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Yao HJ, Yuan Q, Xi CH, Yu C, Du ZY, Chen L, Wu BW, Yang L, Wu G, Hu J. Perioperative Risk Factors Associated with Unplanned Neurological Intensive Care Unit Events Following Elective Infratentorial Brain Tumor Resection. World Neurosurg 2022; 165:e206-e215. [PMID: 35688372 DOI: 10.1016/j.wneu.2022.05.136] [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: 03/17/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Our aim of this study was to identify risk factors and develop a prediction model for unplanned neurological intensive care unit (NICU) events after elective infratentorial brain tumor resection in order to propose an individualized admission to the NICU tailored to patient needs. METHODS Patients admitted to our NICU between September 2018 and May 2021 after elective infratentorial brain tumor resection were reviewed. Prolonged NICU stays and unplanned NICU admissions were defined as unplanned NICU events. The prognostic model of unplanned NICU events was developed using a forward stepwise logistic regression analysis, and external validation was evaluated. The C-statistic was used to assess discrimination, and a smooth, nonparametric calibration line was used to assess calibration graphically in the model. RESULTS Of the 1,710 patients in the development cohort, unplanned NICU events occurred in 162 (9.5%). Based on the lesion type, a Karnofsky Performance Status score <70 at admission, longer duration of surgery, bleeding in the operative area evident on postoperative computed tomography, higher fibrinogen and blood glucose levels at admission, and more intraoperative blood loss were independently associated with unplanned NICU events. The external validation test showed good discrimination (C-statistic = 0.811) and calibration (Hosmer-Lemeshow P = 0.141) for unplanned NICU events. CONCLUSIONS Several patient and operative characteristics are associated with a greater likelihood of the occurrence of unplanned NICU events. In the future, we may be able to provide better help for the resource allocation of NICUs according to these risk factors and prediction models.
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Affiliation(s)
- Hai-Jun Yao
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; National Center for Neurological Disorders, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Cai-Hua Xi
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Chun Yu
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhuo-Ying Du
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; National Center for Neurological Disorders, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Long Chen
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Bi-Wu Wu
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lei Yang
- Department of Neurosurgery & Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Gang Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; National Center for Neurological Disorders, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; National Center for Neurological Disorders, Shanghai, China; Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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Cena T, Cammarota G, Azzolina D, Barini M, Bazzano S, Zagaria D, Negroni D, Castello L, Carriero A, Corte FD, Vaschetto R. Predictors of intubation and mortality in COVID-19 patients: a retrospective study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2021. [PMCID: PMC8626752 DOI: 10.1186/s44158-021-00016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Estimating the risk of intubation and mortality among COVID-19 patients can help clinicians triage these patients and allocate resources more efficiently. Thus, here we sought to identify the risk factors associated with intubation and intra-hospital mortality in a cohort of COVID-19 patients hospitalized due to hypoxemic acute respiratory failure (ARF). Results We included retrospectively a total of 187 patients admitted to the subintensive and intensive care units of the University Hospital “Maggiore della Carità” of Novara between March 1st and April 30th, 2020. Based on these patients’ demographic characteristics, early clinical and laboratory variables, and quantitative chest computerized tomography (CT) findings, we developed two random forest (RF) models able to predict intubation and intra-hospital mortality. Variables independently associated with intubation were C-reactive protein (p < 0.001), lactate dehydrogenase level (p = 0.018) and white blood cell count (p = 0.026), while variables independently associated with mortality were age (p < 0.001), other cardiovascular diseases (p = 0.029), C-reactive protein (p = 0.002), lactate dehydrogenase level (p = 0.018), and invasive mechanical ventilation (p = 0.001). On quantitative chest CT analysis, ground glass opacity, consolidation, and fibrosis resulted significantly associated with patient intubation and mortality. The major predictors for both models were the ratio between partial pressure of arterial oxygen and fraction of inspired oxygen, age, lactate dehydrogenase, C-reactive protein, glycemia, CT quantitative parameters, lymphocyte count, and symptom onset. Conclusions Altogether, our findings confirm previously reported demographic, clinical, hemato-chemical, and radiologic predictors of adverse outcome among COVID-19-associated hypoxemic ARF patients. The two newly developed RF models herein described show an overall good level of accuracy in predicting intra-hospital mortality and intubation in our study population. Thus, their future development and implementation may help not only identify patients at higher risk of deterioration more effectively but also rebalance the disproportion between resources and demand. Supplementary Information The online version contains supplementary material available at 10.1186/s44158-021-00016-5.
