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Montrucchio G, Balzani E, Sales G, Vaninetti A, Grillo F, Trompeo AC, Zanierato M, Fanelli V, Corcione S, De Rosa FG, Curtoni A, Costa C, Brazzi L. Multidrug-resistant pathogens and ventilator-associated pneumonia in critically ill COVID-19 and non-COVID-19 patients: a prospective observational monocentric comparative study. Respir Res 2024; 25:168. [PMID: 38637766 PMCID: PMC11027225 DOI: 10.1186/s12931-024-02779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic has increased the incidence of ventilator-associated pneumonia (VAP) among critically ill patients. However, a comparison of VAP incidence in COVID-19 and non-COVID-19 cohorts, particularly in a context with a high prevalence of multidrug-resistant (MDR) organisms, is lacking. MATERIAL AND METHODS We conducted a single-center, mixed prospective and retrospective cohort study comparing COVID-19 patients admitted to the intensive care unit (ICU) of the "Città della Salute e della Scienza" University Hospital in Turin, Italy, between March 2020 and December 2021 (COVID-19 group), with a historical cohort of ICU patients admitted between June 2016 and March 2018 (NON-COVID-19 group). The primary objective was to define the incidence of VAP in both cohorts. Secondary objectives were to evaluate the microbial cause, resistance patters, risk factors and impact on 28 days, ICU and in-hospital mortality, duration of ICU stay, and duration of hospitalization). RESULTS We found a significantly higher incidence of VAP (51.9% - n = 125) among the 241 COVID-19 patients compared to that observed (31.2% - n = 78) among the 252 NON-COVID-19 patients. The median SOFA score was significantly lower in the COVID-19 group (9, Interquartile range, IQR: 7-11 vs. 10, IQR: 8-13, p < 0.001). The COVID-19 group had a higher prevalence of Gram-positive bacteria-related VAP (30% vs. 9%, p < 0.001), but no significant difference was observed in the prevalence of difficult-to-treat (DTR) or MDR bacteria. ICU and in-hospital mortality in the COVID-19 and NON-COVID-19 groups were 71% and 74%, vs. 33% and 43%, respectively. The presence of COVID-19 was significantly associated with an increased risk of 28-day all-cause hospital mortality (Hazard ratio, HR: 7.95, 95% Confidence Intervals, 95% CI: 3.10-20.36, p < 0.001). Tracheostomy and a shorter duration of mechanical ventilation were protective against 28-day mortality, while dialysis and a high SOFA score were associated with a higher risk of 28-day mortality. CONCLUSION COVID-19 patients with VAP appear to have a significantly higher ICU and in-hospital mortality risk regardless of the presence of MDR and DTR pathogens. Tracheostomy and a shorter duration of mechanical ventilation appear to be associated with better outcomes.
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Affiliation(s)
- Giorgia Montrucchio
- Department of Surgical Sciences, University of Turin, Turin, Italy.
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy.
