplant recipients.
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Affiliation(s)
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota.,Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota.,Department of Surgery, North Memorial Health Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah Menk
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota.,Division of Critical Care and Acute Care Surgery, University of Minnesota, Minneapolis, Minnesota
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23
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TORUN NAZAN. UZUN SÜRELİ YOĞUN BAKIM HASTASI OLAN AİLELERİN DENEYİMLERİ: NİTEL BİR ÇALIŞMA. DÜZCE ÜNIVERSITESI SAĞLIK BILIMLERI ENSTITÜSÜ DERGISI 2019. [DOI: 10.33631/duzcesbed.540190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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24
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Fumis RRL, Ferraz AB, de Castro I, Barros de Oliveira HS, Moock M, Junior JMV. Mental health and quality of life outcomes in family members of patients with chronic critical illness admitted to the intensive care units of two Brazilian hospitals serving the extremes of the socioeconomic spectrum. PLoS One 2019; 14:e0221218. [PMID: 31518359 PMCID: PMC6743763 DOI: 10.1371/journal.pone.0221218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/01/2019] [Indexed: 01/29/2023] Open
Abstract
Chronic critical illness (CCI) is a relevant clinical, social and financial health issue. The aim of this study was to compare the mental outcomes (symptoms of anxiety and depression) and quality of life outcomes of the family members of patients with CCI from different socioeconomic backgrounds who were admitted to one of the intensive care units (ICUs) in two Brazilian hospitals, one private and one public. It is a prospective study involving a public hospital that serves a low-income population and a tertiary private hospital that serves a high-income population. Family members of patients with CCI answered the Hospital Anxiety and Depression Scale (HADS) and The World Health Organization Quality of Life–WHOQOL-bref questionnaires. They responded to the European Quality of life Five Dimension three Level (EuroQol-5D-3L) and the Activities of Daily Living (ADL) questionnaires on behalf of the patients at three time points: during the ICU stay, 30 and 90 days after the patient was discharged. We used logistic regression models to evaluate the main predictors of a binary outcome regarding symptoms of anxiety and depression. We enrolled 186 patients with CCI. Many patients from public hospitals who were independent became dependent for their ADLs at 90 days (41.7% versus 14.3%, p = 0.03). At 30 days, family members from public hospital had worse impact on all domains of WHOQOL-bref compared with families from private hospital. At 90-days, the difference persists in the physical domain, worse for families from public hospital (p = 0.006). The symptoms of depression at 30-days (p = 0.008) and at 90-days (p = 0.013) were worse in the public hospital. CCIs affected quality of life and the emotional condition of family members, especially in families with fewer resources when the patients became more dependent. Family members with higher education were more likely to experience depression, while depression was associated with cohabiting with the patient in low-income families.
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Affiliation(s)
| | | | - Isac de Castro
- Division of Nephrology and Molecular Medicine, Department of Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Marcelo Moock
- Intensive Care Unit, Hospital Geral do Grajaú, São Paulo, Brazil
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25
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Tang H, Shrager JB. The Signaling Network Resulting in Ventilator-induced Diaphragm Dysfunction. Am J Respir Cell Mol Biol 2019; 59:417-427. [PMID: 29768017 DOI: 10.1165/rcmb.2018-0022tr] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving measure for those incapable of adequately ventilating or oxygenating without assistance. Unfortunately, even brief periods of MV result in diaphragm weakness (i.e., ventilator-induced diaphragm dysfunction [VIDD]) that may render it difficult to wean the ventilator. Prolonged MV is associated with cascading complications and is a strong risk factor for death. Thus, prevention of VIDD may have a dramatic impact on mortality rates. Here, we summarize the current understanding of the pathogenic events underlying VIDD. Numerous alterations have been proven important in both human and animal MV diaphragm. These include protein degradation via the ubiquitin proteasome system, autophagy, apoptosis, and calpain activity-all causing diaphragm muscle fiber atrophy, altered energy supply via compromised oxidative phosphorylation and upregulation of glycolysis, and also mitochondrial dysfunction and oxidative stress. Mitochondrial oxidative stress in fact appears to be a central factor in each of these events. Recent studies by our group and others indicate that mitochondrial function is modulated by several signaling molecules, including Smad3, signal transducer and activator of transcription 3, and FoxO. MV rapidly activates Smad3 and signal transducer and activator of transcription 3, which upregulate mitochondrial oxidative stress. Additional roles may be played by angiotensin II and leaky ryanodine receptors causing elevated calcium levels. We present, here, a hypothetical scaffold for understanding the molecular pathogenesis of VIDD, which links together these elements. These pathways harbor several drug targets that could soon move toward testing in clinical trials. We hope that this review will shape a short list of the most promising candidates.