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Herttua K, Vork J, Paljarvi T. Does seafarers' limited access to health care increase risk for community-acquired pneumonia requiring hospital care? A longitudinal register-based analysis. Am J Ind Med 2021; 64:639-645. [PMID: 33792929 DOI: 10.1002/ajim.23248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Limited access to medical care can be considered as an occupational risk of seafaring and it may predispose to developing community-acquired pneumonia (CAP) requiring hospital care. We sought to investigate the risk for CAP and other lower respiratory tract infections (LRTI) requiring hospital care among seafarers. We examined the length of hospital stay (LOS) as a proxy for severity of illness. METHODS The study population in this panel data analysis were all seafarers and a 20% random sample of economically active individuals aged 18-65 years who were residing in Denmark in 1997-2016, constituting more than 11 million person-years of follow-up. Annually-registered socio-demographic and work characteristics were linked to data on cause of hospital admissions. We used fixed-effects and zero-truncated Poisson regression to estimate the rate ratios of hospitalization for CAP and other LRTI, and compared LOS across the two populations. RESULTS The adjusted incident rate ratio (IRR) for CAP in seafarers compared to the economically active population was 1.42 (95% confidence interval [CI]: 1.15-1.77), whereas the IRR was 0.73 (95% CI: 0.38-1.42) for other LRTI. For LOS, the IRRs for CAP and other LRTI in seafarers were 1.08 (95% CI: 1.04-1.12) and 0.92 (95% CI: 0.83-1.01), respectively. CONCLUSIONS Our findings indicate that seafaring was associated with an increased risk for CAP requiring hospital care. Limited access to health care may be an important contributing factor.
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Affiliation(s)
- Kimmo Herttua
- Department of Public Health, Center of Maritime Health and Society University of Southern Denmark Esbjerg Denmark
| | - Jan Vork
- Department of Emergency, Radio Medical Denmark Hospital of South West Jutland Denmark
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Peng L, Luo Z, Liang L, Liu M, Meng L, Tan J, Song L, Zhang Y, Wu L. Comparison of the Performance of 24 Early Warning Scores with the Updated National Early Warning Score (NEWS2) for Predicting Unplanned Intensive Care Unit (ICU) Admission in Postoperative Brain Tumor Patients: A Retrospective Study at a Single Center. Med Sci Monit 2021; 27:e929168. [PMID: 33649288 PMCID: PMC7938866 DOI: 10.12659/msm.929168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background There have been few studies to evaluate early warning score (EWS) systems, or track and trigger systems (TTS), to identify early clinical deterioration in patients following brain tumor surgery who are admitted to the Intensive Care Unit (ICU). The National Early Warning Score (NEWS2) is an established method used in the U.K. National Health Service to improve care for in-hospital patients. This retrospective study from a single center aimed to compare the performance of NEWS2 with 24 other types of EWS to evaluate unplanned ICU admissions within 72 h after brain tumor surgery. Material/Methods A total of 326 patients with brain tumors were included in the study. Patients who experienced unplanned ICU transfer after surgery (69 cases) were diagnostically matched with patients who did not require intensive care (257 controls). We collected the physiological variables to calculate the area under the receiver operator characteristic curve (AUROC), sensitivity, specificity, Youden index values, cutoff values, positive predictive values, and negative predictive values. Results The NEWS2 identified postoperative brain tumor patients with AUROC (0.860, p=0.000). The Patient-At-Risk (PAR) score was higher than NEWS2 in terms of AUROC value (0.870, P=0.000), Youden index (0.589 vs 0.542). Conclusions The findings showed that although the NEWS 2 performed well when used to evaluate unplanned ICU admissions within 72 h of postoperative brain tumor patients, the PAR score was also an accurate EWS.
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Affiliation(s)
- Lingli Peng
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China (mainland).,Orthopedics Department, Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Zhen Luo
- Xiangya Nursing School, Central South University, Changsha, Hunan, China (mainland)
| | - Lingling Liang
- Orthopedics Department, Sixth Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Mingming Liu
- Xiangya Nursing School, Central South University, Changsha, Hunan, China (mainland)
| | - Lingyao Meng
- Xiangya Nursing School, Central South University, Changsha, Hunan, China (mainland)
| | - Jianwen Tan
- Department of Organ Transplantation, Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Lili Song
- Xiangya Nursing School, Central South University, Changsha, Hunan, China (mainland)
| | - Yan Zhang
- Xiangya Nursing School, Central South University, Changsha, Hunan, China (mainland)
| | - Lixiang Wu
- Xiangya School of Public Health, Central South University, Changsha, Hunan, China (mainland)
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Smith MD, Fee C, Mace SE, Maughan B, Perkins JC, Kaji A, Wolf SJ. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia. Ann Emerg Med 2021; 77:e1-e57. [PMID: 33349374 DOI: 10.1016/j.annemergmed.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.
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Hourmant Y, Mailloux A, Valade S, Lemiale V, Azoulay E, Darmon M. Impact of early ICU admission on outcome of critically ill and critically ill cancer patients: A systematic review and meta-analysis. J Crit Care 2020; 61:82-88. [PMID: 33157309 DOI: 10.1016/j.jcrc.2020.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Prognostic impact of early ICU admission remains controversial. The aim of this review was to investigate the impact of early ICU admission in the general ICU population and in critically ill cancer patients and to report level of evidences of this later. METHODS Systematic review and meta-analysis performed on articles published between 1970 and 2017. Two authors extracted data. Influence of early ICU admission on mortality is reported as Risk Ratio (95%CI) using both fixed and random-effects model. DATA SYNTHESIS For general ICU population, 31 studies reporting on 73,213 patients were included (including 66,797 patients with early ICU admission) and for critically ill cancer patients 14 studies reporting on 2414 patients (including 1272 with early ICU admission) were included. Early ICU admission was associated with decreased mortality using a random effect model (RR 0.65; 95% confidence interval 0.58-0.73; I2 = 66%) in overall ICU population as in critically ill cancer patients (RR 0.69; 95% confidence interval 0.52-0.90; I2 = 85%). To explore heterogeneity, a meta-regression was performed. Characteristics of the trials (prospective vs. retrospective, monocenter vs. multicenter) had no impact on findings. Publication after 2010 (median publication period) was associated with a lower effect of early ICU admission (estimate 0.37; 95%CI 0.14-0.60; P = 0.002) in the general ICU population. A significant publication bias was observed. CONCLUSION Theses results suggest that early ICU admission is associated with decreased mortality in the general ICU population and in CICP. These results were however obtained from high risk of bias studies and a high heterogeneity was noted. Systematic review registration: PROSPERO 2018 CRD42018094828.
