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Bekker MA, Rai S, Arbous MS, Georgousopoulou EN, Pilcher DV, van Haren FMP. Annual prevalence, characteristics, and outcomes of intensive care patients with skin or soft tissue infections in Australia and New Zealand: A retrospective cohort study between 2006-2017. Aust Crit Care 2021; 34:403-410. [PMID: 33663947 DOI: 10.1016/j.aucc.2020.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/23/2020] [Accepted: 10/31/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are limited published data on the epidemiology of skin and soft tissue infections (SSTIs) requiring intensive care unit (ICU) admission. This study intended to describe the annual prevalence, characteristics, and outcomes of critically ill adult patients admitted to the ICU for an SSTI. METHODS This was a registry-based retrospective cohort study, using data submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database for all admissions with SSTI between 2006 and 2017. The inclusion criteria were as follows: primary diagnosis of SSTI and age ≥16 years. The exclusion criteria were as follows: ICU readmissions (during the same hospital admission) and transfers from ICUs from other hospitals. The primary outcome was in-hospital mortality, and the secondary outcomes were ICU mortality and length of stay (LOS) in the ICU and hospital with independent predictors of outcomes. RESULTS Admissions due to SSTI accounted for 10 962 (0.7%) of 1 470 197 ICU admissions between 2006 and 2017. Comorbidities were present in 25.2% of the study sample. The in-hospital mortality was 9% (991/10 962), and SSTI necessitating ICU admission accounted for 0.07% of in-hospital mortality of all ICU admissions between 2006 and 2017. Annual prevalence of ICU admissions for SSTI increased from 0.4% to 0.9% during the study period, but in-hospital mortality decreased from 16.1% to 6.8%. The median ICU LOS was 2.1 days (interquartile range = 3.4), and the median hospital LOS was 12.1 days (interquartile range = 20.6). ICU LOS remained stable between 2006 and 2017 (2.0-2.1 days), whereas hospital LOS decreased from 15.7 to 11.2 days. Predictors for in-hospital mortality included Australian and New Zealand Risk of Death scores [odds ratio (OR): 1.07; confidence interval (CI) (1.05, 1.09); p < 0.001], any comorbidity except diabetes [OR: 2.00; CI (1.05, 3.79); p = 0.035], and admission through an emergency response call [OR: 2.07; CI (1.03, 4.16); p = 0.041]. CONCLUSIONS SSTIs are uncommon as primary ICU admission diagnosis. Although the annual prevalence of ICU admissions for SSTI has increased, in-hospital mortality and hospital LOS have decreased over the last decade.
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Affiliation(s)
- Marjolein A Bekker
- Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Yamba Dr, Garran, Australian Capital Territory, 2605, Australia; Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia.
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Ekavi N Georgousopoulou
- Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia.
| | - David V Pilcher
- Intensive Care Unit, Alfred Hospital, 55 Commercial Rd, Melbourne, Victoria, 3004, Australia; The Australian and New Zealand - Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Prahran, Melbourne, Victoria, Australia; The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), 277 Camberwell Road, Camberwell, Melbourne, Victoria, 3124, Australia.
| | - Frank M P van Haren
- Intensive Care Unit, Canberra Hospital, Yamba Dr, Garran, Australian Capital Territory, 2605, Australia; Medical School, Australian National University, Building 4, The Canberra Hospital, Hospital Rd, Garran, Australian Capital Territory, 2605, Australia; Faculty of Health, University of Canberra, 11 Kirninari Street, Bruce, Australian Capital Territory, 2617, Australia.
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Dermatological Manifestations in the Intensive Care Unit: A Practical Approach. Crit Care Res Pract 2020; 2020:9729814. [PMID: 33062328 PMCID: PMC7533796 DOI: 10.1155/2020/9729814] [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: 02/09/2020] [Revised: 07/23/2020] [Accepted: 09/10/2020] [Indexed: 12/04/2022] Open
Abstract
Dermatological problems are not usually related to intensive medicine because they are considered to have a low impact on the evolution of critical patients. Despite this, dermatological manifestations (DMs) are relatively frequent in critically ill patients. In rare cases, DMs will be the main diagnosis and will require intensive treatment due to acute skin failure. In contrast, DMs can be a reflection of underlying systemic diseases, and their identification may be key to their diagnosis. On other occasions, DMs are lesions that appear in the evolution of critical patients and are due to factors derived from the stay or intensive treatment. Lastly, DMs can accompany patients and must be taken into account in the comprehensive pathology management. Several factors must be considered when addressing DMs: on the one hand, the moment of appearance, morphology, location, and associated treatment and, on the other hand, aetiopathogenesis and classification of the cutaneous lesion. DMs can be classified into 4 groups: life-threatening DMs (uncommon but compromise the patient's life); DMs associated with systemic diseases where skin lesions accompany the pathology that requires admission to the intensive care unit (ICU); DMs secondary to the management of the critical patient that considers the cutaneous manifestations that appear in the evolution mainly of infectious or allergic origin; and DMs previously present in the patient and unrelated to the critical process. This review provides a characterization of DMs in ICU patients to establish a better identification and classification and to understand their interrelation with critical illnesses.
