Ionized calcium concentration and outcome in critical illness

COVID-19-Induced Refractory Symptomatic Hypocalcemia in a Patient With Parathyroid Gland Reimplantation

Background: Several cases of severe hypocalcemia in the setting of COVID-19 have been reported. The proposed mechanisms include direct viral interaction with ACE2 receptors in the parathyroid gland, viral chelation of calcium, worsening hypovitaminosis D, critical illness leading to unbound fatty acids binding calcium, and inflammatory cytokines leading to PTH resistance. Given the life-threatening nature of hypocalcemia, this underrecognized phenomenon should be on the forefront of the clinician's attention. This case highlights a rare manifestation of COVID-19 and further complicated by the patient's reimplanted parathyroid gland. Presentation: A 73-year-old female with primary hyperparathyroidism status post parathyroidectomy with reimplantation in the left forearm presented with 4 days of viral syndrome, found to have tetany and Chvostek's sign on physical exam. Pertinent laboratory abnormalities included calcium 5.3 mg/dL, ionized calcium 0.44 mmol/L, magnesium 1.4 mg/dL, phosphorous 5.5 mg/dL, PTH 242 pg/mL, and 25-OH vitamin D 56 ng/mL. Chest CT revealed multifocal pneumonia consistent with positive COVID-19 testing. She was subsequently admitted to the ICU for severe, symptomatic hypocalcemia and was initiated on a continuous calcium infusion, remdesivir, baricitinib, and steroids. Tetany resolved after 9 g calcium repletion, and she was transferred to the medical floor with an ionized calcium of 0.83 mmol/L. On hospital day 3, repeat ionized calcium was 0.78 mmol/L despite ongoing repletion. Given the persistence of hypocalcemia, a repeat PTH level was obtained which remained high at 487 pg/mL, suggesting ongoing PTH interference in the setting of COVID-19. PTH was obtained from the right (nonimplanted) arm which was normal at 74 pg/mL. This indicated an appropriate PTH response from the reimplanted gland, and that ongoing hypocalcemia may be due to insufficient PTH function to maintain systemic calcium levels or a peripheral interference with PTH level. With continued calcium supplementation and treatment of COVID-19, the patient's calcium stabilized at 8.6 mg/dL. She was discharged on oral calcium supplementation with endocrinology follow-up. Conclusion: Acute hypocalcemia strongly correlates with a profound inflammatory response in COVID-19 patients. This case corroborates the cytokine/PTH hypothesis. This patient had a high PTH sampled near the reimplanted gland but an inappropriately normal PTH from the nonimplanted arm, indicating that direct viral interaction interfering with PTH release is an unlikely mechanism. This case represents a scenario where PTH can be sampled directly from the source and this type of model could aid in the process of determining the etiology of hypocalcemia in COVID-19.

Large library docking identifies positive allosteric modulators of the calcium-sensing receptor

Positive allosteric modulator (PAM) drugs enhance the activation of the calcium-sensing receptor (CaSR) and suppress parathyroid hormone (PTH) secretion. Unfortunately, these hyperparathyroidism-treating drugs can induce hypocalcemia and arrhythmias. Seeking improved modulators, we docked libraries of 2.7 million and 1.2 billion molecules against the CaSR structure. The billion-molecule docking found PAMs with a 2.7-fold higher hit rate than the million-molecule library, with hits up to 37-fold more potent. Structure-based optimization led to nanomolar leads. In ex vivo organ assays, one of these PAMs was 100-fold more potent than the standard of care, cinacalcet, and reduced serum PTH levels in mice without the hypocalcemia typical of CaSR drugs. As determined from cryo-electron microscopy structures, the PAMs identified here promote CaSR conformations that more closely resemble the activated state than those induced by the established drugs.

Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience

Background

Regional citrate anticoagulation (RCA) has emerged as a treatment modality that reduces bleeding risk and filter clotting. With initial experience of using RCA with continuous renal replacement therapy (CRRT), we have formulated a working protocol based on published literature.

Objective

The study aimed to evaluate the protocol for routine use of RCA during CRRT requiring anticoagulation and evaluation of filter life.

Methodology

It is a single-center, open-label, prospective, non-randomized, non-interventional, single-arm, observational study conducted at a tertiary care hospital between September 2022 and July 2023. All adult patients with acute kidney injury (AKI) or hyperammonemia requiring CRRT and necessitating the use of anticoagulation were enrolled in the study. The study used Prisma Flex M100 AN 69 dialyzer on Prisma Flex (Baxter) CRRT machines during continuous venovenous hemodiafiltration (CVVHDF). The targeted CRRT dose in all the study patients was 25-30 mL/kg/hour. Based on the published literature, we have developed a working protocol (Appendix 1) for managing patients on CRRT using RCA.

Results

A total of 159 patients were analyzed for the study. The median [interquartile range (IQR)] filter life using RCA was 30 (12-55) hours. Filter clotting was observed in 33.3% of patients. Citrate accumulation was present in 52.25% of patients, but no CRRT was discontinued as citrate accumulation resolved after following the corrective steps in the protocol. None of the patients had citrate toxicity. Chronic liver disease (CLD) (p ≤ 0.001) and those who were post-living donor liver transplant recipients (p = 0.004) had a statistically significant increase in citrate accumulation. Also, patients who had higher lactate at baseline (6 hours post-CRRT initiation), had a higher chance of citrate accumulation.

Conclusion

Our RCA protocol provides a safe approach to regional anticoagulation during CRRT in critically ill patients.

How to cite this article

Pachisia AV, Kumar GP, Harne R, Jagadeesh KN, Patel SJ, Pal D, et al. Protocolized Regional Citrate Anticoagulation during Continuous Renal Replacement Therapy: A Single Center Experience. Indian J Crit Care Med 2024;28(9):859-865.

Hypocalcemia and Hypoparathyroidism Associated With Critical Illness and Aplastic Anemia

Background/Objective

Severe hypocalcemia is common in critically ill patients. There are different mechanisms. To our knowledge, there are no data about the acute presentation of hypocalcemia at the time of diagnosis of aplastic anemia (AA). The objective of this case report was to describe the case of hypoparathyroidism with severe hypocalcemia in a critically ill patient with AA.

Case Report

A 60-year-old man presented with severe hypocalcemia with a calcium level of 6.1 mg/dL (reference range, 8.6-10.3 mg/dL) and hypoparathyroidism with a parathyroid hormone level of 11 pg/mL (reference range, 12-88 pg/mL). He developed a critical state caused by newly diagnosed AA and its complications, such as an acute decrease in the platelet value to a critically low level of 2 × 103/cmm, complicated by neutropenic fever and lower gastrointestinal bleeding. After the initiation of immunosuppressive therapy for AA, his parathyroid hormone-calcium metabolism improved and remained stable but did not normalize completely.

Discussion

In our patient, hypoparathyroidism with hypocalcemia may have been caused by cytokine-related upregulation of the calcium-sensing receptor in the setting of AA. On the other hand, given the severity of the initial hypocalcemia and only partial improvement in calcium homeostasis with residual mild hypocalcemia after treatment initiation for AA, autoimmune causes cannot be entirely ruled out, nor could a combination of cytokine-mediated and autoimmune causes.

Conclusion

It is essential to treat the underlying causes of hypocalcemia, which, in this case, were AA and hypoparathyroidism.

Assessment of drug-induced electrolyte disorders in intensive care units: a multicenter observational study

Objective

Electrolyte disorder (ED) is frequently encountered critically ill patients during admission or admission to the intensive care unit (ICU). This study aimed to determine the frequency of ED encountered in ICU patients to evaluate the relationship of ED with drugs.

Methods

This prospective, multicenter study was conducted in the medical and anesthesiology ICUs of two training and research hospitals and included patients with at least one ED during admission or hospitalization in the ICUs. The relationship between ED and the drug was evaluated by calculating the logistic probabilistic method scale (LPMS) and the expert panel's evaluation. The correlation between EDs and LPMS was determined using Kendal tau. A binary logistic regression model was preferred in the analysis of factors related to ED. Statistical significance was set as p < 0.05.

Results

A total of 117 patients were included in the study. A total of 165 EDs were detected, including at least one in 88 (75.2%) patients. According to the expert panel, 61 (21.7%) of EDs were drug-related, whereas according to the LPMS, 111 (39.6%) (p < 0.001). Mortality (50% vs. 13.7%) and mechanical ventilation rates (52.2% vs. 17.2%) were significantly higher in patients with ED (p < 0.001). Patients with ED had 8.352 times higher odds of exhibiting mortality (OR: 8.352, %95 CI: 1.598-43.648, p: 0.012) and need mechanical ventilation with higher odds of 3.229 (OR: 3.229 95% CI: 0.815-12.787 p: 0.045). Patient who required enteral or parenteral feeding were associated with an increased likelihood of exhibiting ED (respectively OR: 30.057, %95 CI: 2.265-398.892, p: 0.01, OR: 5.537, %95 CI: 1.406-21.800, p: 0.014).

Conclusion

EDs are very common in the ICU. Dysnatremia was detected more commonly in other EDs. It has also been found that patients with ED are more often under mechanical ventilation, have more prolonged hospitalizations, and have higher mortality rates than patients without ED. The suitability of LPMS for assessing ED-drug relationships in the ICU context is questioned.

