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Carr JR, Knox DB, Butler AM, Lum MM, Jacobs JR, Jephson AR, Jones BE, Brown SM, Dean NC. ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support. Crit Care Med 2024; 52:e132-e141. [PMID: 38157205 PMCID: PMC10922756 DOI: 10.1097/ccm.0000000000006163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission. DESIGN Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial. SETTING Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho. PATIENTS Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission. INTERVENTIONS After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP). MEASUREMENTS AND MAIN RESULTS The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03). CONCLUSIONS Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.
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Affiliation(s)
- Jason R Carr
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Daniel B Knox
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Allison M Butler
- Intermountain Healthcare Statistical Data Center, Salt Lake City, UT
| | | | - Jason R Jacobs
- Intermountain Healthcare, Enterprise Data Analytics, Salt Lake City, UT
| | - Al R Jephson
- Intermountain Healthcare, Enterprise Data Analytics, Salt Lake City, UT
| | - Barbara E Jones
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Nathan C Dean
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Hart JH, Sakata T, Eve JR, Butler AM, Wallin A, Carman C, Atwood B, Srivastava R, Jones BE, Stenehjem EA, Dean NC. Diagnosis and Treatment of Pneumonia in Urgent Care Clinics: Opportunities for Improving Care. Open Forum Infect Dis 2024; 11:ofae096. [PMID: 38456194 PMCID: PMC10919392 DOI: 10.1093/ofid/ofae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024] Open
Abstract
Background Community-acquired pneumonia is a well-studied condition; yet, in the urgent care setting, patient characteristics and adherence to guideline-recommended care are poorly described. Within Intermountain Health, a nonprofit integrated US health care system based in Utah, more patients present to urgent care clinics (UCCs) than emergency departments (EDs) for pneumonia care. Methods We performed a retrospective cohort study 1 January 2019 through 31 December 2020 in 28 UCCs within Utah. We extracted electronic health record data for patients aged ≥12 years with ICD-10 pneumonia diagnoses entered by the bedside clinician, excluding patients with preceding pneumonia within 30 days or missing vital signs. We compared UCC patients with radiographic pneumonia (n = 4689), without radiographic pneumonia (n = 1053), without chest imaging (n = 1472), and matched controls with acute cough/bronchitis (n = 15 972). Additional outcomes were 30-day mortality and the proportion of patients with ED visits or hospital admission within 7 days after the index encounter. Results UCC patients diagnosed with pneumonia and possible/likely radiographic pneumonia by radiologist report had a mean age of 40 years and 52% were female. Almost all patients with pneumonia (93%) were treated with antibiotics, including those without radiographic confirmation. Hospital admissions and ED visits within 7 days were more common in patients with radiographic pneumonia vs patients with "unlikely" radiographs (6% vs 2% and 10% vs 6%, respectively). Observed 30-day all-cause mortality was low (0.26%). Patients diagnosed without chest imaging presented similarly to matched patients with cough/acute bronchitis. Most patients admitted to the hospital the same day after the UCC visit (84%) had an interim ED encounter. Pneumonia severity scores (pneumonia severity index, electronic CURB-65, and shock index) overestimated patient need for hospitalization. Conclusions Most UCC patients with pneumonia were successfully treated as outpatients. Opportunities to improve care include clinical decision support for diagnosing pneumonia with radiographic confirmation and development of pneumonia severity scores tailored to the UCC.
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Affiliation(s)
- James H Hart
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Theadora Sakata
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
- Healthcare Delivery Institute, Intermountain Health, Murray, Utah, USA
| | - Jacqueline R Eve
- Enterprise Analytics, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Allison M Butler
- Office of Research, Intermountain Medical Center, Murray, Utah, USA
| | - Anthony Wallin
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Chad Carman
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Brenda Atwood
- Intermountain Healthcare, Intermountain Instacare, Salt Lake City, Utah, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Murray, Utah, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Barbara E Jones
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Disease, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Nathan C Dean
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
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Shi X, Shi Y, Fan L, Yang J, Chen H, Ni K, Yang J. Prognostic value of oxygen saturation index trajectory phenotypes on ICU mortality in mechanically ventilated patients: a multi-database retrospective cohort study. J Intensive Care 2023; 11:59. [PMID: 38031107 PMCID: PMC10685672 DOI: 10.1186/s40560-023-00707-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Heterogeneity among critically ill patients undergoing invasive mechanical ventilation (IMV) treatment could result in high mortality rates. Currently, there are no well-established indicators to help identify patients with a poor prognosis in advance, which limits physicians' ability to provide personalized treatment. This study aimed to investigate the association of oxygen saturation index (OSI) trajectory phenotypes with intensive care unit (ICU) mortality and ventilation-free days (VFDs) from a dynamic and longitudinal perspective. METHODS A group-based trajectory model was used to identify the OSI-trajectory phenotypes. Associations between the OSI-trajectory phenotypes and ICU mortality were analyzed using doubly robust analyses. Then, a predictive model was constructed to distinguish patients with poor prognosis phenotypes. RESULTS Four OSI-trajectory phenotypes were identified in 3378 patients: low-level stable, ascending, descending, and high-level stable. Patients with the high-level stable phenotype had the highest mortality and fewest VFDs. The doubly robust estimation, after adjusting for unbalanced covariates in a model using the XGBoost method for generating propensity scores, revealed that both high-level stable and ascending phenotypes were associated with higher mortality rates (odds ratio [OR]: 1.422, 95% confidence interval [CI] 1.246-1.623; OR: 1.097, 95% CI 1.027-1.172, respectively), while the descending phenotype showed similar ICU mortality rates to the low-level stable phenotype (odds ratio [OR] 0.986, 95% confidence interval [CI] 0.940-1.035). The predictive model could help identify patients with ascending or high-level stable phenotypes at an early stage (area under the curve [AUC] in the training dataset: 0.851 [0.827-0.875]; AUC in the validation dataset: 0.743 [0.709-0.777]). CONCLUSIONS Dynamic OSI-trajectory phenotypes were closely related to the mortality of ICU patients requiring IMV treatment and might be a useful prognostic indicator in critically ill patients.
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Affiliation(s)
- Xiawei Shi
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Yangyang Shi
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Liming Fan
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Hao Chen
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kaiwen Ni
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Junchao Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China.