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Affiliation(s)
- Yannick Hourmant
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Arnaud Mailloux
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Sandrine Valade
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Virginie Lemiale
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France; ECSTRA team, Biostatistics and clinical epidemiology, UMR 1153 (center of epidemiology and biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris, France.
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Summary for Clinicians: Clinical Practice Guideline for the Diagnosis and Treatment of Community-acquired Pneumonia. Ann Am Thorac Soc 2020; 17:133-138. [PMID: 31770496 DOI: 10.1513/annalsats.201909-704cme] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2020; 200:e45-e67. [PMID: 31573350 PMCID: PMC6812437 DOI: 10.1164/rccm.201908-1581st] [Citation(s) in RCA: 1750] [Impact Index Per Article: 437.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia. Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions. Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.
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MESH Headings
- Adult
- Ambulatory Care
- Anti-Bacterial Agents/therapeutic use
- Antigens, Bacterial/urine
- Blood Culture
- Chlamydophila Infections/diagnosis
- Chlamydophila Infections/drug therapy
- Chlamydophila Infections/metabolism
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Culture Techniques
- Drug Therapy, Combination
- Haemophilus Infections/diagnosis
- Haemophilus Infections/drug therapy
- Haemophilus Infections/metabolism
- Hospitalization
- Humans
- Legionellosis/diagnosis
- Legionellosis/drug therapy
- Legionellosis/metabolism
- Macrolides/therapeutic use
- Moraxellaceae Infections/diagnosis
- Moraxellaceae Infections/drug therapy
- Moraxellaceae Infections/metabolism
- Pneumonia, Bacterial/diagnosis
- Pneumonia, Bacterial/drug therapy
- Pneumonia, Mycoplasma/diagnosis
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/metabolism
- Pneumonia, Pneumococcal/diagnosis
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/metabolism
- Pneumonia, Staphylococcal/diagnosis
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/metabolism
- Radiography, Thoracic
- Severity of Illness Index
- Sputum
- United States
- beta-Lactams/therapeutic use
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Minimal Impact of Implemented Early Warning Score and Best Practice Alert for Patient Deterioration. Crit Care Med 2019; 47:49-55. [PMID: 30247239 DOI: 10.1097/ccm.0000000000003439] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Previous studies have looked at National Early Warning Score performance in predicting in-hospital deterioration and death, but data are lacking with respect to patient outcomes following implementation of National Early Warning Score. We sought to determine the effectiveness of National Early Warning Score implementation on predicting and preventing patient deterioration in a clinical setting. DESIGN Retrospective cohort study. SETTING Tertiary care academic facility and a community hospital. PATIENTS Patients 18 years old or older hospitalized from March 1, 2014, to February 28, 2015, during preimplementation of National Early Warning Score to August 1, 2015, to July 31, 2016, after National Early Warning Score was implemented. INTERVENTIONS Implementation of National Early Warning Score within the electronic health record and associated best practice alert. MEASUREMENTS AND MAIN RESULTS In this study of 85,322 patients (42,402 patients pre-National Early Warning Score and 42,920 patients post-National Early Warning Score implementation), the primary outcome of rate of ICU transfer or death did not change after National Early Warning Score implementation, with adjusted hazard ratio of 0.94 (0.84-1.05) and 0.90 (0.77-1.05) at our academic and community hospital, respectively. In total, 175,357 best practice advisories fired during the study period, with the best practice advisory performing better at the community hospital than the academic at predicting an event within 12 hours 7.4% versus 2.2% of the time, respectively. Retraining National Early Warning Score with newly generated hospital-specific coefficients improved model performance. CONCLUSIONS At both our academic and community hospital, National Early Warning Score had poor performance characteristics and was generally ignored by frontline nursing staff. As a result, National Early Warning Score implementation had no appreciable impact on defined clinical outcomes. Refitting of the model using site-specific data improved performance and supports validating predictive models on local data.