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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Marrie RA, Bernstein CN, Peschken CA, Hitchon CA, Chen H, Garland A. Increased Incidence of Critical Illness in Psoriasis. J Cutan Med Surg 2017; 21:395-400. [PMID: 28587481 DOI: 10.1177/1203475417712497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Psoriasis is associated with an increased risk of comorbid disease. Despite the recognition of increased morbidity in psoriasis, the effects on health care utilisation remain incompletely understood. Little is known about the risk of intensive care unit (ICU) admission in persons with psoriasis. OBJECTIVE To compare the incidence of ICU admission and post-ICU mortality rates in a psoriasis population compared with a matched population without psoriasis. METHODS Using population-based administrative data from Manitoba, Canada, we identified 40 930 prevalent cases of psoriasis and an age-, sex-, and geographically matched cohort from the general population (n = 150 210). We compared the incidence of ICU admission between populations using incidence rates and Cox regression models adjusted for age, sex, socioeconomic status, and comorbidity and compared mortality after ICU admission. RESULTS Among incident psoriasis cases (n = 30 150), the cumulative 10-year incidence of ICU admission was 5.6% (95% confidence interval [CI], 5.3%-5.8%), 21% higher than in the matched cohort (incidence rate ratio, 1.21; 95% CI, 1.15-1.27). In the prevalent psoriasis cohort, crude mortality in the ICU was 11.5% (95% CI, 9.9%-13.0%), 32% higher than observed in the matched population admitted to the ICU (8.7%; 95% CI, 8.3%-9.1%). Mortality rates after ICU admission remained elevated at all time points in the psoriasis cohort compared with the matched cohort. CONCLUSION Psoriasis is associated with an increased risk for ICU admission and with an increased risk of mortality post-ICU admission.
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Affiliation(s)
- Ruth Ann Marrie
- 1 Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,2 Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Charles N Bernstein
- 1 Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,3 IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Canada
| | - Christine A Peschken
- 1 Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,2 Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Carol A Hitchon
- 1 Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Hui Chen
- 4 Manitoba Centre for Health Policy, Winnipeg, Canada
| | - Allan Garland
- 1 Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.,2 Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.,4 Manitoba Centre for Health Policy, Winnipeg, Canada
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Burnham JP, Kirby JP, Kollef MH. Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review. Intensive Care Med 2016; 42:1899-1911. [PMID: 27699456 PMCID: PMC6276373 DOI: 10.1007/s00134-016-4576-0] [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: 06/24/2016] [Accepted: 09/24/2016] [Indexed: 01/01/2023]
Abstract
PURPOSE To review the salient features of the diagnosis and management of the most common skin and soft tissue infections (SSTI). This review focuses on severe SSTIs that require care in an intensive care unit (ICU), including toxic shock syndrome, myonecrosis/gas gangrene, and necrotizing fasciitis. METHODS Guidelines, expert opinion, and local institutional policies were reviewed. RESULTS Severe SSTIs are common and their management complex due to regional variation in predominant pathogens and antimicrobial resistance patterns, as well as variations in host immune responses. Unique aspects of care for SSTIs in the ICU are discussed, including the role of prosthetic devices, risk factors for bacteremia, and the need for surgical consultation. SSTI mimetics, the role of dermatologic consultation, and the unique features of SSTIs in immunocompromised hosts are also described. CONCLUSIONS We provide recommendations for clinicians regarding optimal SSTI management in the ICU setting.
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Affiliation(s)
- Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - John P Kirby
- Division of General Surgery, Acute and Critical Care Surgery Section, Washington University School of Medicine, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA.
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Tham WY, Koh HY, Lee HY. Spectrum of dermatological conditions seen in the intensive care unit. Clin Exp Dermatol 2016; 41:920-921. [PMID: 27790735 DOI: 10.1111/ced.12901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 01/21/2023]
Affiliation(s)
- W Y Tham
- Dermatology Unit, Singapore General Hospital, 20 College Road, S 169856, Singapore
| | - H Y Koh
- Dermatology Unit, Singapore General Hospital, 20 College Road, S 169856, Singapore
| | - H Y Lee
- Dermatology Unit, Singapore General Hospital, 20 College Road, S 169856, Singapore
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Wang HE, Wells JM, Rizk DV. Bullous Lesions After Use of a Commercial Therapeutic Hypothermia Temperature Management System: A Possible Burn Injury? Ther Hypothermia Temp Manag 2013; 3:147-150. [PMID: 24066269 DOI: 10.1089/ther.2013.0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Therapeutic hypothermia (TH) is a novel technique for improving the likelihood of survival with good neurologic outcome after cardiopulmonary arrest. While commercial temperature management systems (TMS) are intended to facilitate cooling of the body during TH, their operation also involves body exposure to heat. We describe the case of a 72-year-old female postarrest patient who underwent TH using a commercial water-circulating TMS and concurrent continuous renal replacement therapy. The patient developed bullous lesions on the thigh and torso suspected to constitute a scald burn injury from the TMS. Clinicians must be aware of this important adverse event when providing TH, especially in the setting of concurrent hemodialysis therapy.
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Affiliation(s)
- Henry E Wang
- Department of Emergency Medicine, University of Alabama School of Medicine , Birmingham, Alabama
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