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Nissilä E, Hynninen M, Jalkanen V, Kuitunen A, Bäcklund M, Inkinen O, Hästbacka J. The effectiveness of a brief intervention for intensive care unit patients with hazardous alcohol use: a randomized controlled trial. Crit Care 2024; 28:145. [PMID: 38689346 PMCID: PMC11061909 DOI: 10.1186/s13054-024-04925-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Screening for hazardous alcohol use and performing brief interventions (BIs) are recommended to reduce alcohol-related negative health consequences. We aimed to compare the effectiveness (defined as an at least 10% absolute difference) of BI with usual care in reducing alcohol intake in intensive care unit survivors with history of hazardous alcohol use. METHODS We used Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score to assess history of alcohol use. PATIENTS Emergency admitted adult ICU patients in three Finnish university hospitals, with an AUDIT-C score > 5 (women), or > 6 (men). We randomized consenting eligible patients to receive a BI or treatment as usual (TAU). INTERVENTION BI was delivered by the time of ICU discharge or shortly thereafter in the hospital ward. CONTROLS Control patients received TAU. OUTCOME The primary outcome was self-reported alcohol consumption during the preceding week 6 and 12 months after randomization. Secondary outcomes were the change in AUDIT-C scores from baseline to 6 and 12 months, health-related quality of life, and mortality. The trial was terminated early due to slow recruitment during the pandemic. RESULTS We randomized 234 patients to receive BI (N = 117) or TAU (N = 117). At 6 months, the median alcohol intake in the BI and TAU groups were 6.5 g (interquartile range [IQR] 0-141) and 0 g (0-72), respectively (p = 0.544). At 12 months, it was 24 g (0-146) and 0 g (0-96) in the BI and TAU groups, respectively (p = 0.157). Median change in AUDIT-C from baseline to 6 months was - 1 (- 4 to 0) and 2 (- 6 to 0), (p = 0.144) in the BI and TAU groups, and to 12 months - 3 (- 5 to - 1) and - 4 (- 7 to - 1), respectively (p = 0.187). In total, 4% (n = 5) of patients in the BI group and 11% (n = 13) of patients in the TAU group were abstinent at 6 months, and 10% (n = 12) and 15% (n = 17), respectively, at 12 months. No between-groups difference in mortality emerged. CONCLUSION As underpowered, our study cannot reject or confirm the hypothesis that a single BI early after critical illness is effective in reducing the amount of alcohol consumed compared to TAU. However, a considerable number in both groups reduced their alcohol consumption. TRIAL REGISTRATION ClinicalTrials.gov (NCT03047577).
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Affiliation(s)
- Eliisa Nissilä
- Department of Perioperative and Intensive Care Medicine, Intensive Care Units, Helsinki University Hospital and Helsinki University, Haartmaninkatu 2, PL 340, 00029, Helsinki, Finland.
| | - Marja Hynninen
- Department of Perioperative and Intensive Care Medicine, Intensive Care Units, Helsinki University Hospital and Helsinki University, Haartmaninkatu 2, PL 340, 00029, Helsinki, Finland
| | - Ville Jalkanen
- Department of Intensive Care, Tampere University Hospital, Wellbeing District of Pirkanmaa and Tampere University, Tampere, Finland
| | - Anne Kuitunen
- Department of Intensive Care, Tampere University Hospital, Wellbeing District of Pirkanmaa and Tampere University, Tampere, Finland
| | - Minna Bäcklund
- Department of Perioperative and Intensive Care Medicine, Intensive Care Units, Helsinki University Hospital and Helsinki University, Haartmaninkatu 2, PL 340, 00029, Helsinki, Finland
| | - Outi Inkinen
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Wellbeing District of Southwest Finland and University of Turku, Turku, Finland
| | - Johanna Hästbacka
- Department of Perioperative and Intensive Care Medicine, Intensive Care Units, Helsinki University Hospital and Helsinki University, Haartmaninkatu 2, PL 340, 00029, Helsinki, Finland
- Department of Intensive Care, Tampere University Hospital, Wellbeing District of Pirkanmaa and Tampere University, Tampere, Finland
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Nissilä E, Suojaranta R, Hynninen M, Dahlbacka S, Hästbacka J. Hazardous alcohol consumption and perioperative complications in a cardiac surgery patient. A retrospective study. Acta Anaesthesiol Scand 2024; 68:337-344. [PMID: 38014920 DOI: 10.1111/aas.14361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/09/2023] [Accepted: 11/05/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND We investigated the prevalence and effects of hazardous alcohol consumption on perioperative complications in cardiac surgery patients. Preoperative hazardous alcohol consumption has been associated with an increased risk of postoperative complications in noncardiac patient populations. METHODS We retrospectively collected data from the Finnish Intensive Care Consortium database and electronic patient records on all cardiac surgery patients treated in the intensive care units (ICUs) of Helsinki University Hospital (n = 919) during 2017. Data on preoperative alcohol consumption were routinely collected using the alcohol use disorder identification test consumption (AUDIT-C) questionnaire. We analyzed perioperative data and outcomes for any associations with hazardous alcohol consumption. Outcome measures were length of stay in the ICU, re-admissions to ICU, bleeding and infectious complications, and incidence of postoperative arrhythmias. RESULTS AUDIT-C scores were available for 758 (82.5%) patients, of whom 107 (14.1%) fulfilled the criteria for hazardous alcohol consumption (AUDIT-C score of 5/12 or higher for women and 6/12 or higher for men). Patients with hazardous alcohol consumption were younger, median age 59 (IQR 52.0-67.0) vs. 69.0 (IQR 63.0-74.0), p < .001, and more often men 93.5% vs. 71.9%, p < .001 than other patients and had an increased risk for ICU re-admissions [adjusted OR (aOR) 4.37 (95% CI, 1.60-11.95)] and severe postoperative infections aOR 3.26 (95% CI, 1.42-7.54). CONCLUSION Cardiac surgery patients with a history of hazardous alcohol consumption are younger than other patients and are predominantly men. Hazardous alcohol consumption is associated with an increased risk of severe postoperative infections and ICU re-admissions.
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Affiliation(s)
- Eliisa Nissilä
- Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Raili Suojaranta
- Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marja Hynninen
- Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sebastian Dahlbacka
- Department of Cardiac Surgery, Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Anesthesiology and Intensive Care, Tampere University Hospital and Tampere University, Tampere, Finland
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3
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Pan Y, Xia Y, Zhang X, Cai X, Pan J, Dong Y. FIB-4 index is associated with mortality in critically ill patients with alcohol use disorder: Analysis from the MIMIC-IV database. Addict Biol 2024; 29:e13361. [PMID: 38380780 PMCID: PMC10898836 DOI: 10.1111/adb.13361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/26/2023] [Accepted: 11/17/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND The relationship between fibrosis-4 (FIB-4) index and all-cause mortality in critically ill patients with alcohol use disorder (AUD) is unclear. The present study aimed to investigate the predictive ability of FIB-4 for all-cause mortality in critically ill AUD patients and the association between them. METHODS A total of 2528 AUD patients were included using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. FIB-4 was calculated for each patient using the existing formula. The patients were equally divided into four groups based on the quartiles of FIB-4. Multivariate logistic regression and Cox proportional hazard model were used to evaluate the association of FIB-4 with in-hospital mortality, 28-day mortality and 1-year mortality. Kaplan-Meier curves were used to analyse the incidence of 28-day mortality among four groups. RESULTS FIB-4 was positively associated with 28-day mortality of AUD patients with hazard ratio (HR) of 1.354 [95% confidence interval (CI) 1.192-1.538]. There were similar trends in the in-hospital mortality [odds ratio (OR): 1.440, 95% CI (1.239-1.674)] and 1-year mortality [HR: 1.325, 95% CI (1.178-1.490)]. CONCLUSION Increased FIB-4 is associated with greater in-hospital mortality, 28-day mortality and 1-year mortality in critically ill AUD patients.