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Affiliation(s)
- Huibin Tang
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Joseph B Shrager
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
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26
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Benchmarking clinical outcomes and the immunocatabolic phenotype of chronic critical illness after sepsis in surgical intensive care unit patients. J Trauma Acute Care Surg 2019; 84:342-349. [PMID: 29251709 DOI: 10.1097/ta.0000000000001758] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A growing number of patients survive sepsis but remain chronically critically ill. We sought to define clinical outcomes and incidence of chronic critical illness (CCI) after sepsis and to determine whether selected biomarkers of inflammation, immunosuppression, and catabolism differ between these patients and those that rapidly recover (RAP). METHODS This 3-year prospective observational cohort study (NCT02276417) evaluated 145 surgical intensive care unit patients with sepsis for the development of CCI (≥14 days of intensive care unit resource utilization with persistent organ dysfunction). Patient clinical demographics, outcomes, and serial serum/urine samples were collected for plasma protein and urinary metabolite analyses. RESULTS Of 145 sepsis patients enrolled, 19 (13%) died during their hospitalization and 71 (49%) developed CCI. The CCI patients were significantly older (mean, 63 ± 15 vs. 58 ± 13 years, p = 0.006) and more likely to be discharged to long-term acute care facilities (32% vs. 3%, p < 0.0001), whereas those with RAP were more often discharged to home or a rehabilitation facility. Six-month mortality was significantly higher in CCI as compared with RAP cohort (37% vs. 2%; p < 0.01). Multivariate logistic regression modeling revealed delayed onset sepsis (>48 hours after admission; odds ratio [OR], 10.93; 95% confidence interval [CI], 4.15-28.82]), interfacility transfer (OR, 3.58; 95% CI, 1.43-8.96), vasopressor-dependent septic shock (OR, 3.75; 95% CI, 1.47-9.54), and Sequential Organ Failure Assessment score of 5 or greater at 72 hours (OR, 5.03; 95% CI, 2.00-12.62) as independent risk factors for the development of CCI. The CCI patients also demonstrated greater elevations in inflammatory cytokines (IL-6, IL-8, IL-10), and biomarker profiles are consistent with persistent immunosuppression (absolute lymphocyte count and soluble programmed death ligand 1) and catabolism (plasma insulin-like growth factor binding protein 3 and urinary 3-methylhistidine excretion). CONCLUSION The development of CCI has become the predominant clinical trajectory in critically ill surgical patients with sepsis. These patients exhibit biomarker profiles consistent with an immunocatabolic phenotype of persistent inflammation, immunosuppression, and catabolism. LEVEL OF EVIDENCE Prognostic, level II.
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27
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Baptistella AR, Sarmento FJ, da Silva KR, Baptistella SF, Taglietti M, Zuquello RÁ, Nunes Filho JR. Predictive factors of weaning from mechanical ventilation and extubation outcome: A systematic review. J Crit Care 2018; 48:56-62. [PMID: 30172034 DOI: 10.1016/j.jcrc.2018.08.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/06/2018] [Accepted: 08/18/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify, describe and discuss the parameters used to predict weaning from mechanical ventilation and extubation outcomes. METHODS Systematic review of scientific articles using four electronic databases: PubMed, Embase, PEDro and Cochrane Library. Search terms included "weaning", "extubation", "withdrawal" and "discontinuation", combined with "mechanical ventilation" and "predictive factors", "predictive parameters" and "predictors for success". In this study, we included original articles that presented predictive factors for weaning or extubation outcomes in adult patients and not restricted to a single disease. Articles not written in English were excluded. RESULTS A total of 43 articles were included, with a total of 7929 patients and 56 different parameters related to weaning and extubation outcomes. Rapid Shallow Breathing Index (RSBI) was the most common predictor, discussed in 15 studies (2159 patients), followed by Age and Maximum Inspiratory Pressure in seven studies. The other 53 parameters were found in less than six studies. CONCLUSION There are several parameters used to predict weaning and extubation outcomes. RSBI was the most frequently studied and seems to be an important measurement tool in deciding whether to wean/extubate a patient. Furthermore, the results demonstrated that weaning and extubation should be guided by several parameters, and not only to respiratory ones.
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Affiliation(s)
- Antuani Rafael Baptistella
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil.
| | | | | | - Shaline Ferla Baptistella
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Programa de Pós-Graduação em Biociências e Saúde/Universidade do Oeste de Santa Catarina, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
| | | | | | - João Rogério Nunes Filho
- Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, SC, Brazil; Hospital Universitário Santa Terezinha, Joaçaba, SC, Brazil
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28
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Propensity score-matching analyses on the effectiveness of integrated prospective payment program for patients with prolonged mechanical ventilation. Health Policy 2018; 122:970-976. [PMID: 30097352 DOI: 10.1016/j.healthpol.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES An integrated delivery system with a prospective payment program (IPP) for prolonged mechanical ventilation (PMV) was launched by Taiwan's National Health Insurance (NHI) due to the costly and limited ICU resources. This study aimed to analyze the effectiveness of IPP and evaluate the factors associated with successful weaning and survival among patients with PMV. METHODS Taiwan's NHI Research Database was searched to obtain the data of patients aged ≥17 years who had PMV from 2006 to 2010 (N=50,570). A 1:1 propensity score matching approach was used to compare patients with and without IPP (N=30,576). Cox proportional hazards modeling was used to examine the factors related to successful weaning and survival. RESULTS The related factors of lower weaning rate in IPP participants (hazard ratio [HR]=0.84), were older age, higher income, catastrophic illness (HR=0.87), and higher comorbidity. The effectiveness of IPP intervention for the PMV patients showed longer days of hospitalization, longer ventilation days, higher survival rate, and higher medical costs (in respiratory care center, respiratory care ward). The 6-month mortality rate was lower (34.0% vs. 32.9%). The death risk of IPP patients compared to those non-IPP patients was lower (HR=0.91, P<0.001). CONCLUSIONS The policy of IPP for PMV patients showed higher survival rate although it was costly and related to lower weaning rate.
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29
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Abstract
Management of limited health-care resources has been of growing concern. Stewardship of health-care dollars and avoidance of low-value care is being increasingly recognized as a matter that affects all practitioners. This review aims to examine a particular pathological state with multifactorial origins: chronic critical illness (CCI). This condition exerts a large toll on society as well as individual patients and their families. Here, we offer a brief review as to the incidence/prevalence of CCI and suggestions for prevention. Emphasis should be placed on the importance of early, open communication among physicians and patients about their end-of-life decisions and advanced directives, so that decisions can be made wisely and with the patient's best interests in mind.