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Comparison of the Performance of the CURB-65, A-DROP, and NEWS Scores for the Prediction of Clinical Outcomes in Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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High mortality among hospitalized adult patients with COVID-19 pneumonia in Peru: A single centre retrospective cohort study. PLoS One 2022; 17:e0265089. [PMID: 35259196 PMCID: PMC8903290 DOI: 10.1371/journal.pone.0265089] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/22/2022] [Indexed: 12/15/2022] Open
Abstract
Background Peru is the country with the world’s highest COVID-19 death rate per capita. Characteristics associated with increased mortality among adult patients with COVID-19 pneumonia in this setting are not well described. Methods Retrospective, single-center cohort study including 1537 adult patients hospitalized with a diagnosis of SARS-CoV-2 pneumonia between May 2020 and August 2020 at a national hospital in Lima, Peru. The primary outcome measure was in-hospital mortality. Results In-hospital mortality was 49.71%. The mean age was 60 ± 14.25 years, and 68.38% were males. We found an association between mortality and inflammatory markers, mainly leukocytes, D-dimer, lactate dehydrogenase, C-reactive protein and ferritin. A multivariate model adjusted for age, hypertension, diabetes mellitus, and corticosteroid use demonstrated that in-hospital mortality was associated with greater age (RR: 2.01, 95%CI: 1.59–2.52) and a higher level of oxygen requirement (RR: 2.77, 95%CI: 2.13–3.62). Conclusions: In-hospital mortality among COVID-19 patients in Peru is high and is associated with greater age and higher oxygen requirements.
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Carr JR, Jones BE, Collingridge DS, Webb BJ, Vines C, Zobell B, Allen TL, Srivastava R, Rubin J, Dean NC. Deploying an Electronic Clinical Decision Support Tool for Diagnosis and Treatment of Pneumonia Into Rural and Critical Access Hospitals: Utilization, Effect on Processes of Care, and Clinician Satisfaction. J Rural Health 2022; 38:262-269. [PMID: 33244803 PMCID: PMC8149487 DOI: 10.1111/jrh.12543] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE Electronic clinical decision support (CDS) for treatment of community-acquired pneumonia (ePNa) is associated with improved guideline adherence and decreased mortality. How rural providers respond to CDS developed for urban hospitals could shed light on extending CDS to resource-limited settings. METHODS ePNa was deployed into 10 rural and critical access hospital emergency departments (EDs) in Utah and Idaho in 2018. We reviewed pneumonia cases identified through ICD-10 codes after local deployment to measure ePNa utilization and guideline adherence. ED providers were surveyed to assess quantitative and qualitative aspects of satisfaction. FINDINGS ePNa was used in 109/301 patients with pneumonia (36%, range 0%-67% across hospitals) and was associated with appropriate antibiotic selection (93% vs 65%, P < .001). Fifty percent of survey recipients responded, 87% were physicians, 87% were men, and the median ED experience was 10 years. Mean satisfaction with ePNa was 3.3 (range 1.7-4.8) on a 5-point Likert scale. Providers with a favorable opinion of ePNa were more likely to favor implementation of additional CDS (P = .005). Satisfaction was not associated with provider type, age, years of experience or experience with ePNa. Ninety percent of respondents provided qualitative feedback. The most common theme in high and low utilization hospitals was concern about usability. Compared to high utilization hospitals, low utilization hospitals more frequently identified concerns about adaptation for local needs. CONCLUSIONS ePNa deployment to rural and critical access EDs was moderately successful and associated with improved antibiotic use. Concerns about usability and adapting ePNa for local use predominated the qualitative feedback.
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Affiliation(s)
- Jason R. Carr
- University of Utah School of Medicine, Department of Medicine, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Salt Lake City, Utah
| | - Barbara E. Jones
- University of Utah School of Medicine, Department of Medicine, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Salt Lake City, Utah,Salt Lake City Veterans Affairs Health Care System, Salt Lake City, Utah
| | | | - Brandon J. Webb
- Intermountain Health Care, Division of Infectious Diseases, Salt Lake City, Utah
| | - Caroline Vines
- LDS Hospital, Department of Emergency Medicine, Salt Lake City, Utah
| | - Blake Zobell
- Senior Medical Director for Intermountain Rural Hospitals, Richfield, Utah
| | - Todd L. Allen
- Intermountain Healthcare Delivery Institute, Murray, Utah
| | - Rajendu Srivastava
- Intermountain Healthcare Delivery Institute, Murray, Utah,University of Utah School of Medicine, Department of Pediatrics, Division of Inpatient Medicine, Salt Lake City, Utah
| | - Jenna Rubin
- Department of Emergency Medicine, Intermountain Medical Center, Murray, Utah
| | - Nathan C. Dean
- University of Utah School of Medicine, Department of Medicine, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Salt Lake City, Utah,Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
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Abstract
Supplemental Digital Content is available in the text. Pao2 is the gold standard to assess acute hypoxic respiratory failure, but it is only routinely available by intermittent spot checks, precluding any automatic continuous analysis for bedside tools.
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Assessment of the SpO 2/FiO 2 ratio as a tool for hypoxemia screening in the emergency department. Am J Emerg Med 2021; 44:116-120. [PMID: 33588251 PMCID: PMC7865090 DOI: 10.1016/j.ajem.2021.01.092] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 11/21/2022] Open
Abstract
Objective We assessed the performance of the ratio of peripheral arterial oxygen saturation to the inspired fraction of oxygen (SpO2/FiO2) to predict the ratio of partial pressure arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) among patients admitted to our emergency department (ED) during the SARS-CoV-2 outbreak. Methods We retrospectively studied patients admitted to an academic-level ED in France who were undergoing a joint measurement of SpO2 and arterial blood gas. We compared SpO2 with SaO2 and evaluated performance of the SpO2/FiO2 ratio for the prediction of 300 and 400 mmHg PaO2/FiO2 cut-off values in COVID-19 positive and negative subgroups using receiver-operating characteristic (ROC) curves. Results During the study period from February to April 2020, a total of 430 arterial samples were analyzed and collected from 395 patients. The area under the ROC curves of the SpO2/FiO2 ratio was 0.918 (CI 95% 0.885–0.950) and 0.901 (CI 95% 0.872–0.930) for PaO2/FiO2 thresholds of 300 and 400 mmHg, respectively. The positive predictive value (PPV) of an SpO2/FiO2 threshold of 350 for PaO2/FiO2 inferior to 300 mmHg was 0.88 (CI95% 0.84–0.91), whereas the negative predictive value (NPV) of the SpO2/FiO2 threshold of 470 for PaO2/FiO2 inferior to 400 mmHg was 0.89 (CI95% 0.75–0.96). No significant differences were found between the subgroups. Conclusions The SpO2/FiO2 ratio may be a reliable tool for hypoxemia screening among patients admitted to the ED, particularly during the SARS-CoV-2 outbreak.