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Affiliation(s)
- Yu Pan
- Department of PharmacyWenzhou Hospital of Integrated Traditional Chinese and Western MedicineWenzhouZhejiangChina
| | - Yan‐huo Xia
- Department of Intensive Care UnitThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouZhejiangChina
| | - Xiao‐hua Zhang
- Department of PharmacyWenzhou Hospital of Integrated Traditional Chinese and Western MedicineWenzhouZhejiangChina
| | - Xi‐xi Cai
- Department of PharmacyWenzhou Hospital of Integrated Traditional Chinese and Western MedicineWenzhouZhejiangChina
| | - Jing‐ye Pan
- Department of Intensive Care UnitThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouZhejiangChina
| | - Yi‐hua Dong
- Department of Intensive Care UnitThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouZhejiangChina
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4
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Nissilä E, Hynninen M, Reinikainen M, Bendel S, Suojaranta R, Korhonen A, Suvela M, Loisa P, Kaminski T, Hästbacka J. Prevalence and impact of hazardous alcohol use in intensive care cohort: A multicenter, register-based study. Acta Anaesthesiol Scand 2021; 65:1073-1078. [PMID: 33840090 DOI: 10.1111/aas.13828] [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: 11/19/2020] [Revised: 02/12/2021] [Accepted: 03/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reports of the prevalence and impact of hazardous alcohol use among intensive care unit (ICU) patients are contradictory. We aimed to study the prevalence of hazardous alcohol use among ICU patients and its association with ICU length of stay (LOS) and mortality. METHODS Finnish ICUs have been using the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) to evaluate and record patients' alcohol use into the Finnish Intensive Care Consortium's Database (FICC). We retrieved data from the FICC from a 3-month period. We excluded data from centers with an AUDIT-C recording rate of less than 70% of admissions. We defined hazardous alcohol use as a score of 5 or more for women and 6 or more for men from a maximum score of 12 points. RESULTS Two thousand forty-five patients were treated in the 10 centers with an AUDIT-C recording rate of 70% or higher. AUDIT-C was available for 1576 (77%) patients and indicated hazardous alcohol use for 334 (21%) patients who were more often younger (median age 55 [interquartile range 42-65] vs 67 [57-74] [P < .001]) and male (78.1% vs 61.3% [P < .001]) compared to other patients. We found no difference in LOS or hospital mortality between hazardous and non-hazardous alcohol users. Among the non-abstinent, risk of death within a year increased with increasing AUDIT-C scores adjusted odds ratio 1.077 (95% confidence interval, 1.006-1.152) per point. CONCLUSION The prevalence of hazardous alcohol use in Finnish ICUs was 21%. Patients with hazardous alcohol use were more often younger and male compared with non-hazardous alcohol users.
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Affiliation(s)
- Eliisa Nissilä
- Department of Anaesthesiology, Intensive Care and Pain Medicine Intensive Care Units University of HelsinkiHelsinki University Hospital Helsinki Finland
| | - Marja Hynninen
- Department of Anaesthesiology, Intensive Care and Pain Medicine Intensive Care Units University of HelsinkiHelsinki University Hospital Helsinki Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care Kuopio University HospitalUniversity of Eastern Finland Kuopio Finland
| | - Stepani Bendel
- Department of Anaesthesiology and Intensive Care Kuopio University HospitalUniversity of Eastern Finland Kuopio Finland
| | - Raili Suojaranta
- Department of Cardiac Surgery, Heart and Lung Center University of HelsinkiHelsinki University Hospital Helsinki University Hospital Helsinki Finland
| | - Anna‐Maija Korhonen
- Department of Anaesthesiology, Intensive Care and Pain Medicine Intensive Care Units University of HelsinkiHelsinki University Hospital Helsinki Finland
| | - Markku Suvela
- Intensive Care Unit North Karelia Central Hospital Joensuu Finland
| | - Pekka Loisa
- Intensive Care Unit Päijät‐Häme Central Hospital Lahti Finland
| | - Tadeusz Kaminski
- Intensive Care Unit Central Ostrobothnia Central Hospital Kokkola Finland
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Pain Medicine Intensive Care Units University of HelsinkiHelsinki University Hospital Helsinki Finland
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Pothoulakis I, Nawaz H, Paragomi P, Jeong K, Talukdar R, Kochhar R, Goenka MK, Gulla A, Singh VK, Gonzalez JA, Ferreira M, Barbu ST, Stevens T, Gutierrez SC, Zarnescu NO, Capurso G, Easler J, Triantafyllou K, Pelaez-Luna M, Thakkar S, Ocampo C, de-Madaria E, Wu BU, Cote GA, Abebe K, Tang G, Lahooti A, Phillips AE, Papachristou GI. Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study. United European Gastroenterol J 2021; 9:54-62. [PMID: 32883182 PMCID: PMC8259260 DOI: 10.1177/2050640620957243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/06/2020] [Indexed: 12/15/2022] Open
Abstract
Background Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied. Objective We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis. Methods Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance. Results Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83–5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01–2.69) were independent risk factors for oral feeding intolerance. Conclusion Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.
Current knowledge on this subject
Oral feeding intolerance is a relatively common complication of acute pancreatitis. Oral feeding intolerance results in longer hospitalization and frequent readmissions.
What is new in this study
The incidence of oral feeding intolerance is similar irrespective of the timing of the initial feeding attempt. Oral feeding intolerance is independently associated with systemic inflammatory response syndrome at 48 h and nonbiliary etiology.
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Affiliation(s)
- Ioannis Pothoulakis
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Medicine, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Haq Nawaz
- Department of Gastroenterology, Eastern Maine Medical Center, Bangor, Maine, USA
| | - Pedram Paragomi
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kwonho Jeong
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Gastroenterology Institute, Hyderabad, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Aiste Gulla
- Department of Gastroenterology, Georgetown University Hospital, Washington, District of Columbia, USA.,Department of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Vikesh K Singh
- Department of Gastroenterology, John Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Jose A Gonzalez
- Department of Gastroenterology, Universidad Autonoma de Nueva León, Monterrey, Mexico
| | - Miguel Ferreira
- Department of Gastroenterology, Hospital Nacional de Itaguá, Itagua, Paraguay
| | - Sorin T Barbu
- Department of Surgery, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Tyler Stevens
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Silvia C Gutierrez
- Department of Gastroenterology, Hospital Nacional "Profesor Alejandro Posadas", Buenos Aires, Argentina
| | - Narcis O Zarnescu
- Department of Gastroenterology, University Emergency Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Jeffrey Easler
- Department of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Mario Pelaez-Luna
- Department of Gastroenterology, Instituto Nacional de Ciencias Módicas y Nutrición Salvador Zubirán-Universidad Autonoma d Mexico, Mexico City, Mexico
| | - Shyam Thakkar
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Carlos Ocampo
- Department of Surgery, Hospital General de Argudos "Dr. Cosme Argerich", Buenos Aires, Argentina
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Bechien U Wu
- Department of Gastroenterology, Kaiser Permanente, Pasadena, California, USA
| | - Gregory A Cote
- Department of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kaleab Abebe
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gong Tang
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ali Lahooti
- Department of Gastroenterology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anna E Phillips
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Georgios I Papachristou
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Gastroenterology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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At-Risk Drinking Is Independently Associated With Acute Kidney Injury in Critically Ill Patients. Crit Care Med 2020; 47:1041-1049. [PMID: 31094742 DOI: 10.1097/ccm.0000000000003801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Unhealthy use of alcohol and acute kidney injury are major public health problems, but little is known about the impact of excessive alcohol consumption on kidney function in critically ill patients. We aimed to determine whether at-risk drinking is independently associated with acute kidney injury in the ICU and at ICU discharge. DESIGN Prospective observational cohort study. SETTING A 21-bed polyvalent ICU in a university hospital. PATIENTS A total of 1,107 adult patients admitted over a 30-month period who had an ICU stay of greater than or equal to 3 days and in whom alcohol consumption could be assessed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed Kidney Disease Improving Global Outcomes stages 2-3 acute kidney injury in 320 at-risk drinkers (29%) and 787 non-at-risk drinkers (71%) at admission to the ICU, within 4 days after admission and at ICU discharge. The proportion of patients with stages 2-3 acute kidney injury at admission to the ICU (42.5% vs 18%; p < 0.0001) was significantly higher in at-risk drinkers than in non-at-risk drinkers. Within 4 days and after adjustment on susceptible and predisposing factors for acute kidney injury was performed, at-risk drinking was significantly associated with acute kidney injury for the entire population (odds ratio, 2.15; 1.60-2.89; p < 0.0001) in the subgroup of 832 patients without stages 2-3 acute kidney injury at admission to the ICU (odds ratio, 1.44; 1.02-2.02; p = 0.04) and in the subgroup of 971 patients without known chronic kidney disease (odds ratio, 1.92; 1.41-2.61; p < 0.0001). Among survivors, 22% of at-risk drinkers and 9% of non-at-risk drinkers were discharged with stages 2-3 acute kidney injury (p < 0.001). CONCLUSIONS Our results suggest that chronic and current alcohol misuse in critically ill patients is associated with kidney dysfunction. The systematic and accurate identification of patients with alcohol misuse may allow for the prevention of acute kidney injury.