| | - Eleonora Balzani
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Gabriele Sales
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Anna Vaninetti
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Francesca Grillo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Anna Chiara Trompeo
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Vito Fanelli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, University of Turin, Turin, Italy
- Tufts University School of Medicine, Boston, MA, 02111, USA
| | | | - Antonio Curtoni
- Department of Public Health and Paediatrics, University of Turin, Turin, Italy
- Microbiology and Virology Laboratory, Città Della Salute e Della Scienza Hospital, Corso Dogliotti 14, Turin, 10126, Italy
| | - Cristina Costa
- Department of Public Health and Paediatrics, University of Turin, Turin, Italy
- Microbiology and Virology Laboratory, Città Della Salute e Della Scienza Hospital, Corso Dogliotti 14, Turin, 10126, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anesthesia, Intensive Care and Emergency, Città della Salute e della Scienza Hospital, Turin, Italy
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Guzelj D, Grubelnik A, Greif N, Povalej Bržan P, Fluher J, Kalamar Ž, Markota A. The Effect of Body Temperature Changes on the Course of Treatment in Patients With Pneumonia and Sepsis: Results of an Observational Study. Interact J Med Res 2024; 13:e52590. [PMID: 38427413 PMCID: PMC10943422 DOI: 10.2196/52590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/24/2023] [Accepted: 12/06/2023] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Traditionally, patients who are critically ill with infection and fever have been treated with antipyretics or even physically cooled. Presumed benefits of the reduction of body temperature are mostly based on decreased metabolic demands. However, it has been shown that decreasing body temperature in patients who are critically ill is not associated with improvement in treatment outcomes. Additionally, there is some data to support the use of temperature modulation (therapeutic hyperthermia) as an adjuvant treatment strategy in patients with infection. OBJECTIVE This study aims to determine the effect of body temperature on the course of intensive care unit (ICU) treatment of patients who are mechanically ventilated with pneumonia, sepsis, and positive tracheal aspirates on admission. METHODS We performed a single-center retrospective study. Core body temperature was measured in all patients. We analyzed associations between average temperatures in the first 48 hours after admission to ICU and ICU treatment parameters. Additionally, patients were divided into three groups: patients with negative tracheal aspirates 1 week after ICU admission (P-N group), patients with a different pathogen in tracheal aspirates 1 week after ICU admission (P-HAP group), and patients with a persisting pathogen in tracheal aspirates 1 week after ICU admission (P-P group). Differences in body temperature and interventions aimed at temperature modulation were determined. RESULTS We observed a significantly higher average temperature in the first 48 hours after admission to ICU in patients who survived to hospital discharge compared to nonsurvivors (mean 37.2 °C, SD 1 °C vs mean 36.9 °C, SD 1.6 °C; P=.04). We observed no associations between average temperatures in the first 48 hours after ICU admission and days of mechanical ventilation in the first 7 days of treatment (ρ=-0.090; P=.30), the average maximum daily requirement for noradrenaline in the first 7 days of treatment (ρ=-0.029; P=.80), average maximum FiO2 in the first 7 days of ICU treatment (ρ=0.040; P=.70), and requirement for renal replacement therapy in the first 7 days of ICU treatment (mean 37.3 °C, SD 1.4 °C vs mean 37.0 °C, SD 1.3 °C; P=.23). In an additional analysis, we observed a significantly greater use of paracetamol in the P-N group (mean 1.0, SD 1.1 g vs mean 0.4, SD 0.7 g vs mean 0.4, SD 0.8 g; P=.009), a trend toward greater use of active cooling in the first 24 hours after ICU admission in the P-N group (n=11, 44% vs n=14, 33.3% vs n=16, 32%; P=.57), and no other significant differences in parameters of ICU treatment between patient groups. CONCLUSIONS We observed better survival in patients who developed higher body temperatures in the first 48 hours after admission to the ICU; however, we observed no changes in other treatment parameters. Similarly, we observed greater use of paracetamol in patients with negative tracheal aspirates 1 week after ICU admission. Our results support the strategy of temperature tolerance in patients who are intubated with pneumonia and sepsis.