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Noninvasive SpO2/FiO2 ratio as surrogate for PaO2/FiO2 ratio during simulated prolonged field care and ground and high-altitude evacuation. J Trauma Acute Care Surg 2021; 89:S126-S131. [PMID: 32744837 DOI: 10.1097/ta.0000000000002744] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diagnosis of lung injury requires invasive blood draws to measure oxygen tension in blood. This capability is nonexistent in austere settings and during prolonged field care (PFC), that is, medical care characterized by inability to evacuate casualties from the point of injury for up to 72 hours. We analyzed pulse-oximeter-derived noninvasive SpO2 and assessed the SpO2/FiO2 ratio (SFR) as a surrogate for the PaO2/FiO2 ratio (PFR), an accepted marker of lung function. We hypothesized that SFR is a suitable surrogate for PFR in a data set from animal models of combat-relevant trauma, PFC, and aeromedical evacuation. METHODS Data from anesthetized swine (N = 30) subjected to combat relevant trauma, resuscitation, and critical care interventions were analyzed. Pairwise correlations and Bland-Altman and regression analyses were performed to compare PFR and SFR, based on averaged SpO2 values obtained from two monitoring devices. RESULTS We performed 683 pairwise correlations. SpO2/FiO2 ratio was numerically higher than PFR with a 313 cutoff values for acute respiratory distress syndrome (ARDS) (PFR ≥300). Sensitivity/specificity for detection of mild ARDS was 75%/73% with a 200 to 300 PFR range corresponding to 252 to 312 SFR range. For moderate ARDS, sensitivity/specificity was 61%/93% with a 100 to 200 PFR range corresponding to 191 to 251 SFR range. For severe ARDS, sensitivity/specificity was 49%/97% with a 0 to 100 PFR range corresponding to 0 to 190 SFR range. For all groups, areas under the receiver operating characteristic curves ranged from 0.76 to 0.98. CONCLUSION SpO2/FiO2 ratio is a useful surrogate for PFR when arterial blood gas testing is not available during dynamically changing physiologic conditions, for example, during austere conditions, PFC, or aeromedical evacuation, and may permit early detection of casualties in need of lung-specific life-saving interventions. Studies in critically ill humans are warranted.
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Dewar ZE, Kirchner HL, Rittenberger JC. Risk factors for unplanned ICU admission after emergency department holding orders. J Am Coll Emerg Physicians Open 2020; 1:1623-1629. [PMID: 33392571 PMCID: PMC7771770 DOI: 10.1002/emp2.12203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 11/30/2022] Open
Abstract
STUDY HYPOTHESIS Emergency department (ED) holding orders are used in an effort to streamline patient flow. Little research exists on the safety of this practice. Here, we report on prevalence and risk factors for upgrade of medical admissions to ICU for whom holding orders were written. METHODS Retrospective review of holding order admissions through our ED for years 2013-2018. Pregnancy, prisoner, pediatric, surgical, and ICU admissions were excluded, as were transfers from other hospitals. Risk factors of interest included vital signs, physiologic data, laboratory markers, sequential organ failure assessment (SOFA), Quick SOFA (qSOFA), modified early warning (MEWS) scores, and Charlson Comorbidity Index (CCI). Primary outcome was ICU transfer within 24 hours of admission. Analysis was completed using multivariable logistic regression. RESULTS Between 2013 and 2018, the ED had 203,374 visits. Approximately 20% (N = 54,915) were admitted, 23% of whom had holding orders (N = 12,680). A minority of those with a holding order were transferred to the ICU within 24 hours (N = 79; 0.62%). Those transferred to ICU had increased heart and respiratory rate, P/F ratio, and increased oxygen need. They also had higher MEWS, quick SOFA (qSOFA), and SOFA scores. Multivariable logistic regression demonstrated a significant association between ICU admission and FiO2 (odds ratio [OR] 1.47; 95% confidence interval [CI] 1.25-1.74), MEWS (OR 1.31; 95% CI 1.14-1.52), SOFA Score (OR 1.19; 95% CI 1.05-1.35), and gastrointestinal (OR 3.25; 95% CI: 1.50-7.03) or other combined diagnosis (OR 2.19; CI: 1.07-4.48) (P = 0.0017). CONCLUSION Holding orders are used for >20% of all admissions and <1% of those admissions required transfer to ICU within 24 hours.
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Affiliation(s)
- Zachary E. Dewar
- Department of Emergency Medicine, Emergency Medicine ResidencyGuthrie/Robert Packer HospitalSayrePennsylvaniaUSA
| | - H. Lester Kirchner
- Department of Population Health SciencesGeisinger ClinicSayrePennsylvaniaUSA
| | - Jon C. Rittenberger
- Department of Emergency Medicine, Emergency Medicine ResidencyGuthrie/Robert Packer HospitalSayrePennsylvaniaUSA
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Lee JR, Jung YK, Kim HJ, Koh Y, Lim CM, Hong SB, Huh JW. Derivation and validation of modified early warning score plus SpO2/FiO2 score for predicting acute deterioration of patients with hematological malignancies. Korean J Intern Med 2020; 35:1477-1488. [PMID: 32114753 PMCID: PMC7652654 DOI: 10.3904/kjim.2018.438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/22/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND/AIMS Scoring systems play an important role in predicting intensive care unit (ICU) admission or estimating the risk of death in critically ill patients with hematological malignancies. We evaluated the modified early warning score (MEWS) for predicting ICU admissions and in-hospital mortality among at-risk patients with hematological malignancies and developed an optimized MEWS. METHODS We retrospectively analyzed derivation cohort patients with hematological malignancies who were managed by a medical emergency team (MET) in the general ward and prospectively validated the data. We compared the traditional MEWS with the MEWS plus SpO2/FiO2 (MEWS_SF) score, which were calculated at the time of MET contact. RESULTS In the derivation cohort, the areas under the receiver-operating characteristic (AUROC) curves were 0.81 for the MEWS (95% confidence interval [CI], 0.76 to 0.87) and 0.87 for the MEWS_SF score (95% CI, 0.87 to 0.92) for predicting ICU admission. The AUROC curves were 0.70 for the MEWS (95% CI, 0.63 to 0.77) and 0.76 for the MEWS_SF score (95% CI, 0.70 to 0.83) for predicting in-hospital mortality. In the validation cohort, the AUROC curves were 0.71 for the MEWS (95% CI, 0.66 to 0.77) and 0.83 for the MEWS_SF score (95% CI, 0.78 to 0.87) for predicting ICU admission. The AUROC curves were 0.64 for the MEWS (95% CI, 0.57 to 0.70) and 0.74 for the MEWS_SF score (95% CI, 0.69 to 0.80) for predicting in-hospital mortality. CONCLUSION Compared to the traditional MEWS, the MEWS_SF score may be a useful tool that can be used in the general ward to identify deteriorating patients with hematological malignancies.