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Impact on ICU mortality of moderate alcohol consumption in patients admitted with infection. J Crit Care 2020; 57:91-96. [PMID: 32062291 DOI: 10.1016/j.jcrc.2020.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/05/2020] [Accepted: 02/06/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Alcohol dependence is associated with poor prognosis in the intensive care unit (ICU), but it remains uncertain whether moderate alcohol consumption negatively affects the prognosis of critically ill patients admitted with infection. MATERIALS AND METHODS In a prospective observational cohort study performed in 478 patients admitted with documented infection, mortality at day 28 in the group of abstainers and nontrauma patients with estimated alcohol consumption lower than 100 g/week was compared with that in non-alcohol-dependent patients with estimated alcohol consumption between 100 and 350 g/week. RESULTS In 97 patients (20%), alcohol consumption was estimated to be over 100 g/week, and in 391 patients (80%), alcohol consumption was estimated to be 100 g/week or less. The pathogens identified did not significantly differ between the two groups of patients. After adjusted analysis, alcohol consumption between 100 and 350 g/week remained significantly associated with mortality at day 28 (hazard ratio (HR): 1.67; 95% confidence interval (CI): 1.01-2.77; p = .04). CONCLUSION Alcohol consumption between 100 and 350 g/week was independently associated with mortality at day 28. Our results suggest that in critically ill patients admitted with infection, moderate alcohol consumption is associated with a poorer prognosis.
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Uljas E, Jalkanen V, Kuitunen A, Hynninen M, Hästbacka J. Prevalence of risk-drinking in critically ill patients, screened with carbohydrate-deficient transferrin and AUDIT-C score: A retrospective study. Acta Anaesthesiol Scand 2020; 64:216-223. [PMID: 31541613 DOI: 10.1111/aas.13484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/19/2019] [Accepted: 09/11/2019] [Indexed: 12/13/2022]
Abstract
Background Studies demonstrate that up to one-third of intensive care unit (ICU) admissions are directly or indirectly related to alcohol. Screening for alcohol use is not routine. This study examined the prevalence of elevated %CDT (carbohydrate-deficient transferrin) and above risk-level AUDIT-C (Alcohol Use Disorders Identification Test, Consumption) in patients admitted to ICU. Methods We conducted a retrospective analysis of clinical and laboratory data from a single ICU where %CDT and AUDIT-C were included in routine assessment. After excluding readmissions, 2532 adult patients from a 21-month period were included. Admission values of %CDT were available for 2049 patients, and AUDIT-C was available for 1617 patients. The association of %CDT and AUDIT-C with short- and long-term outcome was studied by using univariate and multivariate logistic regression analysis. Results %CDT was above the reference value in 23.7% (486/2048) of patients with available %CDT. Of patients with available AUDIT-C, 33% (544/1617) had a risk-level AUDIT-C score. Patients with a risk-level AUDIT-C score were significantly younger than those with a lower score (51 vs 64 years, P < .0001). Increased %CDT was associated with higher severity of illness. AUDIT-C was associated independently with increased risk of long-term mortality in multivariate analysis (P = .007). Conclusion One in three of ICU patients are risk-level alcohol users as measured with AUDIT-C score, and one in four are analysed with %CDT. The prevalence varies according to the method used and any method alone may be insufficient to detect risk-level consumption reliably. Editorial Comment Alcohol overconsumption is associated with need for ICU admission and with less favorable outcomes. Diagnosis of alcohol overconsumption though is problematic due to low sensitivity in screening. In a pilot study, a biomarker and a screening tool are compared. The finding is that multiple tools are needed to achieve an adequate sensitivity for detection.
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Affiliation(s)
- Eliisa Uljas
- Division of Intensive Care Department of Anaesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Ville Jalkanen
- Department of Intensive Care University of Tampere Tampere University Hospital Tampere Finland
| | - Anne Kuitunen
- Department of Intensive Care University of Tampere Tampere University Hospital Tampere Finland
| | - Marja Hynninen
- Division of Intensive Care Department of Anaesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Johanna Hästbacka
- Division of Intensive Care Department of Anaesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
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9
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Borg B, Douglas IS, Hull M, Keniston A, Moss M, Clark BJ. Alcohol misuse and outpatient follow-up after hospital discharge: a retrospective cohort study. Addict Sci Clin Pract 2018; 13:24. [PMID: 30514357 PMCID: PMC6278064 DOI: 10.1186/s13722-018-0125-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 11/29/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Patients with alcohol misuse are less likely to receive preventive health services but more likely to utilize emergency health services. However, the association between alcohol misuse and outpatient follow-up after hospitalization is unknown and may depend on whether a patient experiences a critical illness. We sought to determine whether alcohol misuse was associated with lower rates of outpatient follow-up after hospital discharge and whether the magnitude of this association differed in patients who experienced a critical illness. Materials and methods This was a retrospective cohort study using administrative data from an urban safety net hospital. Patients were included if they were admitted between 2011 and 2015, were between the ages of 18 and 89, resided within the safety net county, were discharged home, and were at moderate to high risk for hospital readmission within the subsequent 30 days. Alcohol misuse was identified using a combination of ICD-9 codes and response to a single screening question. The primary outcome was a combined measure of follow-up with a primary care physician or specialist provider in the 30 days following hospital discharge. Multivariable logistic regression was used to adjust for factors known to be associated with healthcare utilization. Results Overall, 17,575 patients were included in the analysis; 4984 (28%) had alcohol misuse. In the 30 days following hospital discharge, 46% of patients saw any outpatient provider. In an unadjusted analysis, the association between alcohol misuse and attending any outpatient follow-up was dependent on whether patients had a critical illness (p value < 0.0001) with the highest rates of follow-up in survivors of critical illness without alcohol misuse (53%, 95% CI 51%, 55%) followed by patients without alcohol misuse or critical illness (49%; 95% CI 48%, 50%), patients with alcohol misuse without critical illness (38%; 95% CI 36%, 39%), and patients with alcohol misuse and a critical illness (37%; 95% CI 35%, 40%). Adjusting for factors associated with healthcare utilization, these findings were modestly attenuated but unchanged. Conclusions Patients with alcohol misuse who are at moderate to high risk for hospital readmission may benefit from targeted interventions to increase rates of outpatient follow-up after hospital discharge. Electronic supplementary material The online version of this article (10.1186/s13722-018-0125-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bryan Borg
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ivor S Douglas
- Denver Health Medical Center, Denver, CO, USA.,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Box C272, RC2, 9th Floor, 12700 East 19th Avenue, Aurora, CO, 80045, USA
| | | | | | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Box C272, RC2, 9th Floor, 12700 East 19th Avenue, Aurora, CO, 80045, USA
| | - Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Box C272, RC2, 9th Floor, 12700 East 19th Avenue, Aurora, CO, 80045, USA. .,Division of Substance Dependence, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Impairment of Hematopoietic Precursor Cell Activation during the Granulopoietic Response to Bacteremia in Mice with Chronic-Plus-Binge Alcohol Administration. Infect Immun 2017; 85:IAI.00369-17. [PMID: 28784931 DOI: 10.1128/iai.00369-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/03/2017] [Indexed: 01/10/2023] Open
Abstract
Alcohol abuse impairs immune defense. To study the effect of chronic-plus-binge alcohol exposure on the granulopoietic response, acute alcohol intoxication (intraperitoneal injection of 5 g alcohol/kg body weight) was introduced to mice chronically fed on the Lieber-DeCarli low-fat liquid alcohol diet for 5 weeks. Bacteremia was induced by intravenous injection of Escherichia coli Bacteremia caused a remarkable increase in marrow lin- c-kit+ Sca-1+ cells. Activation of cell proliferation supported the increase in marrow lin- c-kit+ Sca-1+ cells. Alcohol administration inhibited this activation of lin- c-kit+ Sca-1+ cells. The bone marrow of pair-fed control mice receiving intraperitoneal saline stored a large number of mature granulocytes expressing a high level of Gr1 (Gr1hi cells). The proportion of Gr1hi cells and the total number of Gr1+ cells were markedly reduced in the bone marrow, along with an increase in the ratio of Gr1+ granulocytes in peripheral white blood cells following bacteremia. E. coli infection stimulated proliferation of granulopoietic precursor cells, resulting in a marked increase in the ratio of immature Gr1lo cells in the bone marrow. Alcohol administration itself triggered marrow release of Gr1+ cells, resulting in reduction of the marrow granulocyte reserve with an elevation of granulocytes in the circulation. Alcohol also impaired activation of granulopoietic precursor proliferation following bacteremia. Alcohol disrupted lipopolysaccharide (LPS)-TLR4-ERK1/2-cyclin D1 signaling and inhibited upregulation of Sca-1 and C/EBPβ expression by lineage-negative marrow cells in response to bacteremia. These results indicate that chronic-plus-binge alcohol exposure inhibits the granulopoietic response by disrupting key cell signaling for hematopoietic precursor cell activation and commitment to granulocyte lineage development.