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Launders N, Ryan D, Winchester CC, Skinner D, Konduru PR, Price DB. Management Of Community-Acquired Pneumonia: An Observational Study In UK Primary Care. Pragmat Obs Res 2019; 10:53-65. [PMID: 31576189 PMCID: PMC6765344 DOI: 10.2147/por.s211198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/23/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose In primary care, initial diagnosis of community-acquired pneumonia (CAP) is made on clinical judgment without radiological confirmation or knowledge of the causative organism. Use of CRB65 score has been recommended for assessing the severity of CAP and thereby determining clinical management, but it is not known how frequently these scores are used in primary care. Patients and methods Primary care consultations in adults with a diagnostic code for CAP between 1 January 2009 and 31 December 2016 were extracted from the Optimum Patient Care Research Database, which at the time of data extraction had over 3.4 million patients in the UK. Episodes without antibiotic prescription on day of diagnosis were excluded, as were records describing past events. Patients admitted to hospital on day of diagnosis were excluded, but were included in exploratory analysis of CRB65 recording. Results In total, 4734 episodes of CAP in adults managed in primary care between 1 January 2009 and 31 December 2016 were included. A range of investigations/observations were recorded, including pulse rate (10.7%), chest examinations (9.1%) and blood tests (5.4%). CRB65 scores were recorded in 19 (0.4%) episodes of CAP, 17 of which were after the publication of the NICE guidelines in December 2014. CRB65 recording was no more frequent in 3819 episodes referred to hospital (12, 0.3%; p=0.63), but where recorded, CRB65 scores were higher (Median: 1.0 [interquartile range: 0.5–1.0] vs 2.0 [interquartile range: 1.0–2.0], p=0.04). The most commonly prescribed antibiotic was amoxicillin (40.3%), and 85.9% of episodes had a prescription length of seven days. Conclusion CRB65 scores are seldom recorded in UK primary care. Given that these scores are embedded in UK guidelines, further work is required to assess feasibility and barriers to use of CRB65 scores in primary care.
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Affiliation(s)
| | - Dermot Ryan
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School, Edinburgh EH8 9AG, Scotland
| | | | - Derek Skinner
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | | | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
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Peyrony O, Chevret S, Meert AP, Perez P, Kouatchet A, Pène F, Mokart D, Lemiale V, Demoule A, Nyunga M, Bruneel F, Lebert C, Benoit D, Mirouse A, Azoulay E. Direct admission to the intensive care unit from the emergency department and mortality in critically ill hematology patients. Ann Intensive Care 2019; 9:110. [PMID: 31578641 PMCID: PMC6775178 DOI: 10.1186/s13613-019-0587-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/21/2019] [Indexed: 01/06/2023] Open
Abstract
Background The aim of this study was to assess the benefit of direct ICU admission from the emergency department (ED) compared to admission from wards, in patients with hematological malignancies requiring critical care. Methods Post hoc analysis derived from a prospective, multicenter cohort study of 1011 critically ill adult patients with hematologic malignancies admitted to 17 ICU in Belgium and France from January 2010 to May 2011. The variable of interest was a direct ICU admission from the ED and the outcome was in-hospital mortality. The association between the variable of interest and the outcome was assessed by multivariable logistic regression after multiple imputation of missing data. Several sensitivity analyses were performed: complete case analysis, propensity score matching and multivariable Cox proportional-hazards analysis of 90-day survival. Results Direct ICU admission from the ED occurred in 266 (26.4%) cases, 84 of whom (31.6%) died in the hospital versus 311/742 (41.9%) in those who did not. After adjustment, direct ICU admission from the ED was associated with a decreased in-hospital mortality (adjusted OR: 0.63; 95% CI 0.45–0.88). This was confirmed in the complete cases analysis (adjusted OR: 0.64; 95% CI 0.45–0.92) as well as in terms of hazard of death within the 90 days after admission (adjusted HR: 0.77; 95% CI 0.60–0.99). By contrast, in the propensity score-matched sample of 402 patients, direct admission was not associated with in-hospital mortality (adjusted OR: 0.92; 95% CI 0.84–1.01). Conclusions In this study, patients with hematological malignancies admitted to the ICU were more likely to be alive at hospital discharge if they were directly admitted from the ED rather than from the wards. Assessment of early predictors of poor outcome in cancer patients admitted to the ED is crucial so as to allow early referral to the ICU and avoid delays in treatment initiation and mis-orientation.
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Affiliation(s)
- Olivier Peyrony
- Emergency Department, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France.