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Affiliation(s)
- Ju-Ry Lee
- Medical Emergency Team, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Kyoung Jung
- Medical Emergency Team, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Jin Won Huh, M.D. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3985 Fax: +82-2-3010-6968 E-mail:
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Liljedahl Prytz K, Prag M, Fredlund H, Magnuson A, Sundqvist M, Källman J. Antibiotic treatment with one single dose of gentamicin at admittance in addition to a β-lactam antibiotic in the treatment of community-acquired bloodstream infection with sepsis. PLoS One 2020; 15:e0236864. [PMID: 32730359 PMCID: PMC7392313 DOI: 10.1371/journal.pone.0236864] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/16/2020] [Indexed: 12/29/2022] Open
Abstract
Background Combination therapy in the treatment of sepsis, especially the value of combining a β-Lactam antibiotic with an aminoglycoside, has been discussed. This retrospective cohort study including patients with sepsis or septic shock aimed to investigate whether one single dose of gentamicin at admittance (SGA) added to β-Lactam antibiotic could result in a lower risk of mortality than β-Lactam monotherapy, without exposing the patient to the risk of nephrotoxicity. Methods and findings All patients with positive blood cultures were evaluated for participation (n = 1318). After retrospective medical chart review, a group of patients with community-acquired sepsis with positive blood cultures who received β-Lactam antibiotic with or without the addition of SGA (n = 399) were included for the analysis. Mean age was 74.6 yrs. (range 19–98) with 216 (54%) males. Sequential Organ Failure Assessment score (SOFA score) median was 3 (interquartile range [IQR] 2–5) and the median Charlson Comorbidity Index for the whole group was 2 (IQR 1–3). Sixty-seven (67) patients (17%) had septic shock. The 28-day mortality in the combination therapy group was 10% (20 of 197) and in the monotherapy group 22% (45 of 202), adjusted HR 3.5 (95% CI (1.9–6.2), p = < 0.001. No significant difference in incidence of acute kidney injury (AKI) was detected. Conclusion This retrospective observational study including patients with community-acquired sepsis or septic shock and positive blood cultures, who meet Sepsis-3 criteria, shows that the addition of one single dose of gentamicin to β-lactam treatment at admittance was associated with a decreased risk of mortality and was not associated with AKI. This antibiotic regime may be an alternative to broad-spectrum antibiotic treatment of community-acquired sepsis. Further prospective studies are warranted to confirm these results.
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Affiliation(s)
- Karolina Liljedahl Prytz
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- * E-mail:
| | - Mårten Prag
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Hans Fredlund
- Department of Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Martin Sundqvist
- Department of Clinical Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jan Källman
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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13
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Hayek AJ, Scott V, Yau P, Zolfaghari K, Goldwater M, Almquist J, Arroliga AC, Ghamande S. Bedside risk stratification for mortality in patients with acute respiratory failure treated with noninvasive ventilation. Proc AMIA Symp 2020; 33:172-177. [PMID: 32313455 DOI: 10.1080/08998280.2020.1729612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 10/24/2022] Open
Abstract
Our hypothesis was that patients managed with noninvasive ventilation (NIV) on the wards could be risk-stratified with initial pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratios and tidal volumes (Vte). A prospective study of consecutive patients with acute respiratory failure requiring NIV on the wards was conducted. A multivariate logistic regression model and a negative binomial regression model were used. A total of 403 patients (55.8% women) had a mean age of 65.0 ± 14.9 years with a mean body mass index of 32.1 ± 11.1 kg/m2. The 28-day mortality was 14.1%, and the intubation rate was 16.1%. Pneumonia was associated with the highest 28-day mortality (22.5%) and rate of intubation (36.7%) when compared with chronic obstructive pulmonary disease (4.4% and 7.3%) or congestive heart failure (22.2% and 13.4%). The SpO2/FiO2 groups were <214 (26.6%), 214 -357 (66.0%), and ≥357 (7.4%). Those in the SpO2/FiO2 < 214 group had a higher 28-day mortality rate (odds ratio [OR] = 8.19; 95% confidence interval [CI] 1.02 -65.7), intubation rate (OR = 3.7; 95% CI 1.1 -12.1), intensive care unit admission rate (OR = 2.9; 95% CI 1.2 -7.4), and length of stay (relative risk = 2.0; 95% CI 1.3 -3.0). A Vte/predicted body weight <7.7 mL/kg was associated with increased intubations (OR = 3.1; 95% CI 1.3 -7.4), intensive care unit admissions (OR = 2.5; 95% CI 1.3 -4.6), and 30-day readmissions (OR = 2.9; 95% CI 1.2 -6.8). In conclusion, in patients without acute respiratory distress syndrome who had acute respiratory failure managed with noninvasive ventilation on the wards, severe hypoxemia as assessed by a simple SpO2/FiO2 ≤ 214 was associated with poor outcomes.
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Affiliation(s)
- Adam J Hayek
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott & White Health and Texas A&M University Health Sciences CenterTempleTexas
| | - Vincent Scott
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott & White Health and Texas A&M University Health Sciences CenterTempleTexas
| | - Peter Yau
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott & White Health and Texas A&M University Health Sciences CenterTempleTexas
| | - Kiumars Zolfaghari
- Center for Applied Health Research, Baylor Scott & White HealthTempleTexas
| | - Matthew Goldwater
- Respiratory Therapy Department, Baylor Scott & White HealthTempleTexas
| | - Julie Almquist
- Respiratory Therapy Department, Baylor Scott & White HealthTempleTexas
| | - Alejandro C Arroliga
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott & White Health and Texas A&M University Health Sciences CenterTempleTexas
| | - Shekhar Ghamande
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott & White Health and Texas A&M University Health Sciences CenterTempleTexas
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14
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Gadrey SM, Lau CE, Clay R, Rhodes GT, Lake DE, Moore CC, Voss JD, Moorman JR. Imputation of partial pressures of arterial oxygen using oximetry and its impact on sepsis diagnosis. Physiol Meas 2019; 40:115008. [PMID: 31652430 DOI: 10.1088/1361-6579/ab5154] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The ratio of the partial pressure of arterial oxygen to fraction of inspired oxygen is a key component of the sequential organ failure assessment score that operationally defines sepsis. But, it is calculated infrequently due to the need for the acquisition of an arterial blood gas. So, we sought to find an optimal imputation strategy for the estimation of sepsis-defining hypoxemic respiratory failure using oximetry instead of an arterial blood gas. APPROACH We retrospectively studied a sample of non-intubated acute-care patients with oxygen saturation recorded ⩽10 min before arterial blood sampling (N = 492 from 2013-2017). We imputed ratios of the partial pressure of arterial oxygen to the fraction of inspired oxygen and sepsis criteria from existing imputation equations (Hill, Severinghaus-Ellis, Rice, and Pandharipande) and compared them with the ratios and sepsis criteria measured from arterial blood gases. We devised a modified model-based equation to eliminate the bias of the results. MAIN RESULTS Hypoxemia severity estimates from the Severinghaus-Ellis equation were more accurate than those from other existing equations, but showed significant proportional bias towards under-estimation of hypoxemia severity, especially at oxygen saturations >96%. Our modified equation eliminated bias and surpassed others on all imputation quality metrics. SIGNIFICANCE Our modified imputation equation, [Formula: see text] is the first one that is free of bias at all oxygen saturations. It resulted in ratios of partial pressure of arterial oxygen to fraction of inspired oxygen and sepsis respiratory criteria closest to those obtained by arterial blood gas testing and is the optimal imputation strategy for non-intubated acute-care patients.