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Maldonado JR. Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes–Beyond Benzodiazepines. Crit Care Clin 2017; 33:559-599. [DOI: 10.1016/j.ccc.2017.03.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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12
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Rotevatn TA, Bøggild H, Olesen CR, Torp-Pedersen C, Mortensen RN, Jensen PF, Overgaard C. Alcohol consumption and the risk of postoperative mortality and morbidity after primary hip or knee arthroplasty - A register-based cohort study. PLoS One 2017; 12:e0173083. [PMID: 28306737 PMCID: PMC5357001 DOI: 10.1371/journal.pone.0173083] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/15/2017] [Indexed: 12/21/2022] Open
Abstract
Objective To investigate the implications of low and moderate preoperative alcohol consumption on postoperative mortality and morbidity after primary hip and knee arthroplasty. Methods A total of 30,799 patients who underwent primary hip or knee arthroplasty between January 1st, 2005 and October 8th, 2011 with information on preoperative alcohol consumption (0 grams of pure alcohol/week, >0–168 g/week, >168–252 g/week, and >252 g/week) were identified through the Danish Anesthesia Database. The 90-day and 1-year risks of mortality (primary outcomes), 1-year risk of prosthetic infection, and 30-day risks of cardiovascular disease and deep venous thrombosis (secondary outcomes) were estimated by Cox regression analysis. Results We identified 285 (0.9%) deaths within the first 90 days and 694 (2.3%) within the first year. Within the first 30 days, 209 (0.7%) and 270 (0.9%) patients had acquired cardiovascular disease and deep venous thrombosis, respectively, and 514 (1.7%) patients developed prosthetic infection within the first year. The adjusted mortality models yielded hazard ratios of 0.55 (95% confidence interval [CI] 0.41 to 0.74) at 90 days and 0.61 (95% CI 0.51 to 0.73) at 1 year for the group consuming >0–168 g/week when compared to abstainers. Adjusted hazard ratios showed that the group consuming >0–168 g/week had a 0.91 (95% CI 0.75 to 1.11) risk of prosthetic infection, 0.68 (95% CI 0.50 to 0.92) risk of cardiovascular disease and 0.88 (95% CI 0.67 to 1.15) risk of deep venous thrombosis when compared to abstainers. Conclusions This study demonstrates that low-to-moderate alcohol consumption prior to primary hip or knee arthroplasty is associated with lower risks of mortality at both 90 days and 1 year after surgery and of cardiovascular disease after 30 days. More research from longitudinal studies is needed to identify specific causal relations and explanations.
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Affiliation(s)
- Torill A. Rotevatn
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- * E-mail:
| | - Henrik Bøggild
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Christinna R. Olesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rikke N. Mortensen
- Department of Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Per F. Jensen
- Department of Anesthesia, Næstved Hospital, Næstved, Denmark
| | - Charlotte Overgaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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Patients With Sentinel Acute Pancreatitis of Alcoholic Etiology Are at Risk for Organ Failure and Pancreatic Necrosis: A Dual-Center Experience. Pancreas 2016; 45:997-1002. [PMID: 27101573 PMCID: PMC4940237 DOI: 10.1097/mpa.0000000000000643] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess the relationship between alcoholic etiology, tobacco use, and severe acute pancreatitis (AP). METHODS Smoking and alcohol exposure were recorded upon admission in a cohort of patients with AP within the United States. Patients with first, "sentinel" attack of AP were identified for analysis.Associations between alcohol, smoking, and severe AP were validated in an independent cohort of patients from Spain. RESULTS US cohort (n = 222): Thirty-five percent developed organ failure (OF), 35% pancreatic necrosis (PNec), and 7% died. OF (54% vs 33%, P = 0.03), PNec (62% vs 31%, P = 0.006), intensive care unit admission (58% vs 36%, P = 0.03), and length of stay (LOS) (20 vs 8 days, P = 0.007) were greater in alcoholic when compared to other etiologies.Spanish cohort (n = 366): Similar differences in outcomes were also found with between alcoholic and nonalcoholic etiologies: OF (24% vs 8%, P = 0.001), PNec (38% vs 14%, P < 0.001), intensive care unit admission (20% vs 3%, P < 0.001), and LOS (17 vs 11 days, P = 0.04).Multivariable analysis confirmed alcoholic etiology to be independently associated with OF and PNec in both cohorts. CONCLUSIONS Alcoholic etiology is independently associated with OF and PNec in patients with sentinel AP and is important when evaluating risk for severe disease in AP.
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Association between blood alcohol concentration and mortality in critical illness. J Crit Care 2015; 30:1382-9. [DOI: 10.1016/j.jcrc.2015.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 06/02/2015] [Accepted: 08/30/2015] [Indexed: 11/20/2022]
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Gacouin A, Roussel M, Le Priol J, Azzaoui I, Uhel F, Fest T, Le Tulzo Y, Tadie JM. Acute alcohol exposure has an independent impact on C-reactive protein levels, neutrophil CD64 expression, and subsets of circulating white blood cells differentiated by flow cytometry in nontrauma patients. Shock 2015; 42:192-8. [PMID: 24827394 DOI: 10.1097/shk.0000000000000195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute and massive alcohol exposure (blood alcohol concentration of ≥1 g/L) is a common way to consume alcohol. In a prospective study performed in critically ill nontrauma patients, we compared C-reactive protein (CRP) values, circulating subsets of white blood cells, and neutrophil CD64 indexes recorded at admission to the intensive care unit between abstinent or moderate drinkers (n = 173), patients with acute or chronic alcohol exposure (n = 32), and patients with acute exposure but not chronically exposed to alcohol (n = 27). Values for CRP (P < 0.001), circulating neutrophils (P < 0.001), and neutrophil CD64 indexes (P < 0.001) were significantly lower in patients acutely exposed compared with the other patients, whereas values for B lymphocytes (P < 0.001) and cytotoxic (P < 0.001) and noncytotoxic T lymphocytes (P < 0.001) were significantly higher. After multiple regression analysis, alcohol exposure remained independently associated with values of CRP, neutrophils CD4 indexes, cytotoxic and noncytotoxic T lymphocytes, and CD16-negative and -positive monocytes. These results were not affected by the presence or absence of infection at admission. Our results suggest that in nontrauma critically ill patients, acute alcohol exposure diminishes inflammation and increases numbers of circulating B and T lymphocytes.
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Affiliation(s)
- Arnaud Gacouin
- *CHU Rennes, Maladies Infectieuses et Réanimation Médicale; †Inserm-CIC; ‡Univ Rennes 1, Faculté de Médecine, Biosit; §CHU Rennes, Laboratoire d'Hématologie; and ∥Inserm U 917, Rennes, France
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McPeake JM, Shaw M, O'Neill A, Forrest E, Puxty A, Quasim T, Kinsella J. Do alcohol use disorders impact on long term outcomes from intensive care? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:185. [PMID: 25899245 PMCID: PMC4440292 DOI: 10.1186/s13054-015-0909-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/02/2015] [Indexed: 12/31/2022]
Abstract
Introduction There is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge. Method This was an 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency. Results 34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001). Conclusion Alcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0909-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanne M McPeake
- University of Glasgow, School of Medicine, Glasgow Royal Infirmary, New Lister Building, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.
| | - Martin Shaw
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK.
| | - Anna O'Neill
- University of Glasgow, School of Medicine, Glasgow Royal Infirmary, New Lister Building, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK. anna.o'
| | - Ewan Forrest
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK.
| | - Alex Puxty
- Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK.
| | - Tara Quasim
- University of Glasgow, School of Medicine, Glasgow Royal Infirmary, New Lister Building, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.
| | - John Kinsella
- University of Glasgow, School of Medicine, Glasgow Royal Infirmary, New Lister Building, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.