Investigating Potential Correlations between Calcium Metabolism Biomarkers and Periprocedural Clinical Events in Major Cardiovascular Surgeries: An Exploratory Study

Background: There is emerging but conflicting evidence regarding the association between calcium biomarkers, more specifically ionized calcium and the prognosis of intensive care unit (ICU) postoperative cardiac patients. Methods: Our study investigated the relationship between ionized calcium, vitamin D, and periprocedural clinical events such as cardiac, neurologic and renal complications, major bleeding, vasoactive-inotropic score (VIS), and length of ICU and hospitalization. Results: Our study included 83 consecutive subjects undergoing elective major cardiac surgery requiring cardiopulmonary bypass. The mean age of the participants was 64.9 ± 8.5 years. The majority of procedures comprised isolated CABG (N = 26, 31.3%), aortic valve procedures (N = 26, 31.3%), and mitral valve procedures (N = 12, 14.5%). A difference in calcium levels across all time points (p < 0.001) was observed, with preoperative calcium being directly associated with intraoperative VIS (r = 0.26, p = 0.016). On day 1, calcium levels were inversely associated with the duration of mechanical ventilation (r = -0.30, p = 0.007) and the length of hospital stay (r = -0.22, p = 0.049). At discharge, calcium was inversely associated with length of hospital stay (r = -0.22, p = 0.044). All calcium levels tended to be lower in those who died during the 1-year follow-up (p = 0.054). Preoperative vitamin D levels were significantly higher in those who experienced AKI during hospitalization (median 17.5, IQR 14.5-17.7, versus median 15.3, IQR 15.6-20.5, p = 0.048) Conclusion: Fluctuations in calcium levels and vitamin D may be associated with the clinical course of patients undergoing cardiac surgery. In our study, hypocalcemic patients exhibited a greater severity of illness, as evidenced by elevated VIS scores, and experienced prolonged mechanical ventilation time and hospital stays. Additional larger-scale studies are required to gain a deeper understanding of their impact on cardiac performance and the process of weaning from cardiopulmonary bypass, as well as to distinguish between causal and associative relationships.

Calcium administration appears not to benefit acute pancreatitis patients with hypocalcemia

OBJECTIVE

Hypocalcemia occurs commonly among patients with acute pancreatitis (AP) in the intensive care unit (ICU). Calcium therapy could be used to correct hypocalcemia and maintain calcium levels, but its impact on the prognosis has not been demonstrated. Our study aimed to determine whether calcium therapy could benefit the multiple outcomes of AP patients with hypocalcemia.

METHODS

We extracted 807 AP patients with hypocalcemia from the Beth Israel Deaconess Medical Center (MIMIC-IV) database and performed retrospective analyses. The outcomes were in-hospital, 28 days, ICU mortality, and the length of stay (LOS) in the hospital and ICU. We performed propensity matching (PSM) and inverse probability weighting (IPTW) to balance the baseline differences and conducted multivariate regression to investigate the impact of calcium therapy.

RESULTS

A total of 620 patients (76.8%) received calcium treatment (calcium group) during hospitalization, while 187 patients (non-calcium group) did not. Patients in the calcium group did not present significant survival differences between groups before and after matching. After including covariates, calcium administration had no association with patients' in-hospital (HR: 1.03, 95% Cl: 0.47-2.27, p = .942), 28 days and ICU mortality and was significantly associated with prolonged length of stay in the hospital (effect estimate: 6.18, 95% Cl: 3.27-9.09, p < .001) and ICU (effect estimate: 1.72, 95% Cl: 0.24-3.20, p < .001). Calcium therapy could not benefit patients in subgroups with exclusive parenteral infusion, early calcium therapy (<48 h), or various degrees of hypocalcemia.

CONCLUSION

AP patients with hypocalcemia could not benefit from calcium administration, which has no association with multiple mortality and is significantly associated with prolonged LOS in the hospital and ICU.

Small vs. Large Library Docking for Positive Allosteric Modulators of the Calcium Sensing Receptor

Drugs acting as positive allosteric modulators (PAMs) to enhance the activation of the calcium sensing receptor (CaSR) and to suppress parathyroid hormone (PTH) secretion can treat hyperparathyroidism but suffer from side effects including hypocalcemia and arrhythmias. Seeking new CaSR modulators, we docked libraries of 2.7 million and 1.2 billion molecules against transforming pockets in the active-state receptor dimer structure. Consistent with simulations suggesting that docking improves with library size, billion-molecule docking found new PAMs with a hit rate that was 2.7-fold higher than the million-molecule library and with hits up to 37-fold more potent. Structure-based optimization of ligands from both campaigns led to nanomolar leads, one of which was advanced to animal testing. This PAM displays 100-fold the potency of the standard of care, cinacalcet, in ex vivo organ assays, and reduces serum PTH levels in mice by up to 80% without the hypocalcemia typical of CaSR drugs. Cryo-EM structures with the new PAMs show that they induce residue rearrangements in the binding pockets and promote CaSR dimer conformations that are closer to the G-protein coupled state compared to established drugs. These findings highlight the promise of large library docking for therapeutic leads, especially when combined with experimental structure determination and mechanism.

Predictive value of serum albumin and calcium levels in burn patients with Pseudomonas aeruginosa infection: A comprehensive analysis of clinical outcomes

In the ongoing challenge to reduce burn-associated mortality rates, this study explores the predictive capacity of clinical factors in burn patients, focusing on vitamin D, calcium, and serum albumin levels during hospitalisation in cases with Pseudomonas aeruginosa infection. Our research involves a comprehensive analysis of 100 burn patients, encompassing crucial clinical parameters such as the burn severity index, serum albumin, vitamin D, and calcium levels at admission. Data were meticulously entered into IBM Statistics SPSS software version 28 and subjected to statistical analysis. The study reveals an average patient age of 39.75 years and a notable 34% mortality rate. Additionally, the average lengths of hospital and intensive care unit (ICU) stays are determined to be 11.33 and 7.79 days, respectively. Significantly, a correlation between calcium and albumin variables and treatment outcomes is established, showcasing their potential to predict variable changes in patient mortality rates. Furthermore, a noteworthy association is observed between serum calcium levels and the duration of ICU hospitalisation. In conclusion, albumin and calcium variables emerge as sensitive and specific indicators for predicting outcomes in burn patients. Importantly, the independence of these factors from the physician's experience and diagnosis reduces human error and thus increases the accuracy of mortality prediction in this patient population.

Incidence of admission ionised hypocalcaemia in paediatric major trauma: protocol for a systematic review and meta-analysis

INTRODUCTION

Hypocalcaemia forms part of the 'diamond of death' in major trauma, alongside hypothermia, acidosis and coagulopathy. In adults, admission hypocalcaemia prior to transfusion is associated with increased mortality, increased blood transfusion requirements and coagulopathy. Data on paediatric major trauma patients are limited. This systematic review and meta-analysis aims to describe and synthesise the available evidence relevant to paediatric trauma, admission hypocalcaemia and outcome.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines will be used to construct this review. A planned literature search for articles in the English language will be conducted from inception to the date of searches using MEDLINE on the EBSCO platform, CINAHL on the EBSCO platform and Embase on the Ovid platform. The grey literature will also be searched. Both title and abstract screening and full-text screening will be done by two reviewers, with an adjudicating third reviewer. Heterogeneity will be assessed using the I2 test, and the risk of bias will be assessed using the ROBINS-I tool. A meta-analysis will be undertaken using ratio measures (OR) and mean differences for measures of effect. When possible, the estimate of effect will be presented along with a CI and a p value.

ETHICAL REVIEW AND DISSEMINATION

Ethical review is not required, as no original data will be collected. Results will be disseminated through peer-reviewed publications and at academic conferences.

PROSPERO REGISTRATION NUMBER

CRD42023425172.

Trauma-induced disturbances in ionized calcium levels correlate parabolically with coagulopathy, transfusion, and mortality: a multicentre cohort analysis from the TraumaRegister DGU®

BACKGROUND

To which extent trauma- induced disturbances in ionized calcium (iCa2+) levels have a linear relationship with adverse outcomes remains controversial. The goal of this study was to determine the association between the distribution and accompanying characteristics of transfusion-independent iCa2+ levels versus outcome in a large cohort of major trauma patients upon arrival at the emergency department.

METHODS

A retrospective observational analysis of the TraumaRegister DGU® (2015-2019) was performed. Adult major trauma patients with direct admission to a European trauma centre were selected as the study cohort. Mortality at 6 h and 24 h, in-hospital mortality, coagulopathy, and need for transfusion were considered as relevant outcome parameters. The distribution of iCa2+ levels upon arrival at the emergency department was calculated in relation to these outcome parameters. Multivariable logistic regression analysis was performed to determine independent associations.