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Affiliation(s)
| | - William McGee
- 1 Baystate Medical Center, Springfield, MA, USA.,2 University of Massachusetts Medical School, Worcester, MA, USA
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30
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Robles AJ, Kornblith LZ, Hendrickson CM, Howard BM, Conroy AS, Moazed F, Calfee CS, Cohen MJ, Callcut RA. Health care utilization and the cost of posttraumatic acute respiratory distress syndrome care. J Trauma Acute Care Surg 2018; 85:148-154. [PMID: 29958249 PMCID: PMC6029709 DOI: 10.1097/ta.0000000000001926] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttraumatic acute respiratory distress syndrome (ARDS) is associated with prolonged mechanical ventilation and longer hospitalizations. The relationship between posttraumatic ARDS severity and financial burden has not been previously studied. We hypothesized that increasing ARDS severity is associated with incrementally higher health care costs. METHODS Adults arriving as the highest level of trauma activation were enrolled in an ongoing prospective cohort study. Patients who survived 6 hours or longer are included in the analysis. Blinded review of chest radiographs was performed by two independent physicians for any intubated patient with PaO2:FIO2 ratio of 300 mmHg or lower during the first 8 days of admission. The severity of ARDS was classified by the Berlin criteria. Hospital charge data were used to perform standard costing analysis. RESULTS Acute respiratory distress syndrome occurred in 13% (203 of 1,586). The distribution of disease severity was 33% mild, 42% moderate, and 25% severe. Patients with ARDS were older (41 years vs. 35 years, p < 0.01), had higher median Injury Severity Score (30 vs. 10, p < 0.01), more chest injury (Abbreviated Injury Scale score, ≥ 3: 51% vs. 21%, p < 0.01), and blunt mechanisms (85% vs. 53%, p < 0.01). By ARDS severity, there was no significant difference in age, mechanism, or rate of traumatic brain injury. Increasing ARDS severity was associated with higher Injury Severity Score and higher mortality rates. Standardized total hospital charges were fourfold higher for patients who developed ARDS compared with those who did not develop ARDS (US $434,000 vs. US $96,000; p < 0.01). Furthermore, the daily hospital charges significantly increased across categories of worsening ARDS severity (mild, US $20,451; moderate, US $23,994; severe, US $33,316; p < 0.01). CONCLUSION The development of posttraumatic ARDS is associated with higher health care costs. Among trauma patients who develop ARDS, total hospital charges per day increase with worsening severity of disease. Prevention, early recognition, and treatment of ARDS after trauma are potentially important objectives for efforts to control health care costs in this population. LEVEL OF EVIDENCE Economic and value-based evaluations, level IV.
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Affiliation(s)
- Anamaria J Robles
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Lucy Z Kornblith
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Carolyn M Hendrickson
- Department of Medicine, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Benjamin M Howard
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Amanda S Conroy
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Farzad Moazed
- Department of Medicine, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Carolyn S Calfee
- Department of Medicine, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
| | - Mitchell J Cohen
- Department of Surgery, Denver Health Medical Center and the University of Colorado; Denver, Colorado
| | - Rachael A Callcut
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco; San Francisco, California
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31
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Loss SH, Nunes DSL, Franzosi OS, Salazar GS, Teixeira C, Vieira SRR. Chronic critical illness: are we saving patients or creating victims? Rev Bras Ter Intensiva 2018; 29:87-95. [PMID: 28444077 PMCID: PMC5385990 DOI: 10.5935/0103-507x.20170013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 09/05/2016] [Indexed: 12/15/2022] Open
Abstract
The technological advancements that allow support for organ dysfunction have led
to an increase in survival rates for the most critically ill patients. Some of
these patients survive the initial acute critical condition but continue to
suffer from organ dysfunction and remain in an inflammatory state for long
periods of time. This group of critically ill patients has been described since
the 1980s and has had different diagnostic criteria over the years. These
patients are known to have lengthy hospital stays, undergo significant
alterations in muscle and bone metabolism, show immunodeficiency, consume
substantial health resources, have reduced functional and cognitive capacity
after discharge, create a sizable workload for caregivers, and present high
long-term mortality rates. The aim of this review is to report on the most
current evidence in terms of the definition, pathophysiology, clinical
manifestations, treatment, and prognosis of persistent critical illness.
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Affiliation(s)
- Sergio Henrique Loss
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | - Diego Silva Leite Nunes
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Oellen Stuani Franzosi
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Departamento de Nutrição, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil
| | | | - Cassiano Teixeira
- Faculdade de Medicina, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil
| | - Silvia Regina Rios Vieira
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brasil.,Departamento de Clínica Médica, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Abstract
RATIONALE Limited data are available to characterize the long-term outcomes and associated costs for patients who require prolonged mechanical ventilation (PMV; defined here as mechanical ventilation for longer than 21 d). OBJECTIVES To examine the association between PMV and mortality, health care utilization, and costs after critical illness. METHODS Population-based cohort study of adults who received mechanical ventilation in an intensive care unit (ICU) in Ontario, Canada between 2002 and 2013. MEASUREMENT AND MAIN RESULTS We used linked administrative databases to determine discharge disposition, and ascertain 1-year mortality (primary outcome), readmissions to hospital and ICU, and health care costs for hospital survivors. Overall, 11,594 (5.4%) patients underwent PMV, with 42.4% of patients dying in the hospital (vs. 27.6% of patients who did not undergo prolonged ventilation; P < 0.0001). Patients on prolonged ventilation were more frequently discharged to other facilities or home with health care support (84.8 vs. 43.5%, P < 0.0001). Among hospital survivors, estimated mortality was higher for patients who underwent PMV: 16.6 versus 11% at 1 year and 42.0 versus 30.4% at 5 years. At 1 year after hospital discharge, patients on prolonged ventilation had higher rates of hospital readmission (47.2 vs. 37.7%; adjusted odds ratio = 1.20; 95% confidence interval = 1.14-1.26), ICU readmission (19.0 vs. 11.6%; adjusted odds ratio = 1.49; 95% confidence interval: 1.39, 1.60), and total health care costs: median (interquartile range) Can $32,526 ($20,821-$56,102) versus Can $13,657 ($5,946-$38,022). Increasing duration of mechanical ventilation was associated with higher mortality and health care utilization. CONCLUSIONS Critically ill patients who undergo mechanical ventilation in an ICU for longer than 21 days have high in-hospital mortality and greater postdischarge mortality, health care utilization, and health care costs compared with patients who undergo mechanical ventilation for a shorter period of time.