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Affiliation(s)
- Shrirang M Gadrey
- PO Box 800901, Charlottesville, VA 22908, United States of America. Author to whom any correspondence should be addressed
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15
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Webb BJ, Sorensen J, Jephson A, Mecham I, Dean NC. Broad-spectrum antibiotic use and poor outcomes in community-onset pneumonia: a cohort study. Eur Respir J 2019; 54:13993003.00057-2019. [PMID: 31023851 DOI: 10.1183/13993003.00057-2019] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/01/2019] [Indexed: 01/29/2023]
Abstract
QUESTION Is broad-spectrum antibiotic use associated with poor outcomes in community-onset pneumonia after adjusting for confounders? METHODS We performed a retrospective, observational cohort study of 1995 adults with pneumonia admitted from four US hospital emergency departments. We used multivariable regressions to investigate the effect of broad-spectrum antibiotics on 30-day mortality, length of stay, cost and Clostridioides difficile infection (CDI). To address indication bias, we developed a propensity score using multilevel (individual provider) generalised linear mixed models to perform inverse-probability of treatment weighting (IPTW) to estimate the average treatment effect in the treated. We also manually reviewed a sample of mortality cases for antibiotic-associated adverse events. RESULTS 39.7% of patients received broad-spectrum antibiotics, but drug-resistant pathogens were recovered in only 3%. Broad-spectrum antibiotics were associated with increased mortality in both the unweighted multivariable model (OR 3.8, 95% CI 2.5-5.9; p<0.001) and IPTW analysis (OR 4.6, 95% CI 2.9-7.5; p<0.001). Broad-spectrum antibiotic use by either analysis was also associated with longer hospital stay, greater cost and increased CDI. Healthcare-associated pneumonia was not associated with mortality independent of broad-spectrum antibiotic use. In manual review we identified antibiotic-associated events in 17.5% of mortality cases. CONCLUSION Broad-spectrum antibiotics appear to be associated with increased mortality and other poor outcomes in community-onset pneumonia.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, USA
| | - Jeff Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Al Jephson
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Ian Mecham
- Division of Pulmonary and Critical Care, Utah Valley Regional Medical Center, Intermountain Healthcare, Provo, UT, USA
| | - Nathan C Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Pulmonary Medicine, University of Utah, Salt Lake City, UT, USA
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16
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Yajnik V, Breslin KM, Riley C. Acute Respiratory Distress in the Operating Room and Prone Ventilation: A Case Report. A A Pract 2019; 12:19-21. [PMID: 30004910 DOI: 10.1213/xaa.0000000000000832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There have been many advances in the management of acute respiratory distress syndrome, a condition which Bellani et al, in the LUNG SAFE trial (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure), found represents up to 10.4% of intensive care unit admissions and 23.4% of patients requiring mechanical ventilation, with an unadjusted intensive care unit and hospital mortality of 35.3% and 40%, respectively. Studies have shown that prone positioning can improve oxygenation in patients who are mechanically ventilated for acute respiratory distress syndrome. This case report describes an example in which intraoperative prone positioning improved oxygenation in a patient after aspiration of gastric contents on induction of general anesthesia.
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Affiliation(s)
- Vishal Yajnik
- From the Department of Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, Virginia
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17
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Antibiotic Use and Outcomes After Implementation of the Drug Resistance in Pneumonia Score in ED Patients With Community-Onset Pneumonia. Chest 2019; 156:843-851. [PMID: 31077649 DOI: 10.1016/j.chest.2019.04.093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/19/2019] [Accepted: 04/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To guide rational antibiotic selection in community-onset pneumonia, we previously derived and validated a novel prediction tool, the Drug-Resistance in Pneumonia (DRIP) score. In 2015, the DRIP score was integrated into an existing electronic pneumonia clinical decision support tool (ePNa). METHODS We conducted a quasi-experimental, pre-post implementation study of ePNa with DRIP score (2015) vs ePNa with health-care-associated pneumonia (HCAP) logic (2012) in ED patients admitted with community-onset pneumonia to four US hospitals. Using generalized linear models, we used the difference-in-differences method to estimate the average treatment effect on the treated with respect to ePNa with DRIP score on broad-spectrum antibiotic use, mortality, hospital stay, and cost, adjusting for available patient-level confounders. RESULTS We analyzed 2,169 adult admissions: 1,122 in 2012 and 1,047 in 2015. A drug-resistant pathogen was recovered in 3.2% of patients in 2012 and 2.8% in 2015; inadequate initial empirical antibiotics were prescribed in 1.1% and 0.5%, respectively (P = .12). A broad-spectrum antibiotic was administered in 40.1% of admissions in 2012 and 33.0% in 2015 (P < .001). Vancomycin days of therapy per 1,000 patient days in 2012 were 287.3 compared with 238.8 in 2015 (P < .001). In the primary analysis, the average treatment effect among patients using the DRIP score was a reduction in broad-spectrum antibiotic use (OR, 0.62; 95% CI, 0.39-0.98; P = .039). However, the average effects for ePNa with DRIP on mortality, length of stay, and cost were not statistically significant. CONCLUSIONS Electronic calculation of the DRIP score was more effective than HCAP criteria for guiding appropriate broad-spectrum antibiotic use in community-onset pneumonia.
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18
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Intra-operative high inspired oxygen fraction does not increase the risk of postoperative respiratory complications. Eur J Anaesthesiol 2019; 36:320-326. [DOI: 10.1097/eja.0000000000000980] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Leopold SJ, Ghose A, Plewes KA, Mazumder S, Pisani L, Kingston HWF, Paul S, Barua A, Sattar MA, Huson MAM, Walden AP, Henwood PC, Riviello ED, Schultz MJ, Day NPJ, Kumar Dutta A, White NJ, Dondorp AM. Point-of-care lung ultrasound for the detection of pulmonary manifestations of malaria and sepsis: An observational study. PLoS One 2018; 13:e0204832. [PMID: 30540757 PMCID: PMC6291079 DOI: 10.1371/journal.pone.0204832] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 09/14/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Patients with severe malaria or sepsis are at risk of developing life-threatening acute respiratory distress syndrome (ARDS). The objective of this study was to evaluate point-of-care lung ultrasound as a novel tool to determine the prevalence and early signs of ARDS in a resource-limited setting among patients with severe malaria or sepsis. MATERIALS AND METHODS Serial point-of-care lung ultrasound studies were performed on four consecutive days in a planned sub study of an observational cohort of patients with malaria or sepsis in Bangladesh. We quantified aeration patterns across 12 lung regions. ARDS was defined according to the Kigali Modification of the Berlin Definition. RESULTS Of 102 patients enrolled, 71 had sepsis and 31 had malaria. Normal lung ultrasound findings were observed in 44 patients on enrolment and associated with 7% case fatality. ARDS was detected in 10 patients on enrolment and associated with 90% case fatality. All patients with ARDS had sepsis, 4 had underlying pneumonia. Two patients developing ARDS during hospitalisation already had reduced aeration patterns on enrolment. The SpO2/FiO2 ratio combined with the number of regions with reduced aeration was a strong prognosticator for mortality in patients with sepsis (AUROC 91.5% (95% Confidence Interval: 84.6%-98.4%)). CONCLUSIONS This study demonstrates the potential usefulness of point-of-care lung ultrasound to detect lung abnormalities in patients with malaria or sepsis in a resource-constrained hospital setting. LUS was highly feasible and allowed to accurately identify patients at risk of death in a resource limited setting.