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Gacouin A, Tadié JM, Le Tulzo Y. Infections bronchopulmonaires chez le patient cirrhotique. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1046-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Analysis of perioperative morbidity and mortality in shoulder arthroplasty patients with preexisting alcohol use disorders. J Shoulder Elbow Surg 2015; 24:167-73. [PMID: 25168344 DOI: 10.1016/j.jse.2014.05.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/14/2014] [Accepted: 05/15/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder arthroplasty is becoming increasingly popular in the United States. Given the high prevalence of alcohol abuse and its implications in postoperative morbidity and the increasing incidence of shoulder arthroplasty, it is prudent to explore the effect of alcohol use disorders (AUDs) in this patient population. In this study, we considered numerous outcome variables, including perioperative complications, in-hospital death, prolonged hospital stay, and nonroutine discharge. METHODS Using the Nationwide Inpatient Sample, we performed a retrospective cohort study to identify a population of 422,371 adults (≥18 years old) undergoing total shoulder arthroplasty or hemiarthroplasty between January 1, 2002, and December 31, 2011. We then further subdivided this cohort into those who were classified as having AUDs and those who did not. Comparisons of early postoperative outcome measures were performed by bivariate and multivariable analyses with logistic regression modeling. RESULTS Compared with those without AUDs, patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood to experience death, pneumonia, deep venous thrombosis, acute renal failure, transfusion, prolonged length of stay, and nonroutine discharge irrespective of age, gender, race, and other medical comorbidities. Patients with a preexisting AUD are 2.7 times more likely to experience perioperative complications after shoulder arthroplasty. CONCLUSION Patients undergoing shoulder arthroplasty with a preexisting AUD have a greater likelihood of perioperative complications and health care resource utilization after shoulder arthroplasty. Presurgical alcohol screening may prove effective in identifying at-risk patients, and providing interventions before surgery may effectively limit the complication profile.
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At-risk drinking in the ICU... and beyond!*. Crit Care Med 2014; 42:988-9. [PMID: 24633100 DOI: 10.1097/ccm.0000000000000094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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At-Risk Drinking Is Independently Associated With ICU and One-Year Mortality in Critically Ill Nontrauma Patients*. Crit Care Med 2014; 42:860-7. [DOI: 10.1097/ccm.0000000000000041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
The association between alcohol abuse and pneumonia has been recognized for more than two centuries and represents an enormous health burden worldwide. The first published notation of alcohol as a clinical risk factor for the development of pneumonia is now over 200 years old, and since then there have been over a 1,000 references in the medical literature confirming these observations. Even in this modern era of medicine pneumonia remains a common infection that afflicts over 450 million persons worldwide annually and causes 7 % of all deaths. When one considers that alcohol is the most commonly abused substance in the world, the enormous excessive burden that alcohol contributes to the morbidity and mortality of pneumonia represents a major public health consideration. In this chapter we review the foundational literature that has chronicled the evolution of our understanding of the association between pneumonia and alcohol abuse over the past century. In addition, we discuss some of the specific pathogens that are particularly associated with serious lung infections in individuals with alcohol use disorders. Finally, we consider some of the specific guidelines for the treatment and prevention of pneumonia in the setting of alcohol abuse.
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Affiliation(s)
- David M. Guidot
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia USA
| | - Ashish J. Mehta
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Decatur, Georgia USA
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Mehta AJ, Yeligar SM, Elon L, Brown LA, Guidot DM. Alcoholism causes alveolar macrophage zinc deficiency and immune dysfunction. Am J Respir Crit Care Med 2013; 188:716-23. [PMID: 23805851 DOI: 10.1164/rccm.201301-0061oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Alcohol use disorders cause oxidative stress in the lower airways and increase susceptibility to pneumonia and lung injury. Currently, no therapeutic options exist to mitigate the pulmonary consequences of alcoholism. OBJECTIVES We recently determined in an animal model that alcohol ingestion impairs pulmonary zinc metabolism and causes alveolar macrophage immune dysfunction. The objective of this research is to determine the effects of alcoholism on zinc bioavailability and alveolar macrophage function in human subjects. METHODS We recruited otherwise healthy alcoholics (n = 17) and matched control subjects (n = 17) who underwent bronchoscopy for isolation of alveolar macrophages, which were analyzed for intracellular zinc, phagocytic function, and surface expression of granulocyte-macrophage colony-stimulating factor receptor; all three of these indices are decreased in experimental models. MEASUREMENTS AND MAIN RESULTS Alcoholic subjects had normal serum zinc, but significantly decreased alveolar macrophage intracellular zinc levels (adjusted means [SE], 718 [41] vs. 948 [25] RFU/cell; P < 0.0001); bacterial phagocytosis (adjusted means [SE], 1,027 [48] vs. 1,509 [76] RFU/cell; P < 0.0001); and expression of granulocyte-macrophage colony-stimulating factor receptor β subunit (adjusted means [SE], 1,471 [42] vs. 2,114 [35] RFU/cell; P < 0.0001]. Treating alveolar macrophages with zinc acetate and glutathione in vitro increased intracellular zinc levels and improved their phagocytic function. CONCLUSIONS These novel clinical findings provide evidence that alcohol abuse is associated with significant zinc deficiency and immune dysfunction within the alveolar space and suggest that dietary supplementation with zinc and glutathione precursors could enhance airway innate immunity and decrease the risk for pneumonia or lung injury in these vulnerable individuals.
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Affiliation(s)
- Ashish J Mehta
- 1 Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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Awissi DK, Lebrun G, Fagnan M, Skrobik Y. Alcohol, nicotine, and iatrogenic withdrawals in the ICU. Crit Care Med 2013; 41:S57-68. [PMID: 23989096 DOI: 10.1097/ccm.0b013e3182a16919] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The neurophysiology, risk factors, and screening tools associated with alcohol withdrawal syndrome in the ICU are reviewed. Alcohol withdrawal syndrome assessment and its treatment options are discussed. Description of nicotine withdrawal and related publications specific to the critically ill are also reviewed. A brief comment as to sedative and opiate withdrawal follows. DATA AND SUMMARY The role of currently published alcohol withdrawal syndrome pharmacologic strategies (benzodiazepines, ethanol, clomethiazole, antipsychotics, barbiturates, propofol, and dexmedetomidine) is detailed. Studies on nicotine withdrawal management in the ICU focus mainly on the safety (mortality) of nicotine replacement therapy. Study characteristics and methodological limitations are presented. CONCLUSION We recommend a pharmacologic regimen titrated to withdrawal symptoms in ICU patients with alcohol withdrawal syndrome. Benzodiazepines are a reasonable option; phenobarbital appears to confer some advantages in combination with benzodiazepines. Propofol and dexmedetomidine have not been rigorously tested in comparative studies of drug withdrawal treatment; their use as additional or alternative strategies for managing withdrawal syndromes in ICU patients should therefore be individualized to each patient. Insufficient data preclude recommendations as to nicotine replacement therapy and management of iatrogenic drug withdrawal in ICU patients.