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Rosenthal MD, Kamel AY, Rosenthal CM, Brakenridge S, Croft CA, Moore FA. Chronic Critical Illness: Application of What We Know. Nutr Clin Pract 2018; 33:39-45. [PMID: 29323761 DOI: 10.1002/ncp.10024] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/08/2017] [Indexed: 12/16/2022] Open
Abstract
Over the last decade, chronic critical illness (CCI) has emerged as an epidemic in intensive care unit (ICU) survivors worldwide. Advances in ICU technology and implementation of evidence-based care bundles have significantly decreased early deaths and have allowed patients to survive previously lethal multiple organ failure (MOF). Many MOF survivors, however, experience a persistent dysregulated immune response that is causing an increasingly predominant clinical phenotype called the persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The elderly are especially vulnerable; thus, as the population ages the prevalence of this CCI/PICS clinical trajectory will undoubtedly grow. Unfortunately, there are no proven therapies to prevent PICS, and multimodality interventions will be required. The purpose of this review is to: (1) discuss CCI as it relates to PICS, (2) identify the burden on healthcare and poor outcomes of these patients, and (3) describe possible nutrition interventions for the CCI/PICS phenotype.
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Affiliation(s)
- Martin D Rosenthal
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Amir Y Kamel
- Department of Pharmacy, UF Health, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | - Scott Brakenridge
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Chasen A Croft
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Frederick A Moore
- Department of Surgery, Division of Acute Care Surgery and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, Florida, USA
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Abstract
Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.
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The Epidemiology of Chronic Critical Illness After Severe Traumatic Injury at Two Level-One Trauma Centers. Crit Care Med 2017; 45:1989-1996. [PMID: 28837430 DOI: 10.1097/ccm.0000000000002697] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the incidence and risk factors of chronic critical illness after severe blunt trauma. DESIGN Prospective observational cohort study (NCT01810328). SETTING Two level-one trauma centers in the United States. PATIENTS One hundred thirty-five adult blunt trauma patients with hemorrhagic shock who survived beyond 48 hours after injury. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Chronic critical illness was defined as an ICU stay lasting 14 days or more with evidence of persistent organ dysfunction. Three subjects (2%) died within the first 7 days, 107 (79%) exhibited rapid recovery and 25 (19%) progressed to chronic critical illness. Patients who developed chronic critical illness were older (55 vs 44-year-old; p = 0.01), had more severe shock (base deficit, -9.2 vs -5.5; p = 0.005), greater organ failure severity (Denver multiple organ failure score, 3.5 ± 2.4 vs 0.8 ± 1.1; p < 0.0001) and developed more infectious complications (84% vs 35%; p < 0.0001). Chronic critical illness patients were more likely to be discharged to a long-term care setting (56% vs 34%; p = 0.008) than to a rehabilitation facility/home. At 4 months, chronic critical illness patients had higher mortality (16.0% vs 1.9%; p < 0.05), with survivors scoring lower in general health measures (p < 0.005). Multivariate analysis revealed age greater than or equal to 55 years, systolic hypotension less than or equal to 70 mm Hg, transfusion greater than or equal to 5 units packed red blood cells within 24 hours, and Denver multiple organ failure score at 72 hours as independent predictors of chronic critical illness (area under the receiver operating curve, 0.87; 95% CI, 0.75-0.95). CONCLUSIONS Although early mortality is low after severe trauma, chronic critical illness is a common trajectory in survivors and is associated with poor long-term outcomes. Advancing age, shock severity, and persistent organ dysfunction are predictive of chronic critical illness. Early identification may facilitate targeted interventions to change the trajectory of this morbid phenotype.
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Stieglitz S, Matthes S, Kietzmann I, Priegnitz C, Hagmeyer L, Randerath W. Emergencies and outcome in invasive out-of-hospital ventilation: An observational study over a 1-year period. CLINICAL RESPIRATORY JOURNAL 2017; 12:1447-1453. [PMID: 28776915 DOI: 10.1111/crj.12681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 05/19/2017] [Accepted: 07/30/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The number of ventilated patients is further increasing which leads to an increasing number of patients with weaning failure. In Germany, the treatment of patients with invasive out-of-hospital becomes more and more common. The aim of the study was to observe the outcome, the frequency and character of emergencies of patients with invasive out-of-hospital ventilation. METHODS We conducted a prospective study over 1 year. Fifty-nine invasively ventilated patients living either at home or at nursing homes specialized in ventilator medicine were included. RESULTS Forty-one (71%) of the patients were living in a nursing home. Chronic obstructive pulmonary disease (COPD) was the most common underlying disease (52.5%). Duration of daily ventilation did not change over the 1-year period. 52.8% of the months went without a documented emergency. The most common emergencies were oxygen desaturation (29.6%), increase of secretion (12.2%) and dyspnea (8.7%). We found no difference in the frequency of emergencies between patients cared for in their own home compared with residential care. Ten patients died during the observation period. Fewer emergencies (P = .02, CI 0.03-0.85) was the only parameter associated with a reduced mortality. Frequency of emergencies as well as survival showed no difference regarding the way patients were cared for. CONCLUSIONS In patients with invasive home mechanical ventilation survival for more than 1 year seems to be common. Only the rate of emergencies affected survival.