RESULTS

In the TraumaRegister DGU® 30 183 adult major trauma patients were found eligible for inclusion. iCa2+ disturbances affected 16.4% of patients, with hypocalcemia (< 1.10 mmol/l) being more frequent (13.2%) compared to hypercalcemia (≥ 1.30 mmol/l, 3.2%). Patients with hypo- and hypercalcemia were both more likely (P < .001) to have severe injury, shock, acidosis, coagulopathy, transfusion requirement, and haemorrhage as cause of death. Moreover, both groups had significant lower survival rates. All these findings were most distinct in hypercalcemic patients. When adjusting for potential confounders, mortality at 6 h was independently associated with iCa2+ < 0.90 mmol/L (OR 2.69, 95% CI 1.67-4.34; P < .001), iCa2+ 1.30-1.39 mmol/L (OR 1.56, 95% CI 1.04-2.32, P = 0.030), and iCa2+  ≥ 1.40 mmol/L (OR 2.87, 95% CI 1.57-5.26; P < .001). Moreover, an independent relationship was determined for iCa2+ 1.00-1.09 mmol/L with mortality at 24 h (OR 1.25, 95% CI 1.05-1.48; P = .0011), and with in-hospital mortality (OR 1.29, 95% CI 1.13-1.47; P < .001). Both hypocalcemia < 1.10 mmol/L and hypercalcemia ≥ 1.30 mmol/L had an independent association with coagulopathy and transfusion.

CONCLUSIONS

Transfusion-independent iCa2+ levels in major trauma patients upon arrival at the emergency department have a parabolic relationship with coagulopathy, need for transfusion, and mortality. Further research is needed to confirm whether iCa2+ levels change dynamically and are more a reflection of severity of injury and accompanying physiological derangements, rather than an individual parameter that needs to be corrected as such.

Hypocalcemia is associated with adverse outcomes in patients hospitalized with COVID-19

PURPOSE

Calcium ions are involved in the regulation of several cellular processes and may also influence viral replication. Hypocalcemia has been frequently reported during infectious diseases and in critically ill patients, including also COVID-19 patients, significantly related with the pro-inflammatory state and mortality. The aim of this study is to investigate the prevalence of hypocalcemia at admission in patients hospitalized for COVID-19 (Coronavirus disease 2019) and to evaluate association of hypocalcemia with in-hospital COVID-19 outcomes.

METHODS

Retrospective analysis on 118 consecutive patients, hospitalized for COVID-19 between March and May 2020. Clinical characteristics, inflammation markers, biochemical routine and mineral metabolism parameters at admission were collected. Hypocalcemia was defined as total serum calcium <2.2 mmol/L. Population was stratified by tertiles of total serum calcium. Primary outcome was the composite of in-hospital death or admission to intensive care unit (ICU). Secondary outcomes included in-hospital death, admission to ICU and need for non-invasive ventilation as separate events. Associations were tested by logistic regression and Cox-regression analysis with survival curves.

RESULTS

Overall prevalence of hypocalcemia was 76.6%, with just 6.7% of patients reporting levels of 25-(OH)-vitamin D > 30 ng/ml. Total serum calcium was inversely related with selected inflammatory biomarkers (p < 0.05) and poorer outcome of COVID-19 during hospitalization. Lower tertile of total calcium (≤2.02 mmol/L) had increased risk of in-hospital mortality (HR 2.77; 1.28-6.03, p = 0.01) compared with other groups.

CONCLUSION

Total serum calcium detected on admission is inversely related with proinflammatory biomarkers of severe COVID-19 and is useful to better define risk stratification for adverse in-hospital outcome.

Retrospective evaluation of the effect of inhalant anesthesia on complications and recurrence rates in feline urethral obstruction

OBJECTIVES

The aim of this study was to evaluate the use of inhalant anesthesia vs sedation for urinary catheter placement in male cats with urethral obstruction. The primary outcome measures were the incidence of complications related to catheterization, the incidence of recurrent urethral obstruction (rUO; both during hospitalization and within 1 year) and survival. The secondary aim of this study was to evaluate the association between baseline serum biochemical concentrations and antispasmodic medications with complications and short-term rUO.

METHODS

We carried out a retrospective review of records from a university teaching hospital from 2009 to 2020. Cats were included if diagnosed with a urinary obstruction, based on the presence of a large, painful and non-expressible bladder, a urinary catheter was placed and hospitalization occurred for a minimum of 24 h. Collected baseline data included age, breed, weight, serum biochemical concentrations and if cats underwent sedation or inhalant anesthesia for urethral catheterization. For the comparison of inhalant anesthesia or sedation, univariate logistic regression was used.

RESULTS

There was no statistically significant difference in complications or the recurrence of obstruction in cats with urethral obstruction that underwent inhalant anesthesia compared with sedation. All serum biochemical concentrations were significantly associated with survival. Decreased serum ionized calcium was found to be statistically significantly associated with higher complication rates (P = 0.0086), as well as short-term recurrence of obstruction (P = 0.004). Increased serum potassium concentrations were found to be statistically significantly associated with the risk of short-term recurrent urethral obstruction (P = 0.0345). No significant difference was found between the use of antispasmodic medications with short-term recurrence.

CONCLUSIONS AND RELEVANCE

No significant difference was found between complications or recurrence rates when comparing the use of inhalant anesthesia to sedation protocols. Baseline serum biochemical data were significantly associated with complications, survival and short-term recurrence rates.

Serum Calcium, Magnesium, and Phosphorus Levels in Patients with COVID-19: Relationships with Poor Outcome and Mortality

In this retrospective study to assess the impact of serum corrected calcium (CorrCa), magnesium (Mg) and phosphorus (P) levels, all adult patients with laboratory-confirmed COVID-19 hospitalized during 2020 were included. Poor outcome was considered in patients who presented need for mechanical ventilation, intensive care unit (ICU) admission, or in-hospital mortality. We analyzed 2473 patients (956 females) aged (mean±SD) 63.4±15.9 years. During admission, 169 patients (6.8%) required mechanical ventilation, 205 (8.3%) were admitted to the ICU, and 270 (10.9%) died. Composite variable of poor outcome, defined as need for mechanical ventilation, ICU admission or death, was present in 434 (17.5%) patients. In univariate analysis, the need for mechanical ventilation was positively related to Mg levels (OR 8.37, 95% CI 3.62-19.33; p<0.001); ICU admission was related to CorrCa (OR 0.49, 95% CI 0.25-0.99; p=0.049) and Mg levels (OR 5.81, 95% CI 2.74-12.35; p<0.001); and in-hospital mortality was related to CorrCa (OR 1.73, 95% CI 1.14-2.64; p=0.011). The composite variable of poor outcome was only related to Mg (OR 2.68, 95% CI 1.54-4.68; p=0.001). However, in multivariate analysis only CorrCa was significantly related to the need for mechanical ventilation (OR 0.19, 95% CI 0.05-0.72; p=0.014) and ICU admission (OR 0.25; 95% CI 0.09-0.66; p=0.005), but not with in-hospital mortality or the composite variable. In conclusion, CorrCa can be used as a simple and reliable marker of poor outcome in patients with COVID-19, although not to predict the risk of in-hospital mortality.

Early Hypocalcemia in Pediatric Major Trauma: A Retrospective Cohort Study

OBJECTIVE

Early hypocalcemia (EH) is common in adult major trauma patients and has been associated with coagulopathy, shock, increased transfusion requirements, and mortality. The incidence of EH in pediatric severe trauma has not been investigated. We aimed to explore the incidence of EH among severely injured children.

METHODS

We conducted a retrospective cohort study at a tertiary children's hospital and a level 1 pediatric trauma center. We extracted the medical records of all pediatric major trauma patients, defined as an age less than 18 years and an Injury Severity Score (ISS) greater than 15, admitted after trauma team activation from January 2010 to December 2020.The primary outcome was the presence of EH. Patients were classified into 3 groups: severe hypocalcemia (ionized calcium [iCa] <1 mmol/L), hypocalcemia (1 < iCa < 1.16 mmol/L), and normal calcium (iCa ≥1.16 mmol/L).

RESULTS

During the study period, 5126 children were hospitalized because of trauma. One hundred eleven children met the inclusion criteria. The median age was 11 years (interquartile range [IQR], 4-15), and 78.4% (87) were male. The median ISS was 21 (IQR, 17-27).Hypocalcemia was found in 19.8% (22) and severe hypocalcemia in 2.7% (3) of the patients.Although not statistically significant, hypocalcemic pediatric trauma patients had higher ISS (25.5 [IQR, 17-29] vs 21 [IQR, 17-26], P = 0.39), lower Glasgow Coma Scale (11 [IQR, 3-15] vs 13 [IQR, 7-15], P = 0.24), a more prolonged hospital stay (8 days [IQR, 2-16] vs 6 days [IQR, 3-13], P = 0.36), a more frequent need for blood products (27.3% vs 20.2%, P = 0.74), and higher mortality rates (9.1% vs 1.1%, P = 0.18) compared with normocalcemic patients.

CONCLUSIONS

Our data suggest that in the setting of major trauma, EH is less frequent in children than previously reported in adults. Our preliminary data suggest that pediatric patients with EH may be at risk of increased morbidity and mortality compared with children with normal admission iCa requiring further studies.

Predictive Value of Ionized Calcium for Prognosis of Sepsis in Very Low Birth Weight Infants

Purpose

Previous studies have shown that ionized calcium (iCa) is strongly correlated with critical illnesses, including sepsis. However, there are few studies on the association of iCa levels and sepsis in very low birth weight infants (VLBWI). Therefore, the aim of this study was to investigate the role of iCa in assessing the severity of sepsis and in predicting the prognosis of sepsis in VLBWI.

Patients and Methods

249 eligible VLBWI with sepsis were included in the present study and were divided into good and poor prognosis groups according to prognosis. We collected complete laboratory and clinical data. The lowest iCa measured during the first 24h from sepsis onset was recorded, and the Pediatric Risk of Mortality (PRISM III) score was calculated for each newborn.