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Affiliation(s)
- Stije J. Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Aniruddha Ghose
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Katherine A. Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Subash Mazumder
- Department of Radiology, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Luigi Pisani
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hugh W. F. Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sujat Paul
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Anupam Barua
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - M. Abdus Sattar
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Michaëla A. M. Huson
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrew P. Walden
- Department of Intensive Care, Royal Berkshire Hospital, Reading, United Kingdom
| | - Patricia C. Henwood
- Department of Emergency Medicine, Brigham and Woman’s Hospital, Boston, Massachusetts, United States of America
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Marcus J. Schultz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Asok Kumar Dutta
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M. Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Fimognari FL, Rizzo M, Cuccurullo O, Cristiano G, Ricchio R, Ricci C, Iorio C, Borrelli E. High‐flow nasal cannula oxygen therapy for acute respiratory failure in a non‐intensive geriatric setting. Geriatr Gerontol Int 2018; 18:1652-1653. [DOI: 10.1111/ggi.13557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/18/2018] [Accepted: 10/08/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Filippo Luca Fimognari
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Massimo Rizzo
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Olga Cuccurullo
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Giovanna Cristiano
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Roberto Ricchio
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Consalvo Ricci
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Claudio Iorio
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
| | - Eugenio Borrelli
- Unit of Geriatrics, Department of Internal MedicineAzienda Ospedaliera di Cosenza Cosenza Italy
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21
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Smart L, Bosio E, Macdonald SP, Dull R, Fatovich DM, Neil C, Arendts G. Glycocalyx biomarker syndecan-1 is a stronger predictor of respiratory failure in patients with sepsis due to pneumonia, compared to endocan. J Crit Care 2018; 47:93-98. [DOI: 10.1016/j.jcrc.2018.06.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 05/22/2018] [Accepted: 06/14/2018] [Indexed: 12/20/2022]
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22
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Hypoxemia in the ICU: prevalence, treatment, and outcome. Ann Intensive Care 2018; 8:82. [PMID: 30105416 PMCID: PMC6089859 DOI: 10.1186/s13613-018-0424-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/02/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Information is limited regarding the prevalence, management, and outcome of hypoxemia among intensive care unit (ICU) patients. We assessed the prevalence and severity of hypoxemia in ICU patients and analyzed the management and outcomes of hypoxemic patients. METHODS This is a multinational, multicenter, 1-day point prevalence study in 117 ICUs during the spring of 2016. All patients hospitalized in an ICU on the day of the study could be enrolled. Hypoxemia was defined as a PaO2/FiO2 ratio ≤ 300 mmHg and classified as mild (PaO2/FiO2 between 300 and 201), moderate (PaO2/FiO2 between 200 and 101), and severe (PaO2/FiO2 ≤ 100 mmHg). RESULTS Of 1604 patients included, 859 (54%, 95% CI 51-56%) were hypoxemic, 51% with mild (n = 440), 40% with moderate (n = 345), and 9% (n = 74) with severe hypoxemia. Among hypoxemic patients, 61% (n = 525) were treated with invasive ventilation, 10% (n = 84) with non-invasive ventilation, 5% (n = 45) with high-flow oxygen therapy, 22% (n = 191) with standard oxygen, and 1.6% (n = 14) did not receive oxygen. Protective ventilation was widely used in invasively ventilated patients. Twenty-one percent of hypoxemic patients (n = 178) met criteria for acute respiratory distress syndrome (ARDS) including 65 patients (37%) with mild, 82 (46%) with moderate, and 31 (17%) with severe ARDS. ICU mortality was 27% in hypoxemic patients and significantly differed according to severity: 21% in mild, 26% in moderate, and 50% in patients with severe hypoxemia, p < 0.001. Multivariate Cox regression identified moderate and severe hypoxemia as independent factors of ICU mortality compared to mild hypoxemia (adjusted hazard ratio 1.38 [1.00-1.90] and 2.65 [1.69-4.15], respectively). CONCLUSIONS Hypoxemia affected more than half of ICU patients in this 1-day point prevalence study, but only 21% of patients had ARDS criteria. Severity of hypoxemia was an independent risk factor of mortality among hypoxemic patients. Trial registration NCT 02722031.
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23
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Cinesi-Gómez C, García-García P, López-Pelayo I, Giménez J, González-Torres L, Bernal-Morell E. Correlación entre la saturación de oxihemoglobina por pulsioximetría y la presión arterial de oxígeno en pacientes con insuficiencia respiratoria aguda. Rev Clin Esp 2017; 217:522-525. [DOI: 10.1016/j.rce.2017.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/14/2017] [Accepted: 08/12/2017] [Indexed: 10/18/2022]
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24
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Correlation between oxyhaemoglobin saturation by pulse oximetry and partial pressure of oxygen in patients with acute respiratory failure. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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25
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Pisani L, Roozeman JP, Simonis FD, Giangregorio A, van der Hoeven SM, Schouten LR, Horn J, Neto AS, Festic E, Dondorp AM, Grasso S, Bos LD, Schultz MJ. Risk stratification using SpO 2/FiO 2 and PEEP at initial ARDS diagnosis and after 24 h in patients with moderate or severe ARDS. Ann Intensive Care 2017; 7:108. [PMID: 29071429 PMCID: PMC5656507 DOI: 10.1186/s13613-017-0327-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 10/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We assessed the potential of risk stratification of ARDS patients using SpO2/FiO2 and positive end-expiratory pressure (PEEP) at ARDS onset and after 24 h. METHODS We used data from a prospective observational study in patients admitted to a mixed medical-surgical intensive care unit of a university hospital in the Netherlands. Risk stratification was by cutoffs for SpO2/FiO2 and PEEP. The primary outcome was in-hospital mortality. Patients with moderate or severe ARDS with a length of stay of > 24 h were included in this study. Patients were assigned to four predefined risk groups: group I (SpO2/FiO2 ≥ 190 and PEEP < 10 cm H2O), group II (SpO2/FiO2 ≥ 190 and PEEP ≥ 10 cm), group III (SpO2/FiO2 < 190 and PEEP < 10 cm H2O) and group IV (SpO2/FiO2 < 190 and PEEP ≥ 10 cm H2O). RESULTS The analysis included 456 patients. SpO2/FiO2 and PaO2/FiO2 had a strong relationship (P < 0.001, R 2 = 0.676) that could be described in a linear regression equation (SpO2/FiO2 = 42.6 + 1.0 * PaO2/FiO2). Risk stratification at initial ARDS diagnosis resulted in groups that had no differences in in-hospital mortality. Risk stratification at 24 h resulted in groups with increasing mortality rates. The association between group assignment at 24 h and outcome was confounded by several factors, including APACHE IV scores, arterial pH and plasma lactate levels, and vasopressor therapy. CONCLUSIONS In this cohort of patients with moderate or severe ARDS, SpO2/FiO2 and PaO2/FiO2 have a strong linear relationship. In contrast to risk stratification at initial ARDS diagnosis, risk stratification using SpO2/FiO2 and PEEP after 24 h resulted in groups with worsening outcomes. Risk stratification using SpO2/FiO2 and PEEP could be practical, especially in resource-limited settings.