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Affiliation(s)
- Sven Stieglitz
- Medical Department I, Petrus Hospital Wuppertal, Academic Teaching Hospital of the University of Duesseldorf, Wuppertal, Germany
| | - Sandhya Matthes
- Medical Department V, LMU Hospital of the University of Munich, Munich, Germany
| | - Ilona Kietzmann
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
| | - Christina Priegnitz
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
| | - Lars Hagmeyer
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
| | - Winfried Randerath
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
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A Murine Model of Persistent Inflammation, Immune Suppression, and Catabolism Syndrome. Int J Mol Sci 2017; 18:ijms18081741. [PMID: 28796194 PMCID: PMC5578131 DOI: 10.3390/ijms18081741] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 08/02/2017] [Accepted: 08/07/2017] [Indexed: 01/29/2023] Open
Abstract
Critically ill patients that survive sepsis can develop a Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS), which often leads to extended recovery periods and multiple complications. Here, we utilized a cecal ligation and puncture (CLP) method in mice with the goal of creating a model that concurrently displays all the characteristics of PICS. We observed that, after eight days, mice that survive the CLP develop persistent inflammation with significant myelopoiesis in the bone marrow and spleen. These mice also demonstrate ongoing immune suppression, as evidenced by the decreased total and naïve splenic CD4 and CD8 T cells with a concomitant increase in immature myeloid cells. The mice further display significant weight loss and decreased muscle mass, indicating a state of ongoing catabolism. When PICS mice are challenged with intranasal Pseudomonas aeruginosa, mortality is significantly elevated compared to sham mice. This mortality difference is associated with increased bacterial loads in the lung, as well as impaired neutrophil migration and neutrophil dysfunction in the PICS mice. Altogether, we have created a sepsis model that concurrently exhibits PICS characteristics. We postulate that this will help determine the mechanisms underlying PICS and identify potential therapeutic targets to improve outcomes for this patient population.
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Chronic Critical Illness: The Limbo Between Life and Death. Am J Med Sci 2017; 355:286-292. [PMID: 29549932 DOI: 10.1016/j.amjms.2017.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/03/2017] [Accepted: 07/05/2017] [Indexed: 11/21/2022]
Abstract
The entity of chronic critical illness (CCI) has shown a rise in the past decades for popularity and prevalence. CCI is loosely defined as the group of patients who require the intensive care setting for weeks to months; its hallmark is prolonged mechanical ventilation. The outcomes of chronically critically ill patients have been dismal and have not improved over time; 1-year survival hovers at approximately 50%. Given the high mortality, prognostic variables are important when making medical decisions. CCI encompasses a syndrome that includes altered pathophysiology across a variety of organ systems. Another crucial element of CCI is the symptom burden that patients experience which include feelings of dyspnea, difficulty communicating and pain. This patient population necessitates the combined efforts of multiple care teams and the early integration of palliative and critical care. Future directions need to include improving the symptom management and communication for patients with CCI.
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The long-term quality of life in patients with persistent inflammation-immunosuppression and catabolism syndrome after severe acute pancreatitis: A retrospective cohort study. J Crit Care 2017; 42:101-106. [PMID: 28710987 DOI: 10.1016/j.jcrc.2017.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/20/2017] [Accepted: 07/07/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To explore clinical characteristics and long-term quality of life (QOL) in severe acute pancreatitis (SAP) patients with persistent inflammation-immunosuppression and catabolism syndrome (PICS). MATERIALS AND METHODS SAP patients admitted to ICU were eligible for the retrospective cohort study if they needed prolonged intensive care (>14days). Post-ICU QOL was assessed by a questionnaire, including 36-item Short Form Health Survey (SF-36) and record of re-work in a long-term follow-up. RESULTS 214 SAP patients were enrolled, in which 149 (69.6%) patients met the criteria of PICS. PICS patients had more complications and ICU days compared to non-PICS patients (P<0.001), and their post-ICU mortality was higher (P=0.046). When adjusted for confounders, PICS was independently associated with higher post-ICU mortality (hazard ratio 4.5; 95% CI, 1.2 to 16.3; P=0.024). The 36-item Short Form Health Survey (SF-36) score was lower for PICS group in six subscales (P<0.001). Only 28.8% patients in the PICS group returned to work compared to 60% patients in the non-PICS group (P=0.001) CONCLUSIONS: SAP patients with prolonged ICU stay had a high morbidity of PICS, which was a risk factor for the post-ICU mortality and poor long-term QOL.
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Hospital Variation in Early Tracheostomy in the United States: A Population-Based Study. Crit Care Med 2017; 44:1506-14. [PMID: 27031382 DOI: 10.1097/ccm.0000000000001674] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States. DESIGN In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression. SETTING 2012 National Inpatient Sample. PATIENTS A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home. CONCLUSION Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.
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Sepsis Pathophysiology, Chronic Critical Illness, and Persistent Inflammation-Immunosuppression and Catabolism Syndrome. Crit Care Med 2017; 45:253-262. [PMID: 27632674 DOI: 10.1097/ccm.0000000000002074] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To provide an appraisal of the evolving paradigms in the pathophysiology of sepsis and propose the evolution of a new phenotype of critically ill patients, its potential underlying mechanism, and its implications for the future of sepsis management and research. DESIGN Literature search using PubMed, MEDLINE, EMBASE, and Google Scholar. MEASUREMENTS AND MAIN RESULTS Sepsis remains one of the most debilitating and expensive illnesses, and its prevalence is not declining. What is changing is our definition(s), its clinical course, and how we manage the septic patient. Once thought to be predominantly a syndrome of over exuberant inflammation, sepsis is now recognized as a syndrome of aberrant host protective immunity. Earlier recognition and compliance with treatment bundles has fortunately led to a decline in multiple organ failure and in-hospital mortality. Unfortunately, more and more sepsis patients, especially the aged, are suffering chronic critical illness, rarely fully recover, and often experience an indolent death. Patients with chronic critical illness often exhibit "a persistent inflammation-immunosuppression and catabolism syndrome," and it is proposed here that this state of persisting inflammation, immunosuppression and catabolism contributes to many of these adverse clinical outcomes. The underlying cause of inflammation-immunosuppression and catabolism syndrome is currently unknown, but there is increasing evidence that altered myelopoiesis, reduced effector T-cell function, and expansion of immature myeloid-derived suppressor cells are all contributory. CONCLUSIONS Although newer therapeutic interventions are targeting the inflammatory, the immunosuppressive, and the protein catabolic responses individually, successful treatment of the septic patient with chronic critical illness and persistent inflammation-immunosuppression and catabolism syndrome may require a more complementary approach.