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Affiliation(s)
- Domen Guzelj
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Anže Grubelnik
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Nina Greif
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Petra Povalej Bržan
- Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia
| | - Jure Fluher
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
| | - Žiga Kalamar
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
| | - Andrej Markota
- Medical Intensive Care Unit, University Medical Centre Maribor, Maribor, Slovenia
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Li Z, Yang L, Xu Q, Wu F. Relation between red blood cell distribution width and 30-day in-hospital mortality of patients with ventilator-associated pneumonia. BMC Infect Dis 2023; 23:696. [PMID: 37853360 PMCID: PMC10585831 DOI: 10.1186/s12879-023-08692-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Epidemiological studies have demonstrated an association between red blood cell distribution width (RDW) and the prognosis of pneumonia-associated diseases. However, prognostic value of RDW in patients with ventilator-associated pneumonia (VAP) has yet to be investigated. This study aimed to explore the association between RDW and in-hospital mortality in VAP patients and explore predictive value of RDW for VAP patients. METHODS This retrospective cohort study included 1,543 VAP patients from the Medical Information Mart for Intensive Care IV database 2008-2019. The primary outcome was considered to 30-day in-hospital mortality of VAP patients in this study. Non-high RDW level group was defined as <15 %, and high RDW level group as ≥15%. The possible confounding factors were screened by least absolute shrinkage and selection operator regression. Univariate and multivariate COX regression analyses were used for the assessment on the association of RDW and 30-day in-hospital mortality in VAP patients. We also performed subgroup analyses. Furthermore, a comparative analysis of RDW and sequential organ failure assessment (SOFA) score and simplified acute physiology score II (SAPS II) were performed by receiver operating characteristic (ROC) curves. RESULTS The 30-day in-hospital mortality of VAP patients was approximately 19.05%. After adjusting all confounding factors, high RDW was associated with 30-day in-hospital mortality among VAP patients by using non-high RDW as the reference [hazard ratio (HR) =1.29, 95% confidence interval (CI): 1.01-1.63]. Additionally, the relationship was also robust in several populations, such as patients were younger than 60 years, or had not a history of congestive heart failure, or had a history of sepsis, or had not received renal replacement therapy, or had a duration of mechanical ventilation for more than 7 days. The result of ROC indicated that RDW had a better prognostic value in predicting 30-day in-hospital mortality for VAP patients than SOFA score and SAPS II score. CONCLUSION High RDW level is associated with an increased 30-day in-hospital mortality. The RDW is a promising biomarker in predicting 30-day in-hospital mortality for patients admitted to the ICU, regardless of VAP.
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Affiliation(s)
- Zhonghua Li
- Department of Infection Management, Jiangsu Province, Taicang First People's Hospital, 58 South Changsheng Road, Taicang 215400, Taicang, No, P. R. China.
| | - Liping Yang
- Department of Infection Management, Jiangsu Province, Taicang First People's Hospital, 58 South Changsheng Road, Taicang 215400, Taicang, No, P. R. China
| | - Qin Xu
- Department of Infection Management, Jiangsu Province, Taicang First People's Hospital, 58 South Changsheng Road, Taicang 215400, Taicang, No, P. R. China
| | - Feifei Wu
- Department of Infection Management, Jiangsu Province, Taicang First People's Hospital, 58 South Changsheng Road, Taicang 215400, Taicang, No, P. R. China
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Wang YC, Lin WY, Tseng YJ, Fu Y, Li W, Huang YC, Wang HY. Risk Stratification for Herpes Simplex Virus Pneumonia Using Elastic Net Penalized Cox Proportional Hazard Algorithm with Enhanced Explainability. J Clin Med 2023; 12:4489. [PMID: 37445525 DOI: 10.3390/jcm12134489] [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: 04/04/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
Herpes simplex virus (HSV) pneumonia is a serious and often fatal respiratory tract infection that occurs in immunocompromised individuals. The early detection of accurate risk stratification is essential in identifying patients who are at high risk of mortality and may benefit from more aggressive treatment. In this study, we developed and validated a risk stratification model for HSV bronchopneumonia using an elastic net penalized Cox proportional hazard algorithm. We analyzed data from a cohort of 104 critically ill patients with HSV bronchopneumonia identified in Chang Gung Memorial Hospital, Linkou, Taiwan: one of the largest tertiary medical centers in the world. A total of 109 predictors, both clinical and laboratory, were identified in this process to develop a risk stratification model that could accurately predict mortality in patients with HSV bronchopneumonia. This model was able to differentiate the risk of death and predict mortality in patients with HSV bronchopneumonia compared to the APACHE II score in the early stage of ICU admissions. Both hazard ratio coefficient and selection frequency were used as the metrics to enhance the explainability of the informative predictors. Our findings suggest that the elastic net penalized Cox proportional hazard algorithm is a promising tool for risk stratification in patients with HSV bronchopneumonia and could be useful in identifying those at high risk of mortality.