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Affiliation(s)
- Luigi Pisani
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. .,Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Jan-Paul Roozeman
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Fabienne D Simonis
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Antonio Giangregorio
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sophia M van der Hoeven
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Laura R Schouten
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Pediatrics, Academic Medical Center, Amsterdam, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Emir Festic
- Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Arjen M Dondorp
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Salvatore Grasso
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Lieuwe D Bos
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands.,Department of Pulmonology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands.,Mahidol-Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Matsunami K, Tomita K, Touge H, Sakai H, Yamasaki A, Shimizu E. Physical Signs and Clinical Findings Before Death in Ill Elderly Patients. Am J Hosp Palliat Care 2017; 35:712-717. [DOI: 10.1177/1049909117733661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Keiji Matsunami
- Department of Palliative Care Medicine, Yonago Medical Centre, Yonago, Japan
| | - Katsuyuki Tomita
- Depertment of Respiratory Medicine, Yonago Medical Centre, Yonago, Japan
| | - Hirokazu Touge
- Depertment of Respiratory Medicine, Yonago Medical Centre, Yonago, Japan
| | - Hiromitsu Sakai
- Depertment of Respiratory Medicine, Yonago Medical Centre, Yonago, Japan
| | - Akira Yamasaki
- Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Eiji Shimizu
- Division of Medical Oncology and Molecular Respirology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Tottori, Japan
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Nonlinear Imputation of PaO2/FIO2 From SpO2/FIO2 Among Mechanically Ventilated Patients in the ICU: A Prospective, Observational Study. Crit Care Med 2017; 45:1317-1324. [PMID: 28538439 DOI: 10.1097/ccm.0000000000002514] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES In the contemporary ICU, mechanically ventilated patients may not have arterial blood gas measurements available at relevant timepoints. Severity criteria often depend on arterial blood gas results. Retrospective studies suggest that nonlinear imputation of PaO2/FIO2 from SpO2/FIO2 is accurate, but this has not been established prospectively among mechanically ventilated ICU patients. The objective was to validate the superiority of nonlinear imputation of PaO2/FIO2 among mechanically ventilated patients and understand what factors influence the accuracy of imputation. DESIGN Simultaneous SpO2, oximeter characteristics, receipt of vasopressors, and skin pigmentation were recorded at the time of a clinical arterial blood gas. Acute respiratory distress syndrome criteria were recorded. For each imputation method, we calculated both imputation error and the area under the curve for patients meeting criteria for acute respiratory distress syndrome (PaO2/FIO2 ≤ 300) and moderate-severe acute respiratory distress syndrome (PaO2/FIO2 ≤ 150). SETTING Nine hospitals within the Prevention and Early Treatment of Acute Lung Injury network. PATIENTS We prospectively enrolled 703 mechanically ventilated patients admitted to the emergency departments or ICUs of participating study hospitals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We studied 1,034 arterial blood gases from 703 patients; 650 arterial blood gases were associated with SpO2 less than or equal to 96%. Nonlinear imputation had consistently lower error than other techniques. Among all patients, nonlinear had a lower error (p < 0.001) and higher (p < 0.001) area under the curve (0.87; 95% CI, 0.85-0.90) for PaO2/FIO2 less than or equal to 300 than linear/log-linear (0.80; 95% CI, 0.76-0.83) imputation. All imputation methods better identified moderate-severe acute respiratory distress syndrome (PaO2/FIO2 ≤ 150); nonlinear imputation remained superior (p < 0.001). For PaO2/FIO2 less than or equal to 150, the sensitivity and specificity for nonlinear imputation were 0.87 (95% CI, 0.83-0.90) and 0.91 (95% CI, 0.88-0.93), respectively. Skin pigmentation and receipt of vasopressors were not associated with imputation accuracy. CONCLUSIONS In mechanically ventilated patients, nonlinear imputation of PaO2/FIO2 from SpO2/FIO2 seems accurate, especially for moderate-severe hypoxemia. Linear and log-linear imputations cannot be recommended.
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Mellhammar L, Wullt S, Lindberg Å, Lanbeck P, Christensson B, Linder A. Sepsis Incidence: A Population-Based Study. Open Forum Infect Dis 2016; 3:ofw207. [PMID: 27942538 PMCID: PMC5144652 DOI: 10.1093/ofid/ofw207] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/02/2016] [Indexed: 11/13/2022] Open
Abstract
Background. Although sepsis is a major health problem, data on sepsis epidemiology are scarce. The aim of this study was to assess the incidence of sepsis, based on clinical findings in all adult patients treated with intravenous antibiotic in all parts of all hospitals in an entire population. Methods. This is a retrospective chart review of patients ≥18 years, living in 2 regions in Sweden, who were started on an intravenous antibiotic therapy on 4 dates, evenly distributed over the year of 2015. The main outcome was the incidence of sepsis with organ dysfunction. The mean population ≥18 years at 2015 in the regions was 1275753. Five hundred sixty-three patients living in the regions were started on intravenous antibiotic treatment on the dates of the survey. Patients who had ongoing intravenous antibiotic therapy preceding the inclusion dates were excluded, if sepsis was already present. Results. Four hundred eighty-two patients were included in the study; 339 had a diagnosed infection, of those, 96 had severe sepsis according to the 1991/2001 sepsis definitions, and 109 had sepsis according to the sepsis-3. This is equivalent to an annual incidence of traditional severe sepsis of 687/100000 persons (95% confidence interval [CI], 549–824) or according to the sepsis-3 definition of 780/100000 persons (95% CI, 633–926). Seventy-four patients had sepsis according to both definitions. Conclusions. The incidence of sepsis with organ dysfunction is higher than most previous estimates independent of definition. The inclusion of all inpatients started on intravenous antibiotic treatment of sepsis in a population makes an accurate assessment of sepsis incidence possible.