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Nguyen MC, Strosberg DS, Jones TS, Bhakta A, Jones EL, Lyaker MR, Byrd CA, Sobol C, Eiferman DS. Mortality and readmission of outcomes after discharge from the surgical intensive care unit to long-term, acute-care hospitals. Surgery 2017; 161:1367-1375. [DOI: 10.1016/j.surg.2016.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 11/01/2016] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
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Club cell protein 16 and cytokeratin fragment 21-1 as early predictors of pulmonary complications in polytraumatized patients with severe chest trauma. PLoS One 2017; 12:e0175303. [PMID: 28380043 PMCID: PMC5381917 DOI: 10.1371/journal.pone.0175303] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 03/23/2017] [Indexed: 01/11/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) and pneumonia have a great impact on the treatment regimen of polytraumatized patients with severe chest trauma. The objective of our study was to determine whether biomarker levels assessed shortly after multiple trauma may predict the occurrence of these conditions. Methods and findings Our patient population included 71 men and 30 women (mean age, 40.3 ± 15.8 years) with an Injury Severity Score that ranged from 17 to 59 and an Abbreviated Injury Scale Thorax of at least 3. They were admitted to our level I trauma center within one post-traumatic hour and survived for at least 24 hours after the trauma occurred. Thirty-five patients developed ARDS, 30 patients pneumonia and 21 patients both. Five individuals died during hospitalization. The levels of five selected biomarkers, which were identified by a literature search, were assessed at admission (initial levels) and on day 2 after trauma. We performed comparisons of medians, logistic regression analyses and receiver operating characteristic analyses for initial and day-2 levels of each biomarker. With regard to ARDS, initial levels of cytokeratin fragment 21–1, the soluble fragment of cytokeratin 19 (CYFRA21-1) and of the club cell protein 16 (CC16) provided significant results in each statistical analysis. With regard to pneumonia, each statistical analysis supplied significant results for both initial and day-2 levels of CYFRA21-1 and CC16. Consistently, initial CYFRA21-1 levels were identified as the most promising predictor of ARDS, whereas day-2 CC16 levels have to be considered as most appropriate for predicting pneumonia. Conclusions CYFRA21-1 levels exceeding cut-off value of 1.85 ng/ml and 2.49 ng/ml in the serum shortly after multiple injury occurred may identify polytraumatized patients at risk for ARDS and pneumonia, respectively. However, CC16 levels exceeding 30.51 ng/ml on day 2 may allow a firmer diagnosis for the development of pneumonia.
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Rosenthal MD, Carrott PW, Patel J, Kiraly L, Martindale RG. Parenteral or Enteral Arginine Supplementation Safety and Efficacy. J Nutr 2016; 146:2594S-2600S. [PMID: 27934650 DOI: 10.3945/jn.115.228544] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/01/2016] [Accepted: 10/04/2016] [Indexed: 01/01/2023] Open
Abstract
Arginine supplementation has the potential to improve the health of patients. Its use in hospitalized patients has been a controversial topic in the nutrition literature, especially concerning supplementation of septic patients. In this article, we review the relevant literature both for and against the use of arginine in critically ill, surgical, and hospitalized patients. The effect of critical illness on arginine metabolism is reviewed, as is its use in septic and critically ill patients. Although mounting evidence supports immunonutrition, there are only a few studies that suggest that this is safe in patients with severe sepsis. The use of arginine has been shown to benefit a variety of critically ill patients. It should be considered for inclusion in combinations of immunonutrients or commercial formulations for groups in whom its benefit has been reported consistently, such as those who have suffered trauma and those in acute surgical settings. The aims of this review are to discuss the role of arginine in health, the controversy surrounding arginine supplementation of septic patients, and the use of arginine in critically ill patients.
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Affiliation(s)
- Martin D Rosenthal
- Division of Acute Care Surgery, Department of Surgery, and.,Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL
| | - Phillip W Carrott
- Section of Cardiothoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jayshil Patel
- Division of Pulmonary Critical Care, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI; and
| | - Laszlo Kiraly
- Division of Gastrointestinal Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Robert G Martindale
- Division of Gastrointestinal Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
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Sancho J, Servera E, Jara-Palomares L, Barrot E, Sanchez-Oro-Gómez R, Gómez de Terreros FJ, Martín-Vicente MJ, Utrabo I, Núñez MB, Binimelis A, Sala E, Zamora E, Segrelles G, Ortega-Gonzalez A, Masa F. Noninvasive ventilation during the weaning process in chronically critically ill patients. ERJ Open Res 2016; 2:00061-2016. [PMID: 28053973 PMCID: PMC5152849 DOI: 10.1183/23120541.00061-2016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/10/2016] [Indexed: 11/17/2022] Open
Abstract
Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process. We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h. 231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01–1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97). NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning. NIV is a useful tool during weaning in chronic critically ill patients independent of their premorbid conditionhttp://ow.ly/j4Av304sEoJ
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Affiliation(s)
- Jesus Sancho
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain; INCLIVA Institute of Health Research, Valencia, Spain
| | - Emilio Servera
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain; INCLIVA Institute of Health Research, Valencia, Spain; Dept of Physical Therapy, Universitat de Valencia, Valencia, Spain
| | - Luis Jara-Palomares
- Unidad Médico-Quirurgica de Enfermedades Respiratorias, Hospital Virgen del Rocio, Seville, Spain
| | - Emilia Barrot
- Unidad Médico-Quirurgica de Enfermedades Respiratorias, Hospital Virgen del Rocio, Seville, Spain
| | - Raquel Sanchez-Oro-Gómez
- Unidad Médico-Quirurgica de Enfermedades Respiratorias, Hospital Virgen del Rocio, Seville, Spain
| | - F Javier Gómez de Terreros
- Servicio de Neumología, Hospital San Pedro Alcántara, Cáceres, Spain; Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain
| | - M Jesús Martín-Vicente
- Servicio de Neumología, Hospital San Pedro Alcántara, Cáceres, Spain; Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain
| | - Isabel Utrabo
- Servicio de Neumología, Hospital San Pedro Alcántara, Cáceres, Spain; Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain
| | - M Belen Núñez
- Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain; Servicio de Neumología, Hospital Son Espases, Palma de Mallorca, Spain
| | - Alicia Binimelis
- Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain; Servicio de Neumología, Hospital Son Espases, Palma de Mallorca, Spain
| | - Ernest Sala
- Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain; Servicio de Neumología, Hospital Son Espases, Palma de Mallorca, Spain
| | - Enrique Zamora
- Intermediate Care Unit, Pulmonology Dept, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Gonzalo Segrelles
- Intermediate Care Unit, Pulmonology Dept, La Princesa Institute for Health Research, Hospital Universitario de La Princesa, Madrid, Spain