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Affiliation(s)
- Don-Kelena Awissi
- Pharmacy Department, Hôpital Maisonneuve-Rosemont, Montréal, QC, Canada
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Impact of tobacco and alcohol consumption in patients registered on waiting list on early morbidity following liver transplantation. Clin Res Hepatol Gastroenterol 2013; 37:473-8. [PMID: 23522692 DOI: 10.1016/j.clinre.2013.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/14/2013] [Accepted: 01/30/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Liver transplantation (LT) is a high-risk surgery associated with postoperative complications. Smoking and drinking are known risk factors of long-term post-LT complications, but their role in early complications is still questioned. PATIENTS AND METHODS We retrieved from our medical files the data of all patients registered for LT and who had had a consultation with a physician specialized in substance abuse. Consumption of alcohol, tobacco, and drugs before and after registration for LT was assessed. RESULTS One hundred and five patients were included. Pre-registration smoking and drinking rates were 75.3 and 69.5%, respectively. Forty-three patients continued smoking and nine continued drinking until LT. Mortality and early morbidity rates were not impacted by smoking or drinking. Active smokers had significantly increased prevalence of bacterial cholangitis in comparison to patients who stopped smoking when registered for LT. CONCLUSION Persistent drinking in patients registered for LT is rare as compared to smoking; however, in our series, smoking until LT was not associated with major risk of early complication, except for cholangitis. This suggests that clinicians should take time to encourage patients to quit smoking and the intervention of a team specialized in substance abuse could be highly beneficial.
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Esperatti M, Ferrer M, Giunta V, Ranzani OT, Saucedo LM, Li Bassi G, Blasi F, Rello J, Niederman MS, Torres A. Validation of predictors of adverse outcomes in hospital-acquired pneumonia in the ICU. Crit Care Med 2013; 41:2151-61. [PMID: 23760154 DOI: 10.1097/ccm.0b013e31828a674a] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To validate a set of predictors of adverse outcomes in patients with ICU-acquired pneumonia in relation to clinically relevant assessment at 28 days. DESIGN Prospective, observational study. SETTING Six medical and surgical ICUs of a university hospital. PATIENTS Three hundred thirty-five patients with ICU-acquired pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Development of predictors of adverse outcomes was defined when at least one of the following criteria was present at an evaluation made 72-96 hours after starting treatment: no improvement of PaO2/FIO2, need for intubation due to pneumonia, persistence of fever or hypothermia with purulent respiratory secretions, greater than or equal to 50% increase in radiographic infiltrates, or occurrence of septic shock or multiple organ dysfunction syndrome. We also assessed the inflammatory response by different serum biomarkers. The presence of predictors of adverse outcomes was related to mortality and ventilator-free days at day 28. Sequential Organ Failure Assessment score was evaluated and related to mortality at day 28.One hundred eighty-four (55%) patients had at least one predictor of adverse outcomes. The 28-day mortality was higher for those with versus those without predictors of adverse outcomes (45% vs 19%, p<0.001), and ventilator-free days were lower (median [interquartile range], 0 [0-17] vs 22 [0-28]) for patients with versus patients without predictors of adverse outcomes (p<0.001). The lack of improvement of PaO2/FIO2 and lack of improvement in Sequential Organ Failure Assessment score from day 1 to day 5 were independently associated with 28-day mortality and fewer ventilator-free days. The marginal structural analysis showed an odds ratio of death 2.042 (95% CI, 1.01-4.13; p=0.047) in patients with predictors of adverse outcomes. Patients with predictors of adverse outcomes had higher serum inflammatory response accordingly to biomarkers evaluated. CONCLUSIONS The presence of any predictors of adverse outcomes was associated with mortality and decreased ventilator-free days at day 28. The lack of improvement in the PaO2/FIO2 and Sequential Organ Failure Assessment score was independently associated with mortality in the multivariate analysis.
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Affiliation(s)
- Mariano Esperatti
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
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Clark BJ, Jones J, Cook P, Tian K, Moss M. Facilitators and barriers to initiating change in medical intensive care unit survivors with alcohol use disorders: a qualitative study. J Crit Care 2013; 28:849-56. [PMID: 23876701 PMCID: PMC4117201 DOI: 10.1016/j.jcrc.2013.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/12/2013] [Accepted: 06/16/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Alcohol abuse and dependence are collectively referred to as alcohol use disorders (AUD). An AUD is present in up to one third of patients admitted to an intensive care unit (ICU). We sought to understand the barriers and facilitators to change in ICU survivors with an AUD to provide a foundation upon which to tailor alcohol-related interventions. METHODS We used a qualitative approach with a broad constructivist framework, conducting semistructured interviews in medical ICU survivors with an AUD. Patients were included if they were admitted to 1 of 2 medical ICUs and were excluded if they refused participation, were unable to participate, or did not speak English. Digitally recorded and professionally transcribed interviews were analyzed using a general inductive approach and grouped into themes. RESULTS Nineteen patients were included, with an average age of 51 (interquartile range, 36-51) years and an average Acute Physiology and Chronic Health Evaluation II score of 9 (interquartile range, 5-13); 68% were white, 74% were male, and the most common reason for admission was alcohol withdrawal (n=8). We identified 5 facilitators of change: empathy of the inpatient health care environment, recognition of accumulating problems, religion, pressure from others to stop drinking, and trigger events. We identified 3 barriers to change: missed opportunities, psychiatric comorbidity, and cognitive dysfunction. Social networks were identified as either a barrier or facilitator to change depending on the specific context. CONCLUSIONS Alcohol-related interventions to motivate and sustain behavior change could be tailored to ICU survivors by accounting for unique barriers and facilitators.
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Affiliation(s)
- Brendan J Clark
- Department of Medicine, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, CO.
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Alcohol use disorders and hospital-acquired infections in women undergoing cesarean delivery. Obstet Gynecol 2013; 122:72-78. [PMID: 23743466 DOI: 10.1097/aog.0b013e318297be8d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the risk of hospital-acquired infection in women with alcohol use disorders undergoing cesarean delivery. METHODS Using the Nationwide Inpatient Sample, we conducted a retrospective cohort study of women undergoing cesarean delivery from 2002 to 2010. Women with a diagnosis of alcohol use disorder were compared with women without alcohol use disorders. Hospital-acquired infections include surgical site infection, endometritis, urinary tract infection, sepsis, and pneumonia. RESULTS A total of 12,081 women with alcohol use disorders were identified and matched with 11,960 women without alcohol use disorders. Women with alcohol use disorders were more likely to have development of urinary tract infection and sepsis. By multivariable analyses, women with alcohol use disorders had higher odds of hospital-acquired infections (odds ratio 2.2, 95% confidence interval [CI] 1.9-2.7; P=2×10; 397 among those with alcohol use disorders and 179 among those without alcohol use disorders; number needed to harm 55). Length of stay was longer in women with alcohol use disorders, but this was unexplained by hospital-acquired infection (3.3 days; 95% CI 3.2-3.3 compared with 3.1 days; 95% CI 3.0-3.1; P=4×10). CONCLUSION Women with alcohol use disorders undergoing cesarean delivery have increased risk of hospital-acquired infections. Interventions aimed at decreasing alcohol use disorders during pregnancy may reduce maternal and fetal complications. LEVEL OF EVIDENCE II.
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McPeake J, Bateson M, O'Neill A, Kinsella J. Assessment and management of alcohol-related admissions to UK intensive care units. Nurs Crit Care 2013; 18:187-92. [PMID: 23782112 DOI: 10.1111/nicc.12006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The critical care environment has felt the overwhelming impact of the growing problem of alcohol abuse. However, there is ambiguity concerning the assessment and management of this patient group. AIM The aim of this study was to explore current practice in the use of assessment and management tools for alcohol-related admissions in UK intensive care units (ICU). METHODS Two hundred and forty-eight lead consultants across England, Scotland, Northern Ireland and Wales were sent an electronic survey using the SurveyMonkey(®) ( www.surveymonkey.com) website. RESULTS A total of 103 (41·05%) lead consultants responded to the survey. Most units (67%) utilized the volume of alcohol consumed per week to assess patient alcohol use. Furthermore, 12 units (11%) used the Clinical Institute Withdrawal Assessment tool, 5 units (5%) used the Glasgow Modified Alcohol Withdrawal Scale and 79 units (73%) used no tool for the management of alcohol withdrawal syndrome. CONCLUSION There appears to be a diverse approach to the assessment and management of alcohol-related admissions in UK ICUs. Further research is required in this area to identify the most effective way to assess and manage alcohol-related admissions within intensive care. RELEVANCE TO CLINICAL PRACTICE Under recognition and poor assessment of alcohol use can have major implications for critically ill patients.
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Affiliation(s)
- Joanne McPeake
- Nursing and Healthcare School, School of Medicine, University of Glasgow, Glasgow G12 8LL, UK.