| | - Sylvie Chevret
- Biostatistics and Medical Information Department, Hôpital Saint-Louis, Paris, France.,Centre de Recherche en Épidémiologie et Statistiques - Université de Paris (CRESS-INSERM-UMR1153), Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team, Paris, France.,Université de Paris, Paris, France
| | - Anne-Pascale Meert
- Intensive Care Unit, Institut Jules Bordet, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Pierre Perez
- Intensive Care Unit, Hôpital Brabois, Vandoeuvre Les Nancy, France
| | - Achille Kouatchet
- Intensive Care Unit, Centre hospitalier régional universitaire, Angers, France
| | - Frédéric Pène
- Université de Paris, Paris, France.,Intensive Care Unit, Hôpital Cochin, Paris, France.,Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris, France
| | - Djamel Mokart
- Intensive Care Unit, Institut Paoli Calmettes, Marseille, France
| | | | - Alexandre Demoule
- Intensive Care Unit, Hôpital Pitié-Salpêtrière, Paris, France.,INSERM, UMRS 1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,Université Paris Sorbonne, Paris, France
| | - Martine Nyunga
- Intensive Care Unit, Hôpital Victor Provo, Roubaix, France
| | - Fabrice Bruneel
- Intensive Care Unit, Hôpital André Mignot, Versailles, France
| | - Christine Lebert
- Intensive Care Unit, Centre hospitalier départemental Vendee, La Roche Sur Yon, France
| | - Dominique Benoit
- Intensive Care Unit, Hôpital universitaire de Ghent, Ghent, Belgium
| | | | - Elie Azoulay
- Centre de Recherche en Épidémiologie et Statistiques - Université de Paris (CRESS-INSERM-UMR1153), Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team, Paris, France.,Université de Paris, Paris, France.,Intensive Care Unit, Hôpital Saint-Louis, Paris, France
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Tanzella G, Motos A, Battaglini D, Meli A, Torres A. Optimal approaches to preventing severe community-acquired pneumonia. Expert Rev Respir Med 2019; 13:1005-1018. [PMID: 31414915 DOI: 10.1080/17476348.2019.1656531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Community-acquired pneumonia (CAP) has the highest rate of mortality of all infectious diseases, especially among the elderly. Severe CAP (sCAP) is defined as a CAP in which intensive care management is required and is associated with an unfavorable clinical course. Areas covered: This review aims to identify prevention strategies for reducing the incidence of CAP and optimized management of sCAP. We highlight the main prevention approaches for CAP, focusing on the latest vaccination plans and on the influence of health-risk behaviors. Lastly, we report the latest recommendations about the optimal approach for sCAP when CAP has already been diagnosed, including prompt admission to ICU, early empirical antibiotic therapy, and optimization of antibiotic use. Expert opinion: Despite improvements in the diagnosis and treatment of sCAP, more efforts are needed to combat preventable causes, including the implementation and improvement of vaccine coverage, anti-tobacco campaigns and correct oral hygiene. Moreover, future research should aim to assess the benefits of early antimicrobial therapy in primary care. Pharmacokinetic studies in the target population may help clinicians to adjust dosage regimens in critically ill patients with CAP and thus reduce rates of treatment failure.
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Affiliation(s)
- Giacomo Tanzella
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Department of Surgical Sciences and Integrated Diagnostics (DISC), San Martino Policlinico Hospital , Genoa , Italy
| | - Ana Motos
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer , Barcelona , Spain.,Faculty of Medicine, University of Barcelona , Barcelona , Spain
| | - Denise Battaglini
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Department of Surgical Sciences and Integrated Diagnostics (DISC), San Martino Policlinico Hospital , Genoa , Italy
| | - Andrea Meli
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,University of Milan , Milan , Italy
| | - Antoni Torres
- Division of Animal Experimentation, Department of Pulmonary and Critical Care Medicine, Hospital Clinic , Barcelona , Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias , Madrid , Spain.,Institut d'Investigacions Biomèdiques August Pi I Sunyer , Barcelona , Spain.,Faculty of Medicine, University of Barcelona , Barcelona , Spain
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Knapik P, Knapik M, Trejnowska E, Kłaczek B, Śmietanka K, Cieśla D, Krzych ŁJ, Kucewicz EM. Should we admit more patients not requiring invasive ventilation to reduce excess mortality in Polish intensive care units? Data from the Silesian ICU Registry. Arch Med Sci 2019; 15:1313-1320. [PMID: 31572479 PMCID: PMC6764313 DOI: 10.5114/aoms.2019.84401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/03/2019] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Mortality in Polish intensive care units (ICU) is excessively high. Only a few patients do not require intubation and invasive ventilation throughout the whole ICU treatment period. We aimed to define this population, as pre-emptive admissions of such patients may increase the population which benefits from ICU admission and reduce excessive mortality in Polish ICUs. MATERIAL AND METHODS Data on 20 651 patients from the Silesian Registry of Intensive Care Units were analysed. Patients who did not require intubation and invasive ventilation (referred to as non-ventilated patients) were identified and compared to the remaining ICU population. Independent variables that influence being non-intubated in the ICU were identified. RESULTS Among 20 368 analyzed adult patients, only 1233 (6.1%) were in the non-ventilated group. Non-ventilated patients were younger, with fewer comorbidities and a lower APACHE II score at admission (13.0 ±7.1 vs. 23.7 ±8.6 points, p < 0.001). Patients with cardiac arrest prior to admission were particularly rare in this group (2.6% vs. 26.8%, p < 0.001). The ICU mortality among non-ventilated patients was 6 to 7 times lower (7.0% vs. 46.7%, p < 0.001). Independent variables that influenced the ICU stay in non-ventilated patients were: obstetric complications as the primary cause of ICU admission, presence of a systemic autoimmune disease, invasive monitoring as the primary cause of ICU admission, ICU readmission and the presence of cancer. CONCLUSIONS Non-ventilated patients have a high potential for a favourable outcome. Pre‑emptive ICU admissions have a potential to reduce mortality in Polish ICUs.