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Affiliation(s)
- Yu-Chiang Wang
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | | | - Yi-Ju Tseng
- Department of Computer Science, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA 02115, USA
| | - Yiwen Fu
- Department of Medicine, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA 95051, USA
| | - Weijia Li
- Cardiovascular Institute, AdventHealth Orlando, Orlando, FL 32803, USA
| | - Yu-Chen Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taipei 333, Taiwan
| | - Hsin-Yao Wang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taipei 333, Taiwan
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Ishii E, Nawa N, Hashimoto S, Shigemitsu H, Fujiwara T. Development, validation, and feature extraction of a deep learning model predicting in-hospital mortality using Japan's largest national ICU database: a validation framework for transparent clinical Artificial Intelligence (cAI) development. Anaesth Crit Care Pain Med 2023; 42:101167. [PMID: 36302489 DOI: 10.1016/j.accpm.2022.101167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE While clinical Artificial Intelligence (cAI) mortality prediction models and relevant studies have increased, limitations including the lack of external validation studies and inadequate model calibration leading to decreased overall accuracy have been observed. To combat this, we developed and evaluated a novel deep neural network (DNN) and a validation framework to promote transparent cAI development. METHODS Data from Japan's largest ICU database was used to develop the DNN model, predicting in-hospital mortality including ICU and post-ICU mortality by days since ICU discharge. The most important variables to the model were extracted with SHapley Additive exPlanations (SHAP) to examine the DNN's efficacy as well as develop models that were also externally validated. MAIN RESULTS The area under the receiver operating characteristic curve (AUC) for predicting ICU mortality was 0.94 [0.93-0.95], and 0.91 [0.90-0.92] for in-hospital mortality, ranging between 0.91-0.95 throughout one year since ICU discharge. An external validation using only the top 20 variables resulted with higher AUCs than traditional severity scores. CONCLUSIONS Our DNN model consistently generated AUCs between 0.91-0.95 regardless of days since ICU discharge. The 20 most important variables to our DNN, also generated higher AUCs than traditional severity scores regardless of days since ICU discharge. To our knowledge, this is the first study that predicts ICU and in-hospital mortality using cAI by post-ICU discharge days up to over a year. This finding could contribute to increased transparency on cAI applications.
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Affiliation(s)
- Euma Ishii
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutoshi Nawa
- Department of Medical Education Research and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidenobu Shigemitsu
- Institute of Global Affairs, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
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Tan Y, Young M, Girish A, Hu B, Kurian Z, Greenstein JL, Kim H, Winslow RL, Fackler J, Bergmann J. Predicting respiratory decompensation in mechanically ventilated adult ICU patients. Front Physiol 2023; 14:1125991. [PMID: 37123253 PMCID: PMC10140580 DOI: 10.3389/fphys.2023.1125991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/06/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction: Mechanical ventilation is a life-saving treatment in the Intensive Care Unit (ICU), but often causes patients to be at risk of further respiratory complication. We created a statistical model utilizing electronic health record and physiologic vitals data to predict the Center for Disease Control and Prevention (CDC) defined Ventilator Associated Complications (VACs). Further, we evaluated the effect of data temporal resolution and feature generation method choice on the accuracy of such a constructed model. Methods: We constructed a random forest model to predict occurrence of VACs using health records and chart events from adult patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. We trained the machine learning models on two patient populations of 1921 and 464 based on low and high frequency data availability. Model features were generated using both basic statistical summaries and tsfresh, a python library that generates a large number of derived time-series features. Classification to determine whether a patient will experience VAC one hour after 35 h of ventilation was performed using a random forest classifier. Two different sample spaces conditioned on five varying feature extraction techniques were evaluated to identify the most optimal selection of features resulting in the best VAC discrimination. Each dataset was assessed using K-folds cross-validation (k = 10), giving average area under the receiver operating characteristic curves (AUROCs) and accuracies. Results: After feature selection, hyperparameter tuning, and feature extraction, the best performing model used automatically generated features on high frequency data and achieved an average AUROC of 0.83 ± 0.11 and an average accuracy of 0.69 ± 0.10. Discussion: Results show the potential viability of predicting VACs using machine learning, and indicate that higher-resolution data and the larger feature set generated by tsfresh yield better AUROCs compared to lower-resolution data and manual statistical features.