| | - Angel Ortega-Gonzalez
- Servicio de Neumología, Hospital Nuestra Señora del Prado, Talavera de la Reina, Spain
| | - Fernando Masa
- Servicio de Neumología, Hospital San Pedro Alcántara, Cáceres, Spain; Centro de Investigación Biomédica de Enfermedades Respiratorias (CIBERES), University Carlos III, Madrid, Spain
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Abstract
OBJECTIVES To evaluate the association between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States. DESIGN Retrospective cohort study of a random sample of Medicare beneficiaries who survived to hospital discharge, with 1- and 3-year follow-up, stratified by the number of days of intensive care and with additional stratification based on receipt of mechanical ventilation. INTERVENTIONS None. PATIENTS The cohort included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005. MEASUREMENTS AND MAIN RESULTS Among 34,696 patients who survived to hospital discharge, the mean ICU length of stay was 3.4 days (± 4.5 d). Patients (88.9%) were in the ICU for 1-6 days, representing 58.6% of ICU bed-days. Patients (1.3%) were in the ICU for 21 or more days, but these patients used 11.6% of bed-days. The percentage of mechanically ventilated patients increased with increasing length of stay (6.3% for 1-6 d in the ICU and 71.3% for ≥ 21 d). One-year mortality was 26.6%, ranging from 19.4% for patients in the ICU for 1 day, up to 57.8% for patients in the ICU for 21 or more days. For each day beyond 7 days in the ICU, there was an increased odds of death by 1 year of 1.04 (95% CI, 1.03-1.05) irrespective of the need for mechanical ventilation. CONCLUSIONS Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non-mechanically ventilated patients. No specific cutoff was associated with a clear plateau or sharp increase in long-term risk.
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Lai CC, Shieh JM, Chiang SR, Chiang KH, Weng SF, Ho CH, Tseng KL, Cheng KC. The outcomes and prognostic factors of patients requiring prolonged mechanical ventilation. Sci Rep 2016; 6:28034. [PMID: 27296248 PMCID: PMC4906399 DOI: 10.1038/srep28034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/23/2016] [Indexed: 12/29/2022] Open
Abstract
The aims of this study were to investigate the outcomes of patients requiring prolonged mechanical ventilation (PMV) and to identify risk factors associated with its mortality rate. All patients admitted to the respiratory care centre (RCC) who required PMV (the use of MV ≥21 days) between January 2006 and December 2014 were enrolled. A total of 1,821 patients were identified; their mean age was 69.8 ± 14.2 years, and 521 patients (28.6%) were aged >80 years. Upon RCC admission, the APACHE II scores were 16.5 ± 6.3, and 1,311 (72.0%) patients had at least one comorbidity. Pulmonary infection was the most common diagnosis (n = 770, 42.3%). A total of 320 patients died during hospitalization, and the in-hospital mortality rate was 17.6%. A multivariate stepwise logistic regression analysis indicated that patients were more likely to die if they who were >80 years of age, had lower albumin levels (<2 g/dl) and higher APACHE II scores (≥15), required haemodialysis, or had a comorbidity. In conclusion, the in-hospital mortality for patients requiring PMV in our study was 17%, and mortality was associated with disease severity, hypoalbuminaemia, haemodialysis, and an older age.
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Affiliation(s)
- Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Taiwan
| | - Jiunn-Min Shieh
- Departments of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Chia Nan University of Pharmacy &Science, Tainan, Taiwan
| | - Shyh-Ren Chiang
- Departments of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Chia Nan University of Pharmacy &Science, Tainan, Taiwan
| | - Kuo-Hwa Chiang
- Departments of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Shih-Feng Weng
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Han Ho
- Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Kuei-Ling Tseng
- Departments of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Kuo-Chen Cheng
- Departments of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Safety Health and Environmental Engineering, Chung Hwa University of Medical Technology, Tainan, Taiwan
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Iwashyna TJ, Hodgson CL, Pilcher D, Bailey M, van Lint A, Chavan S, Bellomo R. Timing of onset and burden of persistent critical illness in Australia and New Zealand: a retrospective, population-based, observational study. THE LANCET RESPIRATORY MEDICINE 2016; 4:566-573. [PMID: 27155770 DOI: 10.1016/s2213-2600(16)30098-4] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/16/2016] [Accepted: 03/30/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Critical care physicians recognise persistent critical illness as a specific syndrome, yet few data exist for the timing of the transition from acute to persistent critical illness. Defining the onset of persistent critical illness as the time at which diagnosis and illness severity at intensive care unit (ICU) arrival no longer predict outcome better than do simple pre-ICU patient characteristics, we measured the timing of this onset at a population level in Australia and New Zealand, and the variation therein, and assessed the characteristics, burden of care, and hospital outcomes of patients with persistent critical illness. METHODS In this retrospective, population-based, observational study, we used data for ICU admission in Australia and New Zealand from the Australian and New Zealand Intensive Care Society Adult Patient Database. We included all patients older than 16 years of age admitted to a participating ICU. We excluded patients transferred from another hospital and those admitted to an ICU for palliative care or awaiting organ donation. The primary outcome was in-hospital mortality. Using statistical methods in evenly split development and validation samples for risk score development, we examined the ability of characteristics to predict in-hospital mortality. FINDINGS Between Jan, 2000, and Dec, 2014, we studied 1 028 235 critically ill patients from 182 ICUs across Australia and New Zealand. Among patients still in an ICU, admission diagnosis and physiological derangements, which accurately predicted outcome on admission (area under the receiver operating characteristics curve 0·898 [95% CI 0·897-0·899] in the validation cohort), progressively lost their predictive ability and no longer predicted outcome more accurately than did simple antecedent patient characteristics (eg, age, sex, or chronic health status) after 10 days in the ICU, thus empirically defining the onset of persistent critical illness. This transition occurred between day 7 and day 22 across diagnosis-based subgroups and between day 6 and day 15 across risk-of-death-based subgroups. Cases of persistent critical illness accounted for only 51 509 (5·0%) of the 1 028 235 patients admitted to an ICU, but for 1 029 345 (32·8%) of 3 138 432 ICU bed-days and 2 197 108 (14·7%) of 14 961 693 hospital bed-days. Overall, 12 625 (24·5%) of 51 509 patients with persistent critical illness died and only 23 968 (46·5%) of 51 509 were discharged home. INTERPRETATION Onset of persistent critical illness can be empirically measured at a population level. Patients with this condition consume vast resources, have high mortality, have much less chance of returning home than do typical ICU patients, and require dedicated future research. ICU clinicians should be aware that the risk of in-hospital mortality can change quickly over the first 2 weeks of an ICU course and be sure to incorporate such changes in their decision making and prognostication. FUNDING None.