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Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Małgorzata Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Ewa Trejnowska
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Bogumiła Kłaczek
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Konstanty Śmietanka
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science, Education and New Medical Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Łukasz J. Krzych
- Department of Anaesthesiology and Intensive Care, School of Medicine, Medical University of Silesia, Katowice, Poland
| | - Ewa M. Kucewicz
- Department of Anaesthesiology and Intensive Care, School of Medicine, Medical University of Silesia, Katowice, Poland
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Impact of Lymphocyte and Neutrophil Counts on Mortality Risk in Severe Community-Acquired Pneumonia with or without Septic Shock. J Clin Med 2019; 8:jcm8050754. [PMID: 31137863 PMCID: PMC6572378 DOI: 10.3390/jcm8050754] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Community-acquired pneumonia (CAP) is a frequent cause of death worldwide. As recently described, CAP shows different biological endotypes. Improving characterization of these endotypes is needed to optimize individualized treatment of this disease. The potential value of the leukogram to assist prognosis in severe CAP has not been previously addressed. Methods: A cohort of 710 patients with CAP admitted to the intensive care units (ICUs) at Hospital of Mataró and Parc Taulí Hospital of Sabadell was retrospectively analyzed. Patients were split in those with septic shock (n = 304) and those with no septic shock (n = 406). A single blood sample was drawn from all the patients at the time of admission to the emergency room. ICU mortality was the main outcome. Results: Multivariate analysis demonstrated that lymphopenia <675 cells/mm3 or <501 cells/mm3 translated into 2.32- and 3.76-fold risk of mortality in patients with or without septic shock, respectively. In turn, neutrophil counts were associated with prognosis just in the group of patients with septic shock, where neutrophils <8850 cells/mm3 translated into 3.6-fold risk of mortality. Conclusion: lymphopenia is a preserved risk factor for mortality across the different clinical presentations of severe CAP (sCAP), while failing to expand circulating neutrophils counts beyond the upper limit of normality represents an incremental immunological failure observed just in those patients with the most severe form of CAP, septic shock.
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Intensive Care Unit Admission and Survival among Older Patients with Chronic Obstructive Pulmonary Disease, Heart Failure, or Myocardial Infarction. Ann Am Thorac Soc 2018; 14:943-951. [PMID: 28208030 DOI: 10.1513/annalsats.201611-847oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
RATIONALE Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown. OBJECTIVES To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI). METHODS We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs. RESULTS Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P < 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P < 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD. CONCLUSIONS ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs.
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16
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Hadfield J, Bennett L. Determining best outcomes from community-acquired pneumonia and how to achieve them. Respirology 2017; 23:138-147. [PMID: 29150897 DOI: 10.1111/resp.13218] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
Community-acquired pneumonia (CAP) is a common acute medical illness with a standard, effective treatment that was introduced before the evidenced-based medicine era. Mortality rates have improved in recent decades but improvements have been minimal when compared to other conditions such as acute coronary syndromes. The standardized approach to treatment makes CAP a target for comparative performance and outcome measures. While easy to collect, simplistic outcomes such as mortality, readmission and length of stay are difficult to interpret as they can be affected by subjective choices and health care resources. Proposed clinical- and patient-reported outcomes are discussed below and include measures such as the time to clinical stability (TTCS) and patient satisfaction, which can be compared between health institutions. Strategies to improve these outcomes include use of a risk stratification tool, local antimicrobial guidelines with antibiotic stewardship and care bundles to include early administration of antibiotics and early mobilization.
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Affiliation(s)
- Jane Hadfield
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Lesley Bennett
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
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17
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Legionnaires' Disease Complicated with Rhabdomyolysis and Acute Kidney Injury in an AIDS Patient. Case Rep Infect Dis 2017; 2017:8051096. [PMID: 29109879 PMCID: PMC5646314 DOI: 10.1155/2017/8051096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/22/2017] [Accepted: 09/05/2017] [Indexed: 12/19/2022] Open
Abstract
Objective To present a case of an uncommon triad of Legionella pneumonia, rhabdomyolysis, and renal failure, with review of the relevant literature. Case A 51-year-old with a history of human immunodeficiency virus (HIV), chronic obstructive pulmonary disease (COPD), and hypertension presented with fever, cough, and shortness of breath over four days. Chest X-ray showed consolidation in left lower lung field; urine was positive for Legionella antigen and myoglobin; creatine kinase was 51092U/L; creatine was 6.9 mg/dL, and his CD4 count was 41 cells/ul. He was managed with azithromycin and levofloxacin and further required dialysis and ventilatory support in the intensive care unit due to renal failure and respiratory failure. He responded well to the treatment and made a complete recovery. Legionella pneumophila infection is a recognized but rare cause of rhabdomyolysis with high morbidity and mortality when there is extrapulmonary involvement. Early diagnosis and appropriate treatment is essential to improve outcomes. Conclusion Physicians should consider Legionella pneumonia in patients with rhabdomyolysis, renal failure, and respiratory symptoms. Early diagnosis and treatment have been shown to have good clinical response. Timely intensive care management, together with early and judicious use of dialysis in patients complicated with rhabdomyolysis and renal failure, may lead to good outcomes.
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Phua J, Dean NC, Guo Q, Kuan WS, Lim HF, Lim TK. Severe community-acquired pneumonia: timely management measures in the first 24 hours. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:237. [PMID: 27567896 PMCID: PMC5002335 DOI: 10.1186/s13054-016-1414-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.