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Affiliation(s)
- Yvette Tan
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Michael Young
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Akanksha Girish
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Beini Hu
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Zina Kurian
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Joseph L. Greenstein
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Han Kim
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Raimond L Winslow
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - James Fackler
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Jules Bergmann
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Jules Bergmann,
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Moris D, Henao R, Hensman H, Stempora L, Chasse S, Schobel S, Dente CJ, Kirk AD, Elster E. Multidimensional machine learning models predicting outcomes after trauma. Surgery 2022; 172:1851-1859. [PMID: 36116976 DOI: 10.1016/j.surg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND An emerging body of literature supports the role of individualized prognostic tools to guide the management of patients after trauma. The aim of this study was to develop advanced modeling tools from multidimensional data sources, including immunological analytes and clinical and administrative data, to predict outcomes in trauma patients. METHODS This was a prospective study of trauma patients at Level 1 centers from 2015 to 2019. Clinical, flow cytometry, and serum cytokine data were collected within 48 hours of admission. Sparse logistic regression models were developed, jointly selecting predictors and estimating the risk of ventilator-associated pneumonia, acute kidney injury, complicated disposition (death, rehabilitation, or nursing facility), and return to the operating room. Model parameters (regularization controlling model sparsity) and performance estimation were obtained via nested leave-one-out cross-validation. RESULTS A total of 179 patients were included. The incidences of ventilator-associated pneumonia, acute kidney injury, complicated disposition, and return to the operating room were 17.7%, 28.8%, 22.5%, and 12.3%, respectively. Regarding extensive resource use, 30.7% of patients had prolonged intensive care unit stay, 73.2% had prolonged length of stay, and 23.5% had need for prolonged ventilatory support. The models were developed and cross-validated for ventilator-associated pneumonia, acute kidney injury, complicated dispositions, and return to the operating room, yielding predictive areas under the curve from 0.70 to 0.91. Each model derived its optimal predictive value by combining clinical, administrative, and immunological analyte data. CONCLUSION Clinical, immunological, and administrative data can be combined to predict post-traumatic outcomes and resource use. Multidimensional machine learning modeling can identify trauma patients with complicated clinical trajectories and high resource needs.