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Affiliation(s)
- Lisa Mellhammar
- Department of Clinical Sciences, Division of Infection Medicine, University of Lund , Sweden
| | - Sven Wullt
- Department of Clinical Sciences, Division of Infection Medicine, University of Lund , Sweden
| | | | - Peter Lanbeck
- Department of Clinical Sciences, Division of Infection Medicine, University of Lund , Sweden
| | - Bertil Christensson
- Department of Clinical Sciences, Division of Infection Medicine, University of Lund , Sweden
| | - Adam Linder
- Department of Clinical Sciences, Division of Infection Medicine, University of Lund , Sweden
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Serebrovska T, Serebrovska Z, Egorov E. Fitness and therapeutic potential of intermittent hypoxia training: a matter of dose. ACTA ACUST UNITED AC 2016; 62:78-91. [DOI: 10.15407/fz62.03.078] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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31
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Lee P, Leung CC, Restrepo MI, Takahashi K, Song Y, Porcel JM. Year in review 2015: Lung cancer, pleural diseases, respiratory infections, bronchiectasis and tuberculosis, bronchoscopic intervention and imaging. Respirology 2016; 21:961-7. [PMID: 26998678 DOI: 10.1111/resp.12779] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/23/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Pyng Lee
- Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore
| | - Chi Chiu Leung
- Department of Health, TB and Chest Service, Hong Kong, China
| | - Marcos I Restrepo
- South Texas Veterans Health Care System ALMD, San Antonio, Texas, USA
| | - Kazuhisa Takahashi
- Department of Respiratory Medicine, Juntendo University, Graduate School of Medicine, Tokyo, Japan
| | - Yuanlin Song
- Department of Pulmonary Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - José M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, Lleida, Spain
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Brown SM, Grissom CK, Moss M, Rice TW, Schoenfeld D, Hou PC, Thompson BT, Brower RG. Nonlinear Imputation of Pao2/Fio2 From Spo2/Fio2 Among Patients With Acute Respiratory Distress Syndrome. Chest 2016; 150:307-13. [PMID: 26836924 DOI: 10.1016/j.chest.2016.01.003] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/21/2015] [Accepted: 01/04/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND ARDS is an important clinical problem. The definition of ARDS requires testing of arterial blood gas to define the ratio of Pao2 to Fio2 (Pao2/Fio2 ratio). However, many patients with ARDS do not undergo blood gas measurement, which may result in underdiagnosis of the condition. As a consequence, a method for estimating Pao2 on the basis of noninvasive measurements is desirable. METHODS Using data from three ARDS Network studies, we analyzed the enrollment arterial blood gas measurements to compare nonlinear with linear and log-linear imputation methods of estimating Pao2 from percent saturation of hemoglobin with oxygen as measured by pulse oximetry (Spo2). We compared mortality on the basis of various measured and imputed Pao2/Fio2 ratio cutoffs to ensure clinical equivalence. RESULTS We studied 1,184 patients, in 707 of whom the Spo2 ≤ 96%. Nonlinear imputation from the Spo2/Fio2 ratio resulted in lower error than linear or log-linear imputation (P < .001) for patients with Spo2 ≤ 96% but was equivalent to log-linear imputation in all patients. Ninety-day hospital mortality was 26% to 30%, depending on the Pao2/Fio2 ratio, whether nonlinearly imputed or measured. On multivariate regression, the association between imputed and measured Pao2 varied by use of vasopressors and Spo2. CONCLUSIONS A nonlinear equation more accurately imputes Pao2/Fio2 from Spo2/Fio2 than linear or log-linear equations, with similar observed hospital mortality depending on Spo2/Fio2 ratio vs measured Pao2/Fio2 ratios. While further refinement through prospective validation is indicated, a nonlinear imputation appears superior to prior approaches to imputation.
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Affiliation(s)
- Samuel M Brown
- Pulmonary and Critical Care Medicine Section, Intermountain Medical Center/University of Utah School of Medicine, Murray, UT.
| | - Colin K Grissom
- Pulmonary and Critical Care Medicine Section, Intermountain Medical Center/University of Utah School of Medicine, Murray, UT
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - David Schoenfeld
- Biostatistics Section, Massachusetts General Hospital, Boston, MA
| | - Peter C Hou
- Section of Emergency Medicine Critical Care, Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Roy G Brower
- Pulmonary and Critical Medicine Section, Johns Hopkins University School of Medicine, Baltimore, MD
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Dean NC, Griffith PP, Sorensen JS, McCauley L, Jones BE, Lee YCG. Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia. Chest 2016; 149:1509-15. [PMID: 26836918 DOI: 10.1016/j.chest.2015.12.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pleural effusions are present in 15% to 44% of hospitalized patients with pneumonia. It is unknown whether effusions at first presentation to the ED influence outcomes or should be managed differently. METHODS We studied patients in seven hospital EDs with International Statistical Classification of Disease and Health Related Problems-Version 9 codes for pneumonia, or empyema, sepsis, or respiratory failure with secondary pneumonia. Patients with no confirmatory findings on chest imaging were excluded. Pleural effusions were identified with the use of radiographic imaging. RESULTS Over 24 months, 4,771 of 458,837 adult ED patients fulfilled entry criteria. Among the 690 (14.5%) patients with pleural effusions, their median age was 68 years, and 46% were male. Patients with higher Elixhauser comorbidity scores (OR, 1.13 [95% CI, 1.09-1.18]; P < .001), brain natriuretic peptide levels (OR, 1.20 [95% CI, 1.12-1.28]; P < .001), bilirubin levels (OR, 1.07 [95% CI, 1.00-1.15]; P = .04), and age (OR, 1.15 [95% CI, 1.09-1.21]; P < .001) were more likely to have parapneumonic effusions. In patients without effusion, electronic version of CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years accurately predicted mortality (4.7% predicted vs 5.0% actual). However, eCURB underestimated mortality in those with effusions (predicted 7.0% vs actual 14.0%; P < .001). Patients with effusions were more likely to be admitted (77% vs 57%; P < .001) and had a longer hospital stay (median, 2.8 vs 1.3 days; P < .001). After severity adjustment, the likelihood of 30-day mortality was greater among patients with effusions (OR, 2.6 [CI, 2.0-3.5]; P < .001), and hospital stay was disproportionately longer (coefficient, 0.22 [CI, 0.14-0.29]; P < .001). CONCLUSIONS Patients with pneumonia and pleural effusions at ED presentation in this study were more likely to die, be admitted, and had longer hospital stays. Why parapneumonic effusions are associated with adverse outcomes, and whether different management of these patients might improve outcome, needs urgent investigation.
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Affiliation(s)
- Nathan C Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Paula P Griffith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Jeffrey S Sorensen
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Lindsay McCauley
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT; Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Barbara E Jones
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT; Division of Pulmonary and Critical Care Medicine, Salt Lake City VA Health System, Salt Lake City, UT
| | - Y C Gary Lee
- Pleural Diseases Unit, Sir Charles Gairdner Hospital, University of Western Australia-Perth, Western Australia
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