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Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nathan C Dean
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Salt Lake City, UT, USA
| | - Qi Guo
- Department of Respiratory Medicine, Affiliated Futian Hospital, Guangdong Medical College, Shenzhen, Guangdong, China.,Guangzhou Institute of Respiratory Diseases (State Key Laboratory of Respiratory Diseases), First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui Fang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tow Keang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, National University Health System, Tower Block, Level 10, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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19
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Burgos J, Los-Arcos I, Álvarez de la Sierra D, Falcó V, Aguiló A, Sánchez I, Almirante B, Martinez-Gallo M. Determination of neutrophil CD64 expression as a prognostic biomarker in patients with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis 2016; 35:1411-6. [PMID: 27240938 DOI: 10.1007/s10096-016-2678-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
The expression of CD64 in neutrophils (nCD64) has shown utility in the diagnosis of sepsis. The aim of this study was to assess the usefulness of nCD64 expression to identify patients with community-acquired pneumonia (CAP) at risk of a poor outcome. A prospective study of nCD64 expression (determined by flow cytometry) in patients with CAP was performed. The sensitivity/specificity of nCD64 in predicting poor outcome [defined as intensive care unit (ICU) admission and/or clinical deterioration after arrival at the emergency department] was calculated. Eighty-three adults with CAP were included; 14.5 % had septic shock, 19.3 % required ICU admission, and 10.8 % presented clinical deterioration after admission. The mean of the median fluorescence intensity (MFI) of nCD64 expression was 1140 (±1097). Patients with nCD64 expression ≥2700 MFI had more clinical deterioration (36.4 vs. 7.2 %, p = 0.015) and more ICU admission (45.5 vs. 14.5 %, p = 0.028). To identify clinical deterioration and ICU admission, nCD64 expression showed a sensitivity of 44.4 and 33.3 % and a specificity of 90.1 and 90.8 %, respectively. The addition of nCD64 expression to the Pneumonia Severity Index and CURB-65 severity scores did not improve the accuracy of predicting these outcomes. Although nCD64 expression is associated with an increased risk of ICU admission or clinical deterioration after admission, its accuracy in predicting these poor outcomes is modest and does not significantly improve the predictive ability of the PSI and CURB-65 severity scores.
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Affiliation(s)
- J Burgos
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Catalonia, Spain.
| | - I Los-Arcos
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Catalonia, Spain
| | - D Álvarez de la Sierra
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
| | - V Falcó
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Catalonia, Spain
| | - A Aguiló
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain
| | - I Sánchez
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Catalonia, Spain
| | - B Almirante
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Catalonia, Spain
| | - M Martinez-Gallo
- Immunology Division, Hospital Universitari Vall d'Hebron (HUVH), Vall d'Hebron Research Institute (VHIR), Barcelona, Catalonia, Spain.,Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain
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Abstract
BACKGROUND There has been a dramatic increase in the use of intensive care units (ICUs) over the past 25 years. Greater use of validated measures of illness severity may better inform ICU admission decisions in patients with community-acquired pneumonia. This article examined predictors of ICU admission and hospitalization costs, including the pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥65 years) scores. METHODS The study identified 422 patients hospitalized for community-acquired pneumonia, ascertaining patient characteristics by chart review and extraction of administrative data. Multivariate logistic regression was performed to quantify the association of the PSI, CURB-65 and comorbidities with ICU admission. The predictors of cost were estimated using a generalized linear model. RESULTS Compared to 194 general medicine patients, certain clinical and radiographic findings were more common among 228 ICU patients. Compared to PSI reference group I/II/III, ICU admission was strongly associated with risk class IV (odds ratio [OR], 3.06; 95% confidence interval [CI], 1.63-5.72) and V (OR, 4.84; CI, 2.44-9.62), and also CURB-65 ≥3 (OR, 2.90; CI, 1.51-5.56). The relative increase in mortality among PSI risk class V (compared to IV) patients was 2.68 times higher in general medicine, compared with the ICU. Among ICU admissions, risk class V was associated with an additional cost of $14,548 (95% CI, $4,232 to $24,864). CONCLUSIONS Illness severity and chronic pulmonary disease are strong predictors of ICU admission. More extensive use of the PSI may optimize site-of-care decisions, thereby minimizing mortality and unnecessary resource utilization.
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21
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Chen YX, Li CS. Lactate on emergency department arrival as a predictor of mortality and site-of-care in pneumonia patients: a cohort study. Thorax 2015; 70:404-10. [PMID: 25716454 DOI: 10.1136/thoraxjnl-2014-206461] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 02/06/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the predictive performance of lactate, CURB-65, and a combination of lactate and CURB-65 (LAC-CURB-65) for mortality, hospitalisation and intensive care unit (ICU) admission in pneumonia patients in the emergency department (ED). METHODS Consecutive adult patients with pneumonia presenting from January 2012 to May 2014 were divided into low-, moderate- and high-risk groups according to lactate (<2.0, 2.0-4.0, >4.0 mmol/L), CURB-65 (≤1, 2, ≥3) and LAC-CURB-65 (patients with two low risks, any moderate risk, any high risk) values. Mortality, hospitalisation and ICU admission rates were compared between risk classes. RESULTS Of 1641 patients, 861 (53%) were hospitalised (38% to a general ward, 15% to the ICU) while the remaining 780 (47%) were treated as outpatients or observed in the ED. 547/1641 (33%) patients died within 28 days. Lactate and CURB-65 were higher in patients who died, were hospitalised or were admitted to the ICU compared with patients who were not (p<0.001). Lactate and CURB-65 independently predicted outcomes. The performance of lactate in predicting 28-day mortality, hospitalisation and ICU admission was higher than that of CURB-65 (p<0.01). For LAC-CURB-65, patients at low or moderate risk had mortality rates of 2% and 14%, respectively, and hospitalisation rates of 15% and 40%, respectively, while none were admitted to ICU. Patients at high risk had the highest mortality (52%), hospitalisation (70%) and ICU admission rates (27%). CONCLUSIONS Lactate is superior to CURB-65 in predicting mortality, hospitalisation and ICU admission in pneumonia patients in the ED. LAC-CURB-65 significantly improved the predictive value of CURB-65.