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Affiliation(s)
| | | | - Hannah Hensman
- DecisionQ, Arlington, VA; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Linda Stempora
- Medical Center, Duke University Durham, NC; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Scott Chasse
- Medical Center, Duke University Durham, NC; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Seth Schobel
- Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD
| | | | - Allan D Kirk
- Medical Center, Duke University Durham, NC; Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD
| | - Eric Elster
- Surgical Critical Care Initiative, Department of Surgery, Uniformed Services University of the Health Sciences; Bethesda, MD; Walter Reed National Military Medical Center, Bethesda, MD
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Prognostic Role of Serum Adrenomedullin in Patients with Ventilator Associated Pneumonia. Adv Respir Med 2022; 90:349-359. [DOI: 10.3390/arm90040044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/31/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022]
Abstract
Objective: Ventilator associated pneumonia is a common type of sepsis that occurs to about 9–27% of all mechanically ventilated patients and 20–50% of them develop septic shock. Several clinical, laboratory, and radiological methods have been used for diagnosing VAP. Adrenomedullin (ADM) has been found to be elevated in the plasma of septic patients. The study aim was to explore the prognostic role of ADM in the VAP patients. Design: A prospective observational study. Setting: Intensive Care Department of Alexandria University Hospitals. Patients: A total of 140 patients with proven VAP after medical ICU admission were consecutively enrolled. Methods: APACHE II score, SOFA score, CRP, lactate, and serum ADM were measured at day 0 of VAP diagnosis and 5 days later. The results were correlated with the outcomes of patients. Results: APACHE II, lactate, and serum ADM on day 0 could predict an unfavorable outcome. ADM prediction power was significantly higher than APACHE II and lactate. Day 5 readings of all tested parameters could predict occurrence of the unfavorable outcome. ADM on day 0 showed the highest sensitivity (96.25%). Conclusions: Serum adrenomedullin when measured at days 0 and 5 of VAP diagnosis may serve as an early predictor of unfavorable outcome.
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Significance of the Modified NUTRIC Score for Predicting Clinical Outcomes in Patients with Severe Community-Acquired Pneumonia. Nutrients 2021; 14:nu14010198. [PMID: 35011073 PMCID: PMC8747298 DOI: 10.3390/nu14010198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
Nutritional status could affect clinical outcomes in critical patients. We aimed to determine the prognostic accuracy of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for hospital mortality and treatment outcomes in patients with severe community-acquired pneumonia (SCAP) compared to other clinical prediction rules. We enrolled SCAP patients in a multi-center setting retrospectively. The mNUTRIC score and clinical prediction rules for pneumonia, as well as clinical factors, were calculated and recorded. Clinical outcomes, including mortality status and treatment outcome, were assessed after the patient was discharged. We used the receiver operating characteristic (ROC) curve method and multivariate logistic regression analysis to determine the prognostic accuracy of the mNUTRIC score for predicting clinical outcomes compared to clinical prediction rules, while 815 SCAP patients were enrolled. ROC curve analysis showed that the mNUTRIC score was the most effective at predicting each clinical outcome and had the highest area under the ROC curve value. The cut-off value for predicting clinical outcomes was 5.5. By multivariate logistic regression analysis, the mNUTRIC score was also an independent predictor of both clinical outcomes in SCAP patients. We concluded that the mNUTRIC score is a better prognostic factor for predicting clinical outcomes in SCAP patients compared to other clinical prediction rules.
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Prognostic Scores and Azole-Resistant Aspergillus fumigatus in Invasive Aspergillosis from an Indian Respiratory Medicine ICU (ICU Patients with IA Suspicion). J Fungi (Basel) 2021; 7:jof7110991. [PMID: 34829278 PMCID: PMC8625311 DOI: 10.3390/jof7110991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/03/2021] [Accepted: 11/13/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: To assess the effectiveness of three general prognostic models (APACHE II, SAPS II, and SOFA) with serum galactomannan antigen in a clinically suspected invasive aspergillosis (IA) subpopulation admitted to a respiratory medicine ICU and to identify azole-resistant Aspergillus fumigatus (ARAF) cases. Methodology and Results: A total of 235 clinically suspected IA patients were prospectively enrolled and observed 30-day mortality was 29.7%. The three general models showed poor discrimination assessed by area under receiver operating characteristic (ROC) curves (AUCs, <0.7) and good calibration (p = 0.92, 0.14, and 0.13 for APACHE II, SAPS II, and SOFA, respectively), evaluated using Hosmer–Lemeshow goodness-of-fit tests. However, discrimination was significantly better with galactomannan values (AUC, 0.924). In-vitro antifungal testing revealed higher minimum inhibitory concentration (MIC) for 12/34 isolates (35.3%) whereas azole resistance was noted in 40% of Aspergillus fumigatus isolates (6/15) with two hotspot cyp51A mutations, G54R and P216L. Conclusions: Patients diagnosed with putative and probable IA (71.4% and 34.6%, respectively), had high mortality. The general prognostic model APACHE II seemed fairly accurate for this subpopulation. However, the use of local GM cut-offs calculated for mortality, may help the intensivists in prompt initiation or change of therapy for better outcome of patients. In addition, the high MICs highlight the need of antifungal surveillance to know the local resistance rate which might aid in patient treatment.