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Gacouin A, Roussel M, Gros A, Sauvadet E, Uhel F, Chimot L, Marque S, Camus C, Fest T, Le Tulzo Y. Chronic alcohol exposure, infection, extended circulating white blood cells differentiated by flow cytometry and neutrophil CD64 expression: a prospective, descriptive study of critically ill medical patients. Ann Intensive Care 2012; 2:50. [PMID: 23272900 PMCID: PMC3539872 DOI: 10.1186/2110-5820-2-50] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 11/14/2012] [Indexed: 11/29/2022] Open
Abstract
Background A history of prolonged and excessive consumption of alcohol increases the risk for infections. The goal of this study was to investigate circulating white blood cells (WBC) differentiated by flow cytometry and neutrophil CD64 expression in excessive alcohol drinkers versus abstinent or moderate drinkers, and in those with or without infection, in medical patients admitted to the intensive care unit (ICU). Methods All patients admitted between September 2009 and March 2010 with an ICU-stay of 3 days or more were eligible for inclusion. Upon admission, hematological exams were conducted by flow cytometry. Results Overall, 281 adult were included, with 37% identified as at-risk drinkers. The only significant difference found in circulating WBC between at-risk and not-at-risk drinkers was a lower number of B lymphocytes in at-risk drinkers (P = 0.002). Four groups of patients were defined: not-at-risk drinkers with no infection (n = 66); not-at-risk drinkers with infection (n = 112); at-risk drinkers with no infection (n = 53); and at-risk drinkers with infection (n = 50). Whilst the presence of infection significantly reduced levels of noncytotoxic and cytotoxic T lymphocytes and significantly increased levels of CD16– monocytes in not-at-risk drinkers, with variation related to infection severity, infection had no effect on any of the variables assessed in at-risk drinkers. Post-hoc comparisons showed that B-lymphocyte, noncytotoxic, and cytotoxic T lymphocyte and CD16– counts in at-risk drinkers were similar to those in not-at-risk drinkers with infection and significantly lower than those in not-at-risk drinkers without infection. Neutrophil CD64 index varied significantly between groups, with variations related to infection, not previous alcohol consumption. Conclusions These results show that chronic alcohol exposure has an impact on the immune response to infection in critically ill medical patients. The absence of significant variations in circulating WBC seen in at-risk drinkers according to the severity of infection is suggestive of altered immune response.
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Affiliation(s)
- Arnaud Gacouin
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, Rennes, F-35033, France.
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Alcohol withdrawal and delirium tremens in the critically ill: a systematic review and commentary. Intensive Care Med 2012. [PMID: 23184039 DOI: 10.1007/s00134-012-2758-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Alcohol withdrawal is common among intensive care unit (ICU) patients, but no current practice guidelines exist. We reviewed published manuscripts for prevalence, risk factors, screening tools, prophylactic and treatment strategies, and outcomes for alcohol withdrawal syndrome (AWS) and delirium tremens (DT) in the critically ill. METHODS The following databases: PubMed, MEDLINE, Embase, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, Scopus, Web of Knowledge, pain, anxiety and delirium (PAD) Guidelines REFWORKS, International Pharmaceutical Abstracts and references for published papers were searched. Publications with high or moderate Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Oxford levels of evidence were included. RESULTS Reported AWS rates range from <1 % in 'all ICU comers' to 60 % in highly selected alcohol-dependent ICU patients. Alcohol dependence and a history of withdrawal are significant risk factors for AWS occurrence. No screening tools for withdrawal have been validated in the ICU. The benefit of alcohol withdrawal prophylaxis is unproven, and proposed regimens appear equivalent. Early and aggressive titration of medication guided by symptoms is the only feature associated with improved treatment outcome. CONCLUSIONS Treatment of AWS is associated with higher ICU complication rates and resource utilization. The optimal means of identification, prevention and treatment of AWS in order to establish evidence-based guidelines remain to be determined.
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Health care-associated infections in surgical patients undergoing elective surgery: are alcohol use disorders a risk factor? J Am Coll Surg 2012; 215:229-36. [PMID: 22727411 DOI: 10.1016/j.jamcollsurg.2012.04.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 02/17/2012] [Accepted: 04/04/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Health care-associated infections (HAI) result in 100,000 deaths/year. Alcohol use disorders (AUD) increase the risk of community-acquired infections and HAI. Small studies have shown that AUD increase the risk of HAI and surgical site infections (SSI). We sought to determine the risk of HAI and SSI in surgical patients undergoing elective inpatient joint replacement, coronary artery bypass grafting, laparoscopic cholecystectomy, colectomy, and hernia repair. STUDY DESIGN The Nationwide Inpatient Sample was analyzed (years 2007 and 2008). HAI were defined as health care-associated pneumonia, sepsis, SSI, and urinary tract infection. Primary outcomes were risk of HAI and SSI in patients with AUD. Secondary outcomes were mortality and hospital length of stay in patients with HAI and SSI, alpha = 10(-6). RESULTS There were 1,275,034 inpatient admissions analyzed; 38,335 (3.0%) cases of HAI were documented, and 5,756 (0.5%) cases of SSI were identified. AUD was diagnosed in 11,640 (0.9%) of cases. Multivariable analysis demonstrated that AUD was an independent predictor of developing HAI: odds ratio (OR) 1.70, p < 10(-6), and this risk was independent of type of surgery. By multivariable analysis, the risk of SSI in patients with AUD was also higher: OR 2.73, p < 10(-6). Hospital mortality in patients with HAI or SSI was not affected by AUD. However, hospital length of stay was longer in patients with HAI who had AUD (multivariable analysis 2.4 days longer, p < 10(-6)). Among patients with SSI, those with AUD did not have longer hospital length of stay. CONCLUSIONS Patients with AUD who undergo a variety of elective operations have an increased risk of infectious postoperative morbidity.
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Christensen S, Johansen MB, Pedersen L, Jensen R, Larsen KM, Larsson A, Tønnesen E, Christiansen CF, Sørensen HT. Three-year mortality among alcoholic patients after intensive care: a population-based cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R5. [PMID: 22226344 PMCID: PMC3396230 DOI: 10.1186/cc10603] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/03/2011] [Accepted: 01/08/2012] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Alcoholic patients comprise a large proportion of patients in intensive care units (ICUs). However, data are limited on the impact of alcoholism on mortality after intensive care. METHODS We conducted a cohort study among 16,848 first-time ICU patients between 2001 and 2007 to examine 30-day and 3-year mortality among alcoholic patients. Alcoholic patients with and without complications of alcohol misuse (for example, alcoholic liver disease) were identified from previous hospital contacts for alcoholism-related conditions or redemption of a prescription for alcohol deterrents. Data on medication use, demographics, hospital diagnoses, and comorbidity were obtained from medical databases. We computed 30-day and 3-year mortality and mortality rate ratios (MRRs) by using Cox regression analysis, controlling for covariates. RESULTS In total, 1,229 (7.3%) ICU patients were current alcoholics. Among alcoholic patients without complications of alcoholism (n=785, 4.7% of the cohort), 30-day mortality was 15.9% compared with 19.7% among nonalcoholic patients. Compared with nonalcoholic patients, the adjusted 30-day MRR was 1.04 (95% confidence interval (CI), 0.87 to 1.25). Three-year mortality was 36.2% compared with 40.9% among nonalcoholic patients, corresponding to an adjusted 3-year MRR of 1.16 (95% CI, 1.03 to 1.31). For alcoholic patients with complications (n=444, 2.6% of the cohort), 30-day mortality was 33.6%, and 3-year mortality was 64.5%, corresponding to adjusted MRRs, with nonalcoholics as the comparator, of 1.64 (95% CI, 1.38 to 1.95) and 1.67 (95% CI, 1.48 to 1.90), respectively. CONCLUSIONS Alcoholic ICU patients with chronic complications of alcoholism have substantially increased 30-day and 3-year mortality. In contrast, alcoholics without complications have no increased 30-day and only slightly increased 3- year mortality.
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Affiliation(s)
- Steffen Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes alle 43-45, Aarhus N, 8240, Denmark.