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Affiliation(s)
- Yun-Xia Chen
- Emergency Department of Beijing Chao-Yang Hospital, Affiliated to Capital Medical University, Beijing, China
| | - Chun-Sheng Li
- Emergency Department of Beijing Chao-Yang Hospital, Affiliated to Capital Medical University, Beijing, China
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22
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Shiloh AL, Ari Eisen L, Savel RH. The unplanned intensive care unit admission. J Crit Care 2014; 30:419-20. [PMID: 25579373 DOI: 10.1016/j.jcrc.2014.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 12/18/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Ariel L Shiloh
- Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, NY.
| | - Lewis Ari Eisen
- Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, NY, NY
| | - Richard H Savel
- Division of Critical Care Medicine, Department of Surgery, Albert Einstein College of Medicine, Maimonides Medical Center, NY, NY
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Time to intubation is associated with outcome in patients with community-acquired pneumonia. PLoS One 2013; 8:e74937. [PMID: 24069367 PMCID: PMC3777932 DOI: 10.1371/journal.pone.0074937] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 08/06/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction It has been suggested that delayed intensive care unit (ICU) transfer is associated with increased mortality for patients with community-acquired pneumonia (CAP). However, ICU admission policies and patient epidemiology vary widely across the world depending on local hospital practices and organizational constraints. We hypothesized that the time from the onset of CAP symptoms to invasive mechanical ventilation could be a relevant prognostic factor. Methods One hundred patients with a CAP and necessitating invasive mechanical ventilation were included. Prospectively collected data were retrospectively analysed. Two study groups were identified based on the time of the initiation of invasive mechanical ventilation (rapid respiratory failure requiring mechanical ventilation within 72 h of the onset of CAP and progressive respiratory failure requiring invasive mechanical ventilation 4 or more days after the onset of CAP). Results Excepting more COPD patients in the rapid respiratory failure group and more patients with diabetes in the progressive respiratory failure group, these patients had similar characteristics. The overall in-hospital mortality rate was 28% in the rapid respiratory failure group and 51% in the progressive respiratory failure group (P = 0.03). The ICU and the day 30 mortality rates were higher in the progressive respiratory failure group (47% vs. 23%, P = 0.02; and 37.7% vs. 21.3%, P = 0.03; respectively). After adjusting for the propensity score and other potential confounding factors, progressive respiratory failure remained associated with hospital mortality only after 12 days of invasive mechanical ventilation. Conclusions This study suggested that the duration or delay in the time to intubation from the onset of CAP symptoms was associated with the outcomes in those patients who ultimately required invasive mechanical ventilation.
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Emergency Department and Inpatient Community-Acquired Pneumonia: Practical Decision Making and Management Issues. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Labarère J, Schuetz P, Renaud B, Claessens YE, Albrich W, Mueller B. Validation of a clinical prediction model for early admission to the intensive care unit of patients with pneumonia. Acad Emerg Med 2012; 19:993-1003. [PMID: 22978725 DOI: 10.1111/j.1553-2712.2012.01424.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The Risk of Early Admission to the Intensive Care Unit (REA-ICU) index is a clinical prediction model that was derived based on 4,593 patients with community-acquired pneumonia (CAP) for predicting early admission to the intensive care unit (ICU; i.e., within 3 days following emergency department [ED] presentation). This study aimed to validate the REA-ICU index in an independent sample. METHODS The authors retrospectively stratified 850 CAP patients enrolled in a multicenter prospective randomized trial conducted in Switzerland, using the REA-ICU index, alternate clinical prediction models of severe pneumonia (SMART-COP, CURXO-80, and the 2007 IDSA/ATS minor severity criteria), and pneumonia severity assessment tools (the Pneumonia Severity Index [PSI] and CURB-65). RESULTS The rate of early ICU admission did not differ between the validation and derivation samples within each risk class of the REA-ICU index, ranging from 1.1% to 1.8% in risk class I to 27.1% to 27.6% in risk class IV. The areas under the receiver operating characteristic (ROC) curve were 0.76 (95% confidence interval [CI] = 0.70 to 0.83) and 0.80 (95% CI = 0.77 to 0.83) in the validation and derivation samples, respectively. In the validation sample, the REA-ICU index performed better than the pneumonia severity assessment tools, but failed to demonstrate an accuracy advantage over alternate prediction models in predicting ICU admission. CONCLUSIONS The REA-ICU index reliably stratifies CAP patients into four categories of increased risk for early ICU admission within 3 days following ED presentation. Further research is warranted to determine whether inflammatory biomarkers may improve the performance of this clinical prediction model.
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Affiliation(s)
- José Labarère
- Quality of Care Unit, Grenoble University Hospital, Grenoble, France.
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