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Tang R, Luo R, Wu B, Wang F, Song H, Chen X. Effectiveness and safety of adjunctive inhaled antibiotics for ventilator-associated pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2021; 65:133-139. [PMID: 34144265 DOI: 10.1016/j.jcrc.2021.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The efficacy and safety of adjunctive inhaled antibiotic therapy for ventilator-associated pneumonia (VAP) was systematically reviewed based on updated studies. METHODS We searched four databases and four clinical trial registration platforms to identify relevant studies published prior to May 19, 2020. Randomized controlled trials (RCTs) assessing adjunctive antibiotic inhalation treatment for VAP patients were eligible for this review. Two reviewers independently screened the articles and extracted the data. Information on inhaled therapy and clinical outcomes was collected. Study quality was assessed with the Cochrane risk of bias tool. The meta-analysis was conducted with Review Manager and R software. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines were used to evaluate the quality of evidence for each pooled outcome. RESULTS Eleven RCTs and 1210 patients were included in this analysis after the application of the inclusion and exclusion criteria. Compared with the use of intravenous injection alone, the use of adjunctive inhaled antibiotic therapy improved the rates of clinical cure (relative risk (RR) 1.13, 95% CI [1.02,1.26]) and microbiological eradication (RR 1.45, 95% CI [1.19,1.76]) in VAP patients. However, despite these improvements, mortality was not reduced (RR 1.00, 95% CI [0.82,1.21]). Adjunctive antibiotics delivered through the respiratory tract were not associated with a higher risk of renal impairment but were associated with an increased risk of bronchospasm (RR 2.74, 95% CI [1.31,5.73] during treatment. CONCLUSIONS Adjunctive inhaled antibiotics improved the clinical outcomes in VAP patients, but the increased rates clinical cure and microbiological eradication were not associated with reduced mortality. The use of nebulized antibiotics is not supported by the currently available evidence as a routine therapeutic strategy for VAP. PROSPERO REGISTRATION NUMBER CRD42020186970.
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Affiliation(s)
- Rui Tang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China.
| | - Rui Luo
- Department of Pain Medicine, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bin Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fusheng Wang
- Department of Critical Care, The Sixth Affiliated Hospital of Kunming Medical University, Kunming Medical University, Yuxi, China
| | - Haoxin Song
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiujuan Chen
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Xue H, Li C, Cui L, Tian C, Li S, Wang Z, Liu C, Ge Q. M-BLUE protocol for coronavirus disease-19 (COVID-19) patients: interobserver variability and correlation with disease severity. Clin Radiol 2021; 76:379-383. [PMID: 33663912 PMCID: PMC7888246 DOI: 10.1016/j.crad.2021.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022]
Abstract
AIM To retrospectively evaluate the interobserver variability of intensive care unit (ICU) practitioners and radiologists who used the M-BLUE (modified bedside lung ultrasound in emergency) protocol to assess coronavirus disease-19 (COVID-19) patients, and to determine the correlation between total M-BLUE protocol score and three different scoring systems reflecting disease severity. MATERIALS AND METHODS Institutional review board approval was obtained and informed consent was not required. Ninety-six lung ultrasonography (LUS) examinations were performed using the M-BLUE protocol in 79 consecutive COVID-19 patients. Two ICU practitioners and three radiologists reviewed video clips of the LUS of eight different regions in each lung retrospectively. Each observer, who was blind to the patient information, described each clip with M-BLUE terminology and assigned a corresponding score. Interobserver variability was assessed using intraclass correlation coefficient. Spearman's correlation coefficient analysis (R-value) was used to assess the correlation between the total score of the eight video clips and disease severity. RESULTS For different LUS signs, fair to good agreement was obtained (ICC = 0.601, 0.339, 0.334, and 0.557 for 0-3 points respectively). The overall interobserver variability was good for both the five different readers and consensus opinions (ICC = 0.618 and 0.607, respectively). There were good correlations between total LUS score and scores from three systems reflecting disease severity (R=0.394-0.660, p<0.01). CONCLUSION In conclusion, interobserver agreement for different signs and total scores in LUS is good and justifies its use in patients with COVID-19. The total scores of LUS are useful to indicate disease severity.