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Badia M, Justes M, Serviá L, Montserrat N, Vilanova J, Rodríguez Á, Trujillano J. Classification of mental disorders in the Intensive Care Unit. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.medine.2011.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Clark BJ, Smart A, House R, Douglas I, Burnham EL, Moss M. Severity of acute illness is associated with baseline readiness to change in medical intensive care unit patients with unhealthy alcohol use. Alcohol Clin Exp Res 2011; 36:544-51. [PMID: 21950704 DOI: 10.1111/j.1530-0277.2011.01648.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use. METHODS We performed a cross-sectional observational study of current regular drinkers in 3 medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low-risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient's acute illness was assessed by calculating the Acute Physiologic and Chronic Health Evaluation II (APACHE II) score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires. RESULTS Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHE II score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale; p < 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term). CONCLUSIONS Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers.
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Affiliation(s)
- Brendan J Clark
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, Aurora, Colorado 80045, USA.
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Secondary prevention in the intensive care unit: does intensive care unit admission represent a "teachable moment?". Crit Care Med 2011; 39:1500-6. [PMID: 21494113 DOI: 10.1097/ccm.0b013e31821858bb] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a "teachable moment." Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate. DATA SOURCES A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search. SUMMARY Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical intensive care unit population. CONCLUSIONS Intensive care unit admission represents a "teachable moment" for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical intensive care unit patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary.
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Badia M, Justes M, Serviá L, Montserrat N, Vilanova J, Rodríguez A, Trujillano J. [Classification of mental disorders in the Intensive Care Unit]. Med Intensiva 2011; 35:539-45. [PMID: 21784561 DOI: 10.1016/j.medin.2011.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Revised: 05/27/2011] [Accepted: 05/27/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine the incidence and characteristics of mental disorders (MD) in the Intensive Care Unit (ICU), and to define a classification system adapted to the ICU environment. DESIGN A retrospective, descriptive analysis. SETTING Intensive Care Unit, Arnau de Vilanova Hospital in Lérida (Spain). PATIENTS All patients with MD admitted during 5-year period (January, 1 2004 to December 31, 2008). MAIN VARIABLES General variables included clinical-demographic data, diagnostic variables, procedures, severity score, length of stay and mortality. Specific variables included psychiatric history, screening for substance abuse, psychiatric assessment, monitoring and transfer to a psychiatric center. Classification of the MD was as follows: 1) acute substance intoxication (SI); 2) suicide attempts (SA); and 3) MD associated with the main diagnosis (AMD). RESULTS A total of 146 patients had MD (7.8%); they were predominantly male (74%) and were younger than the general ICU population (43.9 vs. 55.3 years, p<0.001). The ICU stays of the patients with MDs were shorter (4 days vs. 7 days, p<0.001), and there was less hospital mortality (17.1 vs. 25%, p<0.05). They also showed a higher incidence of pneumonia (19.9 vs. 13.8%, p<0.05), but no differences in the level of severity were observed. The SI group (24.7%) contained the highest number of young people; the SA group (36.3%) showed a predominance of women; and the AMD (39%) group had the longest stays and the highest mortality. Psychiatric consultation was carried out mainly in the SA group (62.3%). CONCLUSIONS MD is a relatively common problem in the ICU. Collaboration with the Psychiatry Department seldom occurs, but must be encouraged to develop fully integrated management of critical patients with MD.
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Affiliation(s)
- M Badia
- Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lérida, España
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de Wit M, Zilberberg MD, Boehmler JM, Bearman GM, Edmond MB. Outcomes of Patients with Alcohol Use Disorders Experiencing Healthcare-Associated Infections. Alcohol Clin Exp Res 2011; 35:1368-73. [DOI: 10.1111/j.1530-0277.2011.01475.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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de Wit M, Jones DG, Sessler CN, Zilberberg MD, Weaver MF. Alcohol-use disorders in the critically ill patient. Chest 2010; 138:994-1003. [PMID: 20923804 DOI: 10.1378/chest.09-1425] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs. This review discusses the development and progression of critical illness in patients with AUDs. In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies. In particular, surgical patients with AUDs experience higher rates of postoperative hemorrhage, cardiac complications, sepsis, and need for repeat surgery. Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes. AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis. The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome. The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs. Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.
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Affiliation(s)
- Marjolein de Wit
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298-0050, USA.
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Alcohol consumption as a risk factor for pneumonia: a systematic review and meta-analysis. Epidemiol Infect 2010; 138:1789-95. [PMID: 20380771 DOI: 10.1017/s0950268810000774] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The aim of this study was to quantify the association between alcohol consumption and incidence of pneumonia and to examine possible pathways. This was done by a systematic review and meta-analyses on the dose-response relationship between alcohol consumption or alcohol-use disorders and the incidence of community-acquired pneumonia (CAP). The relative risk (RR) of CAP increased monotonically with increasing alcohol consumption. Individuals consuming 24, 60, and 120 g of pure alcohol daily demonstrated RRs for incident CAP of 1·12 (95% CI 1·02-1·23), 1·33 (95% CI 1·06-1·67) and 1·76 (95% CI 1·13-2·77), respectively, relative to non-drinkers. Clinically defined alcohol-use disorders were associated with an eightfold increased risk of CAP (RR 8·22, 95% CI 4·85-13·95). In conclusion, alcohol was found to be a risk factor for pneumonia with a clear statistical association, and a monotonic dose-response relationship.
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Boé DM, Vandivier RW, Burnham EL, Moss M. Alcohol abuse and pulmonary disease. J Leukoc Biol 2009; 86:1097-104. [PMID: 19602670 PMCID: PMC4057657 DOI: 10.1189/jlb.0209087] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2009] [Revised: 03/12/2009] [Accepted: 03/13/2009] [Indexed: 12/13/2022] Open
Abstract
ARDS is a severe form of lung injury characterized by increased permeability of the alveolar capillary membrane, diffuse alveolar damage, the accumulation of proteinaceous interstitial and intra-alveolar edema, and the presence of hyaline membranes. These pathological changes are accompanied by physiological alterations, including severe hypoxemia, an increase in pulmonary dead space, and decreased pulmonary compliance. Approximately 200,000 individuals develop ARDS in the United States each year, and nearly 50% of these patients have a history of alcohol abuse. We have identified alcohol abuse as an independent risk factor for the development of ARDS, and more recent studies have validated these findings in patients following lung resection and blood transfusion. In ARDS survivors, alcohol abuse is also associated with an increased duration of mechanical ventilation and prolonged ICU length of stay. Despite studies aimed at improving outcomes in patients with ARDS, the mortality remains high at > 40%]. For those who abuse alcohol, the mortality is even higher, at 65%. In this review, we will discuss the relationship between alcohol abuse and ARDS, the effects of alcohol abuse on pulmonary function, and future directions and potential therapeutic targets for patients at risk for ARDS as a result of alcohol abuse, which impairs immune function, decreases pulmonary antioxidant capacity, decreases alveolar epithelial cell function, alters activation of the renin angiotensin system, and impairs GM-CSF signaling. These pathways represent potential therapeutic targets for patients at risk for ARDS as a result of alcohol abuse.
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Affiliation(s)
- Darren M Boé
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver, 12700 E. 19th Ave., C272, Aurora, CO 80045, USA.
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Fatal Plasmodium falciparum, Clostridium perfringens, and Candida spp. Coinfections in a Traveler to Haiti. J Trop Med 2009; 2009:969070. [PMID: 20339463 PMCID: PMC2836824 DOI: 10.1155/2009/969070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 01/30/2009] [Accepted: 03/17/2009] [Indexed: 12/04/2022] Open
Abstract
Malaria is one of the most common causes of febrile illness in travelers. Coinfections with bacterial, viral, and fungal pathogens may not be suspected unless a patient fails to respond to malaria treatment. Using novel immunohistochemical and molecular techniques, Plasmodium falciparum, Clostridium perfringens, and Candida spp. coinfections were confirmed in a German traveler to Haiti. Plasmodium falciparum-induced ischemia may have increased this patient's susceptibility to C. perfringens and disseminated candidiasis leading to his death. When a patient presents with P. falciparum and shock and is unresponsive to malaria treatment, secondary infections should be suspected to initiate appropriate
treatment.
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Acute alcohol withdrawal as a risk factor for intensive care unit–acquired infection. Crit Care Med 2008; 36:3131-2. [DOI: 10.1097/ccm.0b013e31818be634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pontier S. Pneumonies du sujet immunodéprimé hors VIH. Rev Mal Respir 2008. [DOI: 10.1016/s0761-8425(08)74077-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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