Results

Neonatal mortality was higher in the hypocalcemia group (32.80% vs 12.80%, P < 0.001), and iCa levels were negatively correlated with PRISM III scores (r= −0.819, P < 0.001). The result of multiple logistic regression analysis showed that iCa was an independent predictor of poor prognosis (odds ratio [OR]= 0.558, 95% confidence interval [CI], 0.406–0.768, P < 0.001). Furthermore, our data demonstrated that iCa was also an independent predictor for the occurrence of death in VLBWI with sepsis who have a poor prognosis (OR= 0.659, 95% CI, 0.445–0.977, P =0.038). ROC curve analysis showed that iCa had good discriminatory power in predicting the poor prognosis (AUC=0.739, 95% CI, 0.664–0.813, P <0.001) in VLBWI with sepsis.

Conclusion

iCa levels correlate with the severity of sepsis and can be an independent predictor of poor prognosis in VLBWI with sepsis.

The Positive and Negative Effects of Calcium Supplementation on Mortality in Septic ICU Patients Depend on Disease Severity: A Retrospective Study from the MIMIC-III

Background. Calcium administration in septic patients with hypocalcemia is a controversial issue. The present study preliminarily investigated the effects of calcium supplementation on the length of hospitalization and mortality in septic ICU patients with different severities of hypocalcemia and disease. Method. A total of 5761 eligible septic patients, including 2689 who received calcium supplementation and 3072 who did not receive calcium supplementation, were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The cofounding covariates between the calcium supplement and nonsupplement groups were balanced using the propensity score matching model. We compared the length of stay (LOS) in the ICU and hospital with 28-day and hospital mortality and stratified the analysis according to the sequential organ failure assessment (SOFA) score and ionized calcium (iCa) at the first ICU admission in the matched groups. Results. The results showed that iCa at the first ICU admission was associated with mortality in sepsis patients (HR: 0.421; 95% CI: 0.211∼0.837), but the lowest mortality rate was observed in patients with mild hypocalcemia. A total of 993 paired patients were included in the analysis after propensity score matching. Regardless of the SOFA score or presence of iCa, the LOS in the ICU was higher in the calcium supplement group than in the nonsupplement group. The survival analysis was stratified by the SOFA score and showed that calcium supplementation reduced mortality when the patient’s SOFA score was ≥8 ( $p=0.002$ ), and it worsened the outcome when the patient’s SOFA score was ≤4 ( $p=0.010$ ). It had no significant effect on patients with SOFA scores ranging from 5 to 7 ( $p=0.911$ ). Conclusion. Our results showed that mild hypocalcemia may be protective in septic patients, and calcium supplementation may have positive and negative effects on mortality depending on disease severity. The SOFA score may be a valuable clinical index for decisions regarding calcium administration.

Association of Hypocalcemia With Mortality of Combat Casualties With Brain Injury and Polytrauma Transported by Critical Care Air Transport Teams

INTRODUCTION

Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements <1.2 mmol/L. Ionized calcium goals for en route critical care (ERCC) following DCR are less defined, and the impact of in-flight hypocalcemia events among critically injured combat wounded is unknown. This study aimed to describe the association between hypocalcemia and mortality for combat-wounded with brain injury and polytrauma requiring transport by Critical Care Air Transport Teams (CCATT).

METHODS

We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa <0.9 mmol/L), hypocalcemia (iCa 0.9-1.11 mmol/L), and never hypocalcemic (iCa ≥1.12 mmol/L). The primary outcome measure was mortality. We calculated descriptive statistics and performed multivariate logistic regression to assess the association between hypocalcemia and mortality.

RESULTS

We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables.

CONCLUSION

In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes.

The Prognostic Value of Calcium in Post-Cardiovascular Surgery Patients in the Intensive Care Unit

Background: Present researches exploring the prognostic value of calcium concentration are undermined by sample size and study design. Our study investigated the association of both total calcium (tCa) and ionized Ca (iCa) to short- and long-term mortality and other outcomes in post-cardiovascular surgery (PCS) patients admitted to intensive care unit (ICU) from two large public data sets.

Methods: The Medical Information Mart for Intensive Care III (MIMIC-III) database and the eICU Collaborative Research Database (eICU) were inspected to identify PCS patients. The primary outcome was 28-day mortality. Multivariate regression was used to elucidate the relationship between calcium concentration and outcomes. The propensity score estimation was performed to validate our findings.

Results: A total of 6122 and 914 patients were included from the MIMIC III and eICU data sets, respectively. The groups with the most patients were the mild hypo-iCa and hypo-tCa groups. The mild hypo-iCa group showed significant association with worse short-term and long-term prognosis, less use of ventilation, longer ICU and hospital stay, and more incidence of 7-day acute kidney injury.

Conclusions: The mild hypo-iCa (0.9–1.15 mmol/L) within the first day of admission to the ICU could serve as an independent prognosis factor for PCS patients.

Out of Control: The Role of the Ubiquitin Proteasome System in Skeletal Muscle during Inflammation

The majority of critically ill intensive care unit (ICU) patients with severe sepsis develop ICU-acquired weakness (ICUAW) characterized by loss of muscle mass, reduction in myofiber size and decreased muscle strength leading to persisting physical impairment. This phenotype results from a dysregulated protein homeostasis with increased protein degradation and decreased protein synthesis, eventually causing a decrease in muscle structural proteins. The ubiquitin proteasome system (UPS) is the predominant protein-degrading system in muscle that is activated during diverse muscle atrophy conditions, e.g., inflammation. The specificity of UPS-mediated protein degradation is assured by E3 ubiquitin ligases, such as atrogin-1 and MuRF1, which target structural and contractile proteins, proteins involved in energy metabolism and transcription factors for UPS-dependent degradation. Although the regulation of activity and function of E3 ubiquitin ligases in inflammation-induced muscle atrophy is well perceived, the contribution of the proteasome to muscle atrophy during inflammation is still elusive. During inflammation, a shift from standard- to immunoproteasome was described; however, to which extent this contributes to muscle wasting and whether this changes targeting of specific muscular proteins is not well described. This review summarizes the function of the main proinflammatory cytokines and acute phase response proteins and their signaling pathways in inflammation-induced muscle atrophy with a focus on UPS-mediated protein degradation in muscle during sepsis. The regulation and target-specificity of the main E3 ubiquitin ligases in muscle atrophy and their mode of action on myofibrillar proteins will be reported. The function of the standard- and immunoproteasome in inflammation-induced muscle atrophy will be described and the effects of proteasome-inhibitors as treatment strategies will be discussed.

Massive transfusions and severe hypocalcemia: An opportunity for monitoring and supplementation guidelines

BACKGROUND

Massive transfusion protocols (MTPs) are associated with severe hypocalcemia, contributing to coagulopathy and mortality in severely injured patients. Severity of hypocalcemia following massive transfusion activation and appropriate treatment strategies remain undefined.

STUDY DESIGN AND METHODS

This was a retrospective study of all MTP activations in adult trauma patients at a Level 1 trauma center between August 2016 and September 2017. Units of blood products transfused, ionized calcium levels, and amount of calcium supplementation administered were recorded. Primary outcomes were ionized calcium levels and the incidence of severe ionized hypocalcemia (iCa ≤1.0 mmol/L) in relation to the volume of blood products transfused.

RESULTS

Seventy-one patients had an MTP activated during the study period. The median amount of packed red blood cells (PRBCs) transfused was 10 units (range 1-52). A total of 42 (59.1%) patients had periods of severe hypocalcemia. Patients receiving 13 or more units of PRBC had a greater prevalence of hypocalcemia with 83.3% having at least one measured ionized calcium ≤1.0 mmoL/L (p = .001). The number of ionized calcium levels checked and the amount of supplemental calcium given in patients who experienced hypocalcemia varied considerably.

DISCUSSION

Severe hypocalcemia commonly occurs during MTP activations and correlates with the number of packed red blood cells transfused. Monitoring of ionized calcium and amount of calcium supplementation administered is widely variable. Standardized protocols for recognition and management of severe hypocalcemia during massive transfusions may improve outcomes.

Admission Serum Ionized and Total Calcium as New Predictors of Mortality in Patients with Cardiogenic Shock

Background

Although serum calcium has been proven to be a predictor of mortality in a wide range of diseases, its prognostic value in critically ill patients with cardiogenic shock (CS) remains unknown. This retrospective observational study is aimed at investigating the association of admission calcium with mortality among CS patients.

Methods

Critically ill patients diagnosed with CS in the Medical Information Mart for Intensive Care-III (MIMIC-III) database were included in our study. The study endpoints included 30-day, 90-day, and 365-day all-cause mortalities. First, admission serum ionized calcium (iCa) and total calcium (tCa) levels were analyzed as continuous variables using restricted cubic spline Cox regression models to evaluate the possible nonlinear relationship between serum calcium and mortality. Second, patients with CS were assigned to four groups according to the quartiles (Q1-Q4) of serum iCa and tCa levels, respectively. In addition, multivariable Cox regression analyses were used to assess the independent association of the quartiles of iCa and tCa with clinical outcomes.