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Affiliation(s)
- H Xue
- Department of Ultrasound, Peking University Third Hospital, Beijing, 1000191, China
| | - C Li
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, 1000191, China
| | - L Cui
- Department of Ultrasound, Peking University Third Hospital, Beijing, 1000191, China
| | - C Tian
- Department of Emergency, Peking University Third Hospital, Beijing, 1000191, China
| | - S Li
- Department of Emergency, Peking University Third Hospital, Beijing, 1000191, China
| | - Z Wang
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, 1000191, China
| | - C Liu
- Department of Ultrasound, Peking University Third Hospital, Beijing, 1000191, China
| | - Q Ge
- Department of Critical Care Medicine, Peking University Third Hospital, Beijing, 1000191, China.
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Yun K, Oh J, Hong TH, Kim EY. Prediction of Mortality in Surgical Intensive Care Unit Patients Using Machine Learning Algorithms. Front Med (Lausanne) 2021; 8:621861. [PMID: 33869245 PMCID: PMC8044535 DOI: 10.3389/fmed.2021.621861] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/12/2021] [Indexed: 12/03/2022] Open
Abstract
Objective: Predicting prognosis of in-hospital patients is critical. However, it is challenging to accurately predict the life and death of certain patients at certain period. To determine whether machine learning algorithms could predict in-hospital death of critically ill patients with considerable accuracy and identify factors contributing to the prediction power. Materials and Methods: Using medical data of 1,384 patients admitted to the Surgical Intensive Care Unit (SICU) of our institution, we investigated whether machine learning algorithms could predict in-hospital death using demographic, laboratory, and other disease-related variables, and compared predictions using three different algorithmic methods. The outcome measurement was the incidence of unexpected postoperative mortality which was defined as mortality without pre-existing not-for-resuscitation order that occurred within 30 days of the surgery or within the same hospital stay as the surgery. Results: Machine learning algorithms trained with 43 variables successfully classified dead and live patients with very high accuracy. Most notably, the decision tree showed the higher classification results (Area Under the Receiver Operating Curve, AUC = 0.96) than the neural network classifier (AUC = 0.80). Further analysis provided the insight that serum albumin concentration, total prenatal nutritional intake, and peak dose of dopamine drug played an important role in predicting the mortality of SICU patients. Conclusion: Our results suggest that machine learning algorithms, especially the decision tree method, can provide information on structured and explainable decision flow and accurately predict hospital mortality in SICU hospitalized patients.
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Affiliation(s)
- Kyongsik Yun
- Computation and Neural Systems, California Institute of Technology, Pasadena, CA, United States
| | - Jihoon Oh
- Department of Psychiatry, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Tae Ho Hong
- Division of Hepato-Biliary and Pancreas Surgery, Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eun Young Kim
- Division of Trauma and Surgical Critical Care, Department of Surgery, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Performance and comparison of assessment models to predict 30-day mortality in patients with hospital-acquired pneumonia. Chin Med J (Engl) 2020; 133:2947-2952. [PMID: 33278090 PMCID: PMC7752693 DOI: 10.1097/cm9.0000000000001252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hospital-acquired pneumonia (HAP) is the most common