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Affiliation(s)
- Theodore J Iwashyna
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, MI, USA.
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Physiotherapy, Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Allison van Lint
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Shaila Chavan
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care Unit, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
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Mok JH, Kim YH, Jeong ES, Eom JS, Kim MH, Kim KU, Lee MK, Lee K. Clinical application of the ProVent score in Korean patients requiring prolonged mechanical ventilation: A 10-year experience in a university-affiliated tertiary hospital. J Crit Care 2016; 33:158-62. [PMID: 26994779 DOI: 10.1016/j.jcrc.2016.02.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/26/2016] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE We evaluated the clinical usefulness of a prognostic scoring system ("the ProVent score") in Korean patients requiring prolonged mechanical ventilation. MATERIAL AND METHODS We retrospectively analyzed the data of 184 patients in a medical intensive care unit of a tertiary care hospital between January 2004 and December 2013. RESULTS The patients' median age was 65 years, and 66.8% were male. One-year mortality was 67.4%. On day 21 of mechanical ventilation, the ProVent score was 0 in 13 patients (7.1%), 1 in 39 patients (21.2%), 2 in 73 patients (39.7%), 3 in 42 patients (22.8%), and greater than or equal to 4 in 17 patients (9.2%). For patients with a ProVent score ranging from 0 to greater than or equal to 4, 1-year mortality was 46.2%, 53.8%, 68.5%, 76.2%, and 88.2%, respectively. The Kaplan-Meier curves of 1-year survival for each ProVent score showed statistically significant differences (log-rank test: P = .001). Logistic regression analysis showed that only thrombocytopenia was independently associated with 1-year mortality in our cohort (odds ratio = 4.786, P < .001). CONCLUSIONS In our study, the ProVent score could be applied to predict 1-year mortality for patients requiring prolonged mechanical ventilation in Korea. Among variables contributing to this score, only thrombocytopenia was an independent prognostic factor for 1-year mortality.
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Affiliation(s)
- Jeong Ha Mok
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Yang Hee Kim
- Department of Respiratory Prevention and Management, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Eun Suk Jeong
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Jung Seop Eom
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Mi Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Ki Uk Kim
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea.
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50
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Five-Year Survival of Children With Chronic Critical Illness in Australia and New Zealand. Crit Care Med 2015; 43:1978-85. [PMID: 25962079 DOI: 10.1097/ccm.0000000000001076] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Outcomes for children with chronic critical illness are not defined. We examined the long-term survival of these children in Australia and New Zealand. DESIGN All cases of PICU chronic critical illness with length of stay more than 28 days and age 16 years old or younger in Australia and New Zealand from 2000 to 2011 were studied. Five-year survival was analyzed using Kaplan-Meir estimates, and risk factors for mortality evaluated using Cox regression. SETTING All PICUs in Australia and New Zealand. PATIENTS Nine hundred twenty-four children with chronic critical illness. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Nine hundred twenty-four children were admitted to PICU for longer than 28 days on 1,056 occasions, accounting for 1.3% of total admissions and 23.5% of bed days. Survival was known for 883 of 924 patients (95.5%), with a median follow-up of 3.4 years. The proportion with primary cardiac diagnosis increased from 27% in 2000-2001 to 41% in 2010-2011. Survival was 81.4% (95% CI, 78.6-83.9) to PICU discharge, 70% (95% CI, 66.7-72.8) at 1 year, and 65.5% (95% CI, 62.1-68.6) at 5 years. Five-year survival was 64% (95% CI, 58.7-68.6) for children admitted in 2000-2005 and 66% (95% CI, 61.7-70) if admitted in 2006-2011 (log-rank test, p = 0.37). After adjusting for admission severity of illness using the Paediatric Index of Mortality 2 score, predictors for 5-year mortality included bone marrow transplant (hazard ratio, 3.66; 95% CI, 2.26-5.92) and single-ventricle physiology (hazard ratio, 1.98; 95% CI, 1.37-2.87). Five-year survival for single-ventricle physiology was 47.2% (95% CI, 34.3-59.1) and for bone marrow transplantation 22.8% (95% CI, 8.7-40.8). CONCLUSIONS Two thirds of children with chronic critical illness survive for at-least 5 years, but there was no improvement between 2000 and 2011. Cardiac disease constitutes an increasing proportion of pediatric chronic critical illness. Bone marrow transplant recipients and single-ventricle physiology have the poorest outcomes.
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