Results

A total of 921 patients hospitalized with CS were enrolled in this study. A nonlinear relationship between serum calcium levels and 30-day mortality was observed (all P values for nonlinear trend < 0.001). Furthermore, multivariable Cox analysis showed that compared with the reference quartile (Q3: 1.11 ≤ iCa < 1.17 mmol/L), the lowest serum iCa level quartile (Q1: iCa < 1.04 mmol/L) was independently associated with an increased risk of 30-day mortality (Q1 vs. Q3: HR 1.35, 95% CI 1.00-1.83, P = 0.049), 90-day mortality (Q1 vs. Q3: HR 1.36, 95% CI 1.03-1.80, P = 0.030), and 365-day mortality (Q1 vs. Q3: HR 1.28, 95% CI 1.01-1.67, P = 0.046) in patients with CS.

Conclusions

Lower serum iCa levels on admission were potential predictors of an increased risk of mortality in critically ill patients with CS.

Electrolyte disorders during the initiation of nutrition therapy in the ICU

PURPOSE OF REVIEW

To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition.

RECENT FINDINGS

Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome.

SUMMARY

Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.

Hypocalcemia is associated with severe COVID-19: A systematic review and meta-analysis

BACKGROUND AND AIMS

Hypocalcemia is commonly in critically ill patients and studies have shown that hypocalcemia is prevalent in patients with COVID-19. This meta-analysis aimed to evaluate the prognostic performance of hypocalcemia in patients with coronavirus disease 2019 (COVID-19).

METHODS

We performed a systematic literature search on PubMed, Scopus, and Embase with keywords "SARS-CoV-2″ OR″COVID-19″ OR ″2019-nCoV" AND "hypocalcemia" up until 10 December 2020. The key exposure was hypocalcemia, defined as serum calcium below study-defined cut-off points. The main outcome was poor outcome, which was a composite of mortality and severity. The effect estimate of the main outcome was reported as odds ratio (OR) and its 95% confidence interval (95% CI). We also generate sensitivity, specificity, positive and negative likelihood ratio (PLR & NLR), diagnostic odds ratio (DOR), and area under curve (AUC).

RESULTS

There are 2032 patients from 7 studies included in this systematic review and meta-analysis. The incidence of poor outcome in this study was 26%. Serum calcium was lower in patients with poor outcome (mean difference -0.173 mmol/L [-0.259, -0.087], p < 0.001; I²: 31.3%). Hypocalcemia was associated with poor outcome (OR 3.19 [2.02, 5.06], p < 0.001; I²: 32.86%); with sensitivity of 0.74 [0.53, 0.88], specificity of 0.54 [0.29, 0.77], PLR of 1.6 [1.1, 2.3], NLR of 0.49 [0.35, 0.66], DOR of 3 [2, 5], and AUC of 0.70 [0.66, 0.74]. In this pooled analysis, the post-test probability was 36% in patients with hypocalcemia and 15% in patients without hypocalcemia.

CONCLUSION

Hypocalcemia was associated with poor outcome in COVID-19 patients.

PROSPERO ID

CRD42020225506.

A deep learning backcasting approach to the electrolyte, metabolite, and acid-base parameters that predict risk in ICU patients

BACKGROUND

A powerful risk model allows clinicians, at the bedside, to ensure the early identification of and decision-making for patients showing signs of developing physiological instability during treatment. The aim of this study was to enhance the identification of patients at risk for deterioration through an accurate model using electrolyte, metabolite, and acid-base parameters near the end of patients' intensive care unit (ICU) stays.

METHODS

This retrospective study included 5157 adult patients during the last 72 hours of their ICU stays. The patients from the MIMIC-III database who had serum lactate, pH, bicarbonate, potassium, calcium, glucose, chloride, and sodium values available, along with the times at which those data were recorded, were selected. Survivor data from the last 24 hours before discharge and four sets of nonsurvivor data from 48-72, 24-48, 8-24, and 0-8 hours before death were analyzed. Deep learning (DL), random forest (RF) and generalized linear model (GLM) analyses were applied for model construction and compared in terms of performance according to the area under the receiver operating characteristic curve (AUC). A DL backcasting approach was used to assess predictors of death vs. discharge up to 72 hours in advance.

RESULTS

The DL, RF and GLM models achieved the highest performance for nonsurvivors 0-8 hours before death versus survivors compared with nonsurvivors 8-24, 24-48 and 48-72 hours before death versus survivors. The DL assessment outperformed the RF and GLM assessments and achieved discrimination, with an AUC of 0.982, specificity of 0.947, and sensitivity of 0.935. The DL backcasting approach achieved discrimination with an AUC of 0.898 compared with the DL native model of nonsurvivors from 8-24 hours before death versus survivors with an AUC of 0.894. The DL backcasting approach achieved discrimination with an AUC of 0.871 compared with the DL native model of nonsurvivors from 48-72 hours before death versus survivors with an AUC of 0.846.

CONCLUSIONS

The DL backcasting approach could be used to simultaneously monitor changes in the electrolyte, metabolite, and acid-base parameters of patients who develop physiological instability during ICU treatment and predict the risk of death over a period of hours to days.

Acute pancreatitis in patients with severe fever with thrombocytopenia syndrome virus infection

BACKGROUND

Severe fever with thrombocytopenia syndrome (SFTS), a novel tick-borne disease caused by SFTS virus (SFTSV), has been reported in China, Japan, South Korea, and Vietnam since 2009. SFTSV infection can cause multiple organ damage, including acute pancreatitis (AP). We summarize the clinical features, treatment and outcome of AP associated with SFTSV.

METHODS

We retrospectively review the clinical manifestations, laboratory tests, treatment, and outcome of AP associated with SFTSV infection from January 2009 to December 2018 in Liaoning Province, China.

RESULTS

A total of 418 SFTS patients were reviewed. Fifteen (3.6%) of 418 met the criteria for AP associated with SFTSV infection. The first reported symptom for all SFTS-AP patients was fever. All the SFTS-AP patients presented with thrombocytopenia, and 13 (86.7%) of them presented with leukopenia on admission. Thirteen (86.7%) of 15 SFTS-AP patients were severe SFTS patients, and 9 (60.0%) patients were diagnosed with multiple organ dysfunction syndrome. One SFTS-AP patient died of multiple organ failure. Six (40%) of 15 SFTS-AP patients were not confirmed with SFTSV infection when AP was diagnosed, and the median delay between SFTSV infection and AP diagnosis was 5 days (range, 2-7 days).

CONCLUSIONS

AP is not a frequent complication of SFTS, and is more frequently seen in severe SFTS patients. Most patients with SFTS-AP have mild or moderate disease, and can recover with conservative management; however, severe SFTS-AP can be fatal. In SFTS endemic areas, clinicians should be alert to the possibility of SFTS when AP patients with tick exposure, thrombocytopenia, and leukopenia have a fever before abdominal pain.

Metabolic and Endocrine Challenges

This review aims to provide an overview of metabolic and endocrine challenges in the setting of intensive care medicine. These are a group of heterogeneous clinical conditions with a high degree of overlap, as well as nonspecific signs and symptoms. Several diseases involve multiple organ systems, potentially causing catastrophic dysfunction and death. In the majority of cases, endocrine challenges accompany other organ failures or manifest as a complication of prolonged intensive care unit stay and malnutrition. However, when endocrine disorders present as an isolated syndrome, they are a rare and extreme manifestation. As they are uncommon, these can typically challenge both with diagnosis and management. Acute exacerbations may be elicited by triggers such as infections, trauma, surgery, and hemorrhage. In this complex scenario, early diagnosis and prompt treatment require knowledge of the specific endocrine syndrome. Here, we review diabetic coma, hyponatremia, hypercalcemia, thyroid emergencies, pituitary insufficiency, adrenal crisis, and vitamin D deficiency, highlighting diagnostic tools and tricks, and management pathways through defining common clinical presentations.

Annexin A1-dependent tethering promotes extracellular vesicle aggregation revealed with single-extracellular vesicle analysis

Extracellular vesicles (EVs) including plasma membrane-derived microvesicles and endosomal-derived exosomes aggregate by unknown mechanisms, forming microcalcifications that promote cardiovascular disease, the leading cause of death worldwide. Here, we show a framework for assessing cell-independent EV mechanisms in disease by suggesting that annexin A1 (ANXA1)-dependent tethering induces EV aggregation and microcalcification. We present single-EV microarray, a method to distinguish microvesicles from exosomes and assess heterogeneity at a single-EV level. Single-EV microarray and proteomics revealed increased ANXA1 primarily on aggregating and calcifying microvesicles. ANXA1 vesicle aggregation was suppressed by calcium chelation, altering pH, or ANXA1 neutralizing antibody. ANXA1 knockdown attenuated EV aggregation and microcalcification formation in human cardiovascular cells and acellular three-dimensional collagen hydrogels. Our findings explain why microcalcifications are more prone to form in vulnerable regions of plaque, regulating critical cardiovascular pathology, and likely extend to other EV-associated diseases, including autoimmune and neurodegenerative diseases and cancer.

Prognostic Value of Ionized Calcium Levels in Neonatal Sepsis

BACKGROUND

Despite recent advances in the treatment of neonatal infection, mortality rates and comorbidities associated with neonatal sepsis remain high. Hypocalcemia has been reported in critically ill patients, especially in as-sociation with sepsis. However, the importance of hypo-calcemia in neonatal sepsis has not been explored in detail.

OBJECTIVES

The purpose of this study was to evaluate the prognostic value of hypocalcemia in neonatal sepsis patients and to identify the risk factors associated with sepsis-related mortality.

METHODS

This retrospective study examined perinatal data from patients in a level IV neonatal in-tensive care unit between January 2010 and June 2016. Univariate analysis was performed to understand the differences in clinical and laboratory characteristics between patients with and without neonatal sepsis. Neonates with sepsis were further stratified as having ionized hypocalcemia (if serum ionized calcium [iCa] <1.0 mmol/L) or not. Uni- and multivariate logistic regression analyses were utilized to evaluate the predictive potential of iCa for identifying sepsis-related mortality.

RESULTS

A total of 472 neonates were enrolled in this study, including 169 neonates diagnosed with culture-proven sepsis and 303 neonates without infection (control group). The comparison of neonates with and without sepsis highlighted significant differences in levels of iCa (0.97 ± 0.26 vs. 1.12 ± 0.25 mmol/L), magnesium (0.75 ± 0.22 vs. 0.89 ± 0.12 mmol/L), and phosphate (2.26 ± 1.08 vs. 1.65 ± 0.85 mmol/L; all p < 0.001). When neonates with sepsis were stratified into 2 subgroups based on serum iCa, neonates with hypocalcemia showed higher rates of organ dysfunction than those with normal iCa, as well as higher rates of cardiovascular system dysfunction (37.35 vs. 17.44%), renal dysfunction (34.94 vs. 30.95%), disseminated intravascular coagulation (26.51 vs. 11.63%), and seizure (16.04 vs. 5.8%; all p < 0.05). Among all neonates who had sepsis, the mortality rate was 13.61%, and this rate was higher among neonates with hypocalcemia than among those with normal iCa (20.48 vs. 6.98%, p < 0.05). Uni- and multivariate analyses showed that acidosis, hypoalbuminemia, hypocalcemia, and hyperphosphatemia were independent prognostic markers of sepsis-related mortality. In receiver-operating characteristic curve analysis, the areas under the curve were 0.70 (95% CI 0.624-0.768; p = 0.0004), 0.74 (95% CI 0.671-0.808; p < 0.0001), 0.73 (95% CI 0.653-0.792; p = 0.0002), and 0.67 (95% CI 0.59-0.737; p = 0.0154) for serum albumin, iCa, phosphate, and acidosis, respectively. Based on these findings, we developed a nomogram to predict sepsis-related mortality.

CONCLUSIONS

Hypocalcemia is common in neonates with sepsis and is significantly associated with organ dysfunction and sepsis-related mortality.

Prevalence and predictive value of hypocalcemia in severe COVID-19 patients

Background

The aim of this study was to investigate the performance and predictive value of hypocalcemia in severe COVID-19 patients.

Methods

We retrospectively investigated the clinical and laboratory characteristics of severe COVID-19 patients. 107 patients were divided into hypocalcemia group and normal serum calcium group. The clinical and laboratory data were compared between two groups. The discriminative power of hypocalcemia regarding poor outcome were evaluated by receiver operating curves (ROC) analyses.

Results

Sixty seven patients (62.6%) had hypocalcemia. In hypocalcemia group, leukocytes, c-reactive protein (CRP), procalcitonin (PCT), Interleukin 6 (IL-6), and D-dimer levels was higher, while lymphocytes and albumin (ALB) levels was lower. No significant difference was identified in gender, age, signs and symptoms, comorbidities and other laboratory indicators. Serum calcium levels were negatively correlated with leukocytes, CRP, PCT, IL-6 and D-dimer, while positively correlated with lymphocytes and ALB. Patients with hypocalcemia more commonly presented poor outcome (47.8% (32/67) vs 25% (10/40), p = 0.02). Median serum calcium levels were significantly lower in the patients with poor outcome (2.01(1.97–2.05) vs 2.10(2.03–2.20), p < 0.001), and it could predict the prognosis with an area under the ROC curve (AUC) of 0.73(95% confidence interval (CI) 0.63–0.83, p < 0.001).

Conclusions

Hypocalcemia commonly occurred in severe COVID-19 patients and it was associated with poor outcome.

Hospital mortality and long-term mortality among hospitalized patients with various admission serum ionized calcium levels

BACKGROUND

We conducted a single-center historical cohort study to evaluate the association between admission serum ionized calcium and mortality in hospitalized patients.

METHODS

We included hospitalized patients from January 2009 to December 2013 who had available serum ionized calcium at the time of admission. We assessed the in-hospital and 1-year mortality risk based on admission serum ionized calcium using multivariate logistic and Cox proportional hazard analysis, respectively. To test non-linear association, we categorized serum ionized calcium into six groups; ≤4.39, 4.40-4.59, 4.60-4.79, 4.80-4.99, 5.00-5.19, ≥5.20 mg/dL and selected serum ionized calcium of 4.80-4.99 mg/dL as a reference group.

RESULTS

We studied a total of 33,255 hospitalized patients. The mean admission serum ionized calcium at 4.8 ± 0.4 mg/dL. Hospital and 1-year mortality observed in 1,099 (3%) and 5,239 (15.8%), respectively. We observed a U-shaped association between admission serum ionized calcium and in-hospital and 1-year mortality. Ionized calcium lower threshold for increased in-hospital and 1-year mortality rates was ≤4.59 and ≤4.39 mg/dL, respectively. Ionized calcium upper threshold for increased in-hospital and 1-year mortality rates was ≥5.20 mg/dL.

CONCLUSION

Both hypocalcemia and hypercalcemia were associated with increased short- and long-term mortality with a U-shape relationship.

Sepsis surveillance: an examination of parameter sensitivity and alert reliability

Objective

To examine performance of a sepsis surveillance system in a simulated environment where modifications to parameters and settings for identification of at-risk patients can be explored in-depth.

Materials and Methods

This was a multiple center observational cohort study. The study population comprised 14 917 adults hospitalized in 2016. An expert-driven rules algorithm was applied against 15.1 million data points to simulate a system with binary notification of sepsis events. Three system scenarios were examined: a scenario as derived from the second version of the Consensus Definitions for Sepsis and Septic Shock (SEP-2), the same scenario but without systolic blood pressure (SBP) decrease criteria (near SEP-2), and a conservative scenario with limited parameters. Patients identified by scenarios as being at-risk for sepsis were assessed for suspected infection. Multivariate binary logistic regression models estimated mortality risk among patients with suspected infection.

Results

First, the SEP-2-based scenario had a hyperactive, unreliable parameter SBP decrease >40 mm Hg from baseline. Second, the near SEP-2 scenario demonstrated adequate reliability and sensitivity. Third, the conservative scenario had modestly higher reliability, but sensitivity degraded quickly. Parameters differed in predicting mortality risk and represented a substitution effect between scenarios.

Discussion

Configuration of parameters and alert criteria have implications for patient identification and predicted outcomes.

Conclusion

Performance of scenarios was associated with scenario design. A single hyperactive, unreliable parameter may negatively influence adoption of the system. A trade-off between modest improvements in alert reliability corresponded to a steep decline in condition sensitivity in scenarios explored.

Epidemiology, clinical features, and management of severe hypercalcemia in critically ill patients

BACKGROUND

Severe hypercalcemia (HCM) is a common reason for admission in intensive-care unit (ICU). This case series aims to describe the clinical and biological features, etiologies, treatments, and outcome associated with severe HCM. This study included all patients with a total calcemia above 12 mg/dL (3 mmol/L) admitted in two ICUs from January 2007 to February 2017.

RESULTS

131 patients with HCM were included. HCM was related to hematologic malignancy in 58 (44.3%), solid tumors in 29 (22.1%), endocrinopathies in 16 (12.2%), and other causes in 28 (21.3%) patients. 108 (82.4%) patients fulfilled acute kidney injury (AKI) criteria. Among them, 25 (19%) patients required renal replacement therapy (RRT). 51 (38.9%) patients presented with neurological symptoms, 73 (55.7%) patients had cardiovascular manifestations, and 50 (38.1%) patients had digestive manifestations. The use of bisphosphonates (HR, 0.42; 95% CI, 0.27-0.67; P < 0.001) was the only treatment significantly associated with a decrease of total calcemia below 12 mg/dL (3 mmol/L) at day 5. ICU and Hospital mortality rates were, respectively, 9.9% and 21.3%. Simplified Acute Physiologic Score (SAPS II) (OR, 1.05; 95% CI 1.01-1.1; P = 0.03) and an underlying solid tumor (OR, 13.83; 95% CI 2.24-141.25; P = 0.01) were two independent factors associated with hospital mortality in multivariate analysis.

CONCLUSIONS

HCM is associated with high mortality rates, mainly due to underlying malignancies. The course of HCM may be complicated by organ failures which are most of the time reversible with early ICU management. Early ICU admission and prompt HCM management are crucial, especially in patients with an underlying solid tumor presenting with neurological symptoms.

Clinical Decision Support for Early Recognition of Sepsis

Sepsis is an inflammatory response triggered by infection, with a high in-hospital mortality rate. Early recognition and treatment can reverse the inflammatory response, with evidence of improved patient outcomes. One challenge clinicians face is identifying the inflammatory syndrome against the background of the patient's infectious illness and comorbidities. An approach to this problem is implementation of computerized early warning tools for sepsis. This multicenter retrospective study sought to determine clinimetric performance of a cloud-based computerized sepsis clinical decision support system (CDS), understand the epidemiology of sepsis, and identify opportunities for quality improvement. Data encompassed 6200 adult hospitalizations from 2012 through 2013. Of 13% patients screened-in, 51% were already suspected to have an infection when the system activated. This study focused on a patient cohort screened-in before infection was suspected; median time from arrival to CDS activation was 3.5 hours, and system activation to diagnostic collect was another 8.6 hours.

Severity of Ionized Hypercalcemia and Hypocalcemia Is Associated With Etiology in Dogs and Cats

Background: Calcium disorders are common in small animals, but few studies have investigated the etiology of ionized hypercalcemia and hypocalcemia in large populations. This study aimed to determine the incidence of ionized calcium disorders in dogs and cats treated at a tertiary referral clinic and to describe the associated diseases.

Methods: An electronic database of electrolyte analyses conducted at the Cornell University Hospital for Animals from 2007 to 2017 was searched. Dogs and cats with ionized hypercalcemia or hypocalcemia were identified based on institution reference intervals. Duplicate case entries were removed. Medical records were reviewed to identify the cause of the calcium abnormality. Chi-squared analysis with Bonferroni adjustment was performed to compare frequencies of disease processes between mild and moderate-severe disturbances.

Results: The database included 15,277 dogs and 3,715 cats. Hypercalcemia was identified in 1,641 dogs and 119 cats. The incidence of canine and feline hypercalcemia was 10.7 and 3.2%, respectively. Hypocalcemia was identified in 1,467 dogs and 450 cats. The incidence of canine and feline hypocalcemia was 9.6% and 12.1%, respectively. The most common pathologic causes of hypercalcemia in dogs were malignancy-associated (12.9%), parathyroid-dependent (4.6%) and hypoadrenocorticism (1.7%). In cats, malignancy-associated hypercalcemia (22.7%), kidney injury (13.4%) and idiopathic hypercalcemia (12.6%) were most common. Dogs presenting with moderate-severe hypercalcemia vs. mild hypercalcemia were significantly more likely to have hyperparathyroidism, malignancy-associated hypercalcemia or hypervitaminosis D, whereas cats were significantly more likely to have malignancy-associated hypercalcemia or idiopathic hypercalcemia. The most common pathologic causes of hypocalcemia in dogs were critical illness (17.4%), kidney injury (10.4%) and toxicity (7.5%). In cats, kidney injury (21.6%), urethral obstruction (15.1%), and critical illness (14.7%) were most frequent. Dogs presenting with moderate-severe hypocalcemia were significantly more likely to have hypoparathyroidism, kidney injury, eclampsia or critical illness, whereas cats were significantly more likely to have kidney injury, soft tissue trauma or urethral obstruction.

Conclusions: Mild calcium disturbances are most commonly associated with non-pathologic or transient conditions. Malignancy-associated hypercalcemia is the most common cause of ionized hypercalcemia in dogs and cats. Critical illness and kidney injury are frequent causes of ionized hypocalcemia in both species.

Calcium Administration During Weaning From Cardiopulmonary Bypass: A Narrative Literature Review

The search for safe and effective patient management strategies during weaning from cardiopulmonary bypass is ongoing; intravenous calcium is occasionally used as a first-line drug. The physiologic role of calcium suggests that it can support the function of the cardiovascular system during this critical period. Patients may be mildly hypocalcemic after cardiopulmonary bypass; however, this degree of hypocalcemia does not significantly impair the cardiovascular system. The transient beneficial effects of calcium administration (increase in arterial blood pressure, systemic vascular resistance, cardiac index, stroke volume, and coronary perfusion pressure) might be helpful in cases of moderate contractility reduction or vasoplegia. Nonetheless, effects on clinically relevant endpoints are unknown, and possible systemic side effects, such as transient reduction in internal mammary artery graft flow, attenuation of the effects of β-sympathomimetics, "stone heart" phenomenon, and pancreatic cellular injury, may limit the use of calcium salts. Further studies are needed to expand the understanding of the effects of calcium administration on patient outcomes.

Association of serum total and ionized calcium with all-cause mortality incritically ill patients with acute kidney injury

BACKGROUND

There have been no epidemiological studies exploring the prognostic ability of serum total and ionized calcium (tCa and iCa) in critically ill patients with acute kidney injury (AKI). We assessed the association of admission tCa and iCa concentrations with all-cause mortality in these patients.

METHODS

We extracted clinical data from the MIMIC-III V1.4 database. Only the data for the first intensive care unit (ICU) admission of each patient were used and baseline data were extracted within 24 h after ICU admission. Cox proportional hazards models and subgroup analyses were used to determine the relationship between tCa and iCa concentrations and 30, 90 and 365-day all-cause mortality in critically ill patients with AKI. A total of 10,207 eligible patients were studied. In multivariate analysis, adjusted for age, ethnicity and gender, both low-tCa (< 7.9 mg/dl) and low-iCa (<1.06 mmol/l) concentrations were significant predictors of risk of all-cause mortality. Furthermore, after adjusting for more confounding factors, low-iCa concentrations remained a significant predictor of all-cause mortality at 30 days, 90 days, 365 days (HR, 95% CI: 1.19, 1.06-1.33; 1.15, 1.05-1.27; 1.10, 1.01-1.20).

CONCLUSIONS

Low-iCa concentrations were independent predictors of all-cause mortality in critically ill patients with AKI.

Serum calcium derangements in neonates with moderate to severe hypoxic ischemic encephalopathy and the impact of therapeutic hypothermia: a cohort study

Background: Perinatal hypoxia is a recognized cause of hypocalcemia in neonates in the first 3 days of life. Therapeutic hypothermia (TH) promotes neuroprotection by decreasing calcium influx into the cells during the reperfusion phase thereby increase serum calcium levels. This study examines the trends of serum calcium levels in neonates with hypoxic ischemic encephalopathy (HIE) and the effect of TH.Material and methods: A retrospective cohort study of neonates with moderate to severe HIE admitted to level III neonatal intensive care units (NICU's) in Calgary between September 2011 and October 2015. HIE was staged using modified Sarnat scoring system. Ionized calcium levels were followed in the first 3 days of age.Results: One hundred thirteen neonates admitted with the diagnosis of moderate to severe HIE were included; 89 (79%) underwent TH. Hypercalcemia was significantly higher with TH 57 (64%) compared to 8 (33%) in noncooled group (p = .007). Hypocalcemia was less in TH group; 11 (12%) compared to 5 (21%) in non TH group. Hypo/hypercarbia did not alter the serum calcium levels. Furthermore; there was no increase in the incidence of intracranial hemorrhage, clinical or electrographic seizures, antiepileptic drug use, or hypoxic/ischemic MRI changes with calcium derangements.Conclusion: The incidence of hypocalcemia was reduced by almost half and hypercalcemia was significantly increased with TH in the first 3 days of life. The reduction in hypocalcemia and the increase in hypercalcemia may be attributed to the neuroprotective effect of TH.

Is severe hypocalcemia immediately life-threatening?

Objective

Severe hypocalcemia (Ca <1.9 mmol/L) is often considered an emergency because of a potential risk of cardiac arrest or seizures. However, there is little evidence to support this. The aim of our study was to assess whether severe hypocalcemia was associated with immediately life-threatening cardiac arrhythmias or neurological complications.

Methods

A retrospective observational study was carried out over a 2 years period in the Adult Emergency Department (ED) of Nantes University Hospital. All patients who had a protein-corrected calcium concentration measure were eligible for inclusion. Patients with multiple myeloma were excluded. The primary outcome was the number of life-threatening cardiac arrhythmias and/or neurological complications during the stay in the ED.

Results

A total of 41,823 patients had protein-corrected calcium (pcCa) concentrations measured, 155 had severe hypocalcaemia, 22 were excluded because of myeloma leaving 133 for analysis. Median pcCa concentration was 1.73 mmol/L [1.57-1.84]. Seventeen (12.8%) patients presented a life threatening condition, 14 (10.5%) neurological and 3 (2.2%) cardiac during ED stay. However these complications could be explained by the presence of underlying co-morbidities and or electrolyte disturbances other than hypocalcaemia. Overall 24 (18%) patients died in hospital. Vitamin D deficiency, chronic kidney disease and hypoparathyroidism were the most frequently found causes of hypocalcemia.

Conclusion

13% of patients with severe hypocalcaemia presented a life-threatening cardiac or neurological complication on the ED. However a perfectly valid alternative cause could account for these complications. Further research is warranted to define the precise role of hypocalcaemia.

Calcium is an essential cofactor for metal efflux by the ferroportin transporter family

Ferroportin (Fpn)-the only known cellular iron exporter-transports dietary and recycled iron into the blood plasma, and transfers iron across the placenta. Despite its central role in iron metabolism, our molecular understanding of Fpn-mediated iron efflux remains incomplete. Here, we report that Ca2+ is required for human Fpn transport activity. Whereas iron efflux is stimulated by extracellular Ca2+ in the physiological range, Ca2+ is not transported. We determine the crystal structure of a Ca2+-bound BbFpn, a prokaryotic orthologue, and find that Ca2+ is a cofactor that facilitates a conformational change critical to the transport cycle. We also identify a substrate pocket accommodating a divalent transition metal complexed with a chelator. These findings support a model of iron export by Fpn and suggest a link between plasma calcium and iron homeostasis.

Predictive accuracy of serum total calcium for both critically high and critically low ionized calcium in critical illness

BACKGROUND

The accuracy of total calcium and its corrected value for predicting critically high and critically low ionized calcium in critical illness is controversial. The aim of this study was to investigate whether the concentration of total serum calcium, either corrected for albumin or not, could predict critically high or low values in critical illness.

METHODS

This report describes a retrospective study using the Medical Information Mart for Intensive Care (MIMIC) III database. Test panels that contained serum albumin, total calcium, and ionized calcium (named ATI panels) with order time intervals of less than one hour were extracted. The predictive accuracy of total calcium, either corrected for albumin or not, was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 12 118 ATIs with 103 critically low and 92 critically high ionized calcium results were extracted. The areas under ROC curves (AUCs) of corrected and uncorrected total calcium for predicting critically low ionized calcium were 0.69 (95% CI: 0.61-0.76) and 0.70 (95% CI: 0.63-0.78), respectively. For predicting critically high ionized calcium, the AUCs were 0.98 (95% CI: 0.97-1.00) and 0.97 (95% CI: 0.95-1.00), respectively. With positive predictive values (PPVs) of 0.05 and 0.10, the sensitivities (both corrected and uncorrected) were approximately 0.50 for predicting critically low ionized calcium and 0.95 for predicting critically high ionized calcium.

CONCLUSIONS

Total calcium, either corrected for albumin or not, is not a reliable test to predict critically low ionized calcium in critical illness. Total calcium's predictive accuracy for critically high ionized calcium is high.

Association of Initial Serum Total Calcium Concentration with Mortality in Critical Illness

Background

Several studies have suggested that serum ionized calcium (iCa) is associated with mortality in critical illness. However, evidence regarding the predictive significance of serum total calcium (tCa) in critical illness remains scarce. The aim of this study was to assess the association of tCa levels with mortality in critical illness.

Methods

We employed the MIMIC-III v1.3 database. tCa was measured upon ICU admission and its relationship with mortality was determined using smooth curve fitting. The association between admission tCa levels and hospital mortality was determined using logistic regression.

Results

Inclusion criteria were met by 44,886 critically ill patients. A U-shaped pattern was observed between tCa and hospital mortality. Similar trends were observed for hospital mortality when quintiles were used to group patients according to tCa. In multivariate analysis, adjusted for age and sex, the model indicated that admission tCa levels ⩽7.6mg/dl, 7.7-8.1mg/dl, and ⩾9.0mg/dl were associated with an increase in mortality when compared to the reference level (8.6-9.0mg/dl). However, adjusted for more clinical characteristics, tCa was not associated with hospital mortality.

Conclusions

The relationship between tCa and hospital mortality followed a ''U" shaped curve. tCa had certain prognostic value in critically ill patients, but it had no independent association with hospital mortality.

Association Between Disease Severity and Calcium Concentration in Critically Ill Patients Admitted to Intensive Care Unit

Background

Hypocalcemia is very common in critically ill patients admitted to ICU. However, its clinical importance and relation to patient’s outcome during early days of ICU admission is questionable. Based on the mentioned problem, it seems that calcium assessment is highly important in these patients. The present study aimed at evaluating the relationship between different calcium concentrations (total/ionized/corrected) and disease severity in critically ill patients.

Methods

A total of 100 patients admitted to intensive care units of Imam Reza and Shohada hospitals during Feb 2014 and Apr 2016 were enrolled in this prospective trial. Concentrations of total, corrected, and ionized calcium and their relationship with APACHE score and disease severity were noted during the study.

Results

There was a strong and inverse correlation between disease severity and ionized calcium concentration (P < 0.001, r = -0.697). There was a medium and significant inverse correlation between disease severity and total calcium concentration (P < 0.001, r = -0.368). Weak and direct significant correlation was observed between disease severity and corrected calcium concentration (P 0.02, r = 0.232).

Conclusions

A significant correlation was found between total and ionized calcium, but there was not any significant correlation between corrected and ionized calcium. Hypocalcemia is a predictor of disease severity and mortality. We recommend measuring ionized calcium concentration for patients admitted to ICU.

An investigation of sepsis surveillance and emergency treatment on patient mortality outcomes: An observational cohort study

Objective

To determine the prevalence of initiating the sepsis 3-h bundle of care and estimate effects of bundle completion on risk-adjusted mortality among emergency department (ED) patients screened-in by electronic surveillance.

Materials and Methods

This was a multiple center observational cohort study conducted in 2016. The study population was comprised of patients screened-in by St. John Sepsis Surveillance Agent within 4 h of ED arrival, had a sepsis bundle initiated, and admitted to hospital. We built multivariable logistic regression models to estimate impact of a 3-h bundle completed within 3 h of arrival on mortality outcomes.

Results

Approximately 3% ED patients were screened-in by electronic surveillance within 4 h of arrival and admitted to hospital. Nearly 7 in 10 (69%) patients had a bundle initiated, with most bundles completed within 3 h of arrival. The fully-adjusted risk model achieved good discrimination on mortality outcomes [area under the receiver operating characteristic 0.82, 95% confidence interval (CI) 0.79-0.85] and estimated 34% reduced mortality risk among patients with a bundle completed within 3 h of arrival compared to non-completers.

Discussion

The sepsis bundle is an effective intervention for many vulnerable patients, and likely to be completed within 3 h after arrival when electronic surveillance with reliable alert notifications are integrated into clinical workflow. Beginning at triage, the platform and sepsis program enables identification and management of patients with greater precision, and increases the odds of good outcomes.

Conclusion

Sepsis surveillance and clinical decision support accelerate accurate recognition and stratification of patients, and facilitate timely delivery of health care.

Association of admission serum levels of vitamin D, calcium, Phosphate, magnesium and parathormone with clinical outcomes in neurosurgical ICU patients

To evaluate the association of admission serum levels of 25(OH)D, parathormone and the related electrolytes with severity of illness and clinical outcomes in neurosurgical critically ill patients, serum levels of 25(OH)D, parathormone, calcium, magnesium, and phosphate, along with APACHE II score were measured for 210 patients upon admission. Mean serum 25(OH)D was 21.1 ± 7.4 ng/mL. 25(OH)D deficiency (less than 20 ng/dL) and elevated serum parathormone level were found in 47.6% and 38% of patients respectively. Hypocalcaemia, hypophosphatemia, hypomagnesaemia and hypermagnesaemia were found in 29.5%, %63.8, 41.9% and 27.6% of patients respectively. The APACHE II score was significantly correlated with serum levels of 25(OH)D, parathormone, calcium, and phosphate. Multivariate regression analysis adjusted by other risk factors showed that among all clinical outcomes, admission hypovitaminosis D was associated with longer duration of ICU stay and a high admission of parathormone was associated with in ICU mortality. We concluded that disorders of admission serum levels of 25(OH)D, parathormone, calcium, magnesium, and phosphate are related to the presence of multiple causal factors such as severity of disease and are not independently associated with clinical outcomes. Most often they are normalize spontaneously with resolution of the disease process.

Prediction of Severity of Acute Pancreatitis Using Total Serum Calcium and Albumin-Corrected Calcium: A Prospective Study in Tertiary Center Hospital in Nepal

Introduction

Total calcium (TC) and albumin-corrected calcium (ACC) are easily accessible AP severity tests in the Primary Health Care Center of Nepal. The aim of the study was to evaluate TC and ACC as prognostic severity markers in acute pancreatitis (AP).

Methods

All patients admitted in Tribhuvan University Teaching Hospital with the diagnosis of AP were studied prospectively over a period of one year from January 2015 to January 2016. TC and ACC were measured in the first 24 hours of admission in each patient. The modified Marshall score was determined at admission and at 48 hours and at any point of time during admission as per the need of the patient. Severity of acute pancreatitis was defined as per the Revised Atlanta Classification 2012.

Results

80 patients of AP were included in the study. Among them, 14% were categorized as having severe AP. The mean total calcium was 8.22, 7.51, and 6.98 for mild, moderate, and severe AP, respectively, which was significant at 0.001.

Conclusion

TC and ACC, measured within the first 24 hours, are useful severity predictors in acute pancreatitis.

Biomarkers as predictors of mortality in critically ill patients with solid tumors

Biochemical markers produced by the affected organ or body in response to disease have gained high clinical value due to assess disease development and being excellent predictors of morbidity and mortality. The aim of this study is to analyze different biochemical markers in critically cancer patients and to determine which of them can be used as predictors of mortality. This is a prospective, cross-sectional study conducted at a University Hospital in Porto Alegre - RS. Screening was done to include patients in the study. Serum biochemical markers obtained in the first 24 hours of Intensive Care Unit hospitalization were analyzed. A second review of medical records occurred after three months objected to identify death or Unit discharged. A sample of 130 individuals was obtained (control group n = 65, study group n = 65). In the multivariate model, serum magnesium values ​​OR = 3.97 (1.17; 13.5), presence of neoplasia OR = 2.68 (95% CI 1.13; 6.37) and absence of sepsis OR = 0.31 (95% CI 0.12; 0.79) were robust predictors of mortality. The association of solid tumors, sepsis presence and alteration in serum magnesium levels resulted in an increased chance of mortality in critically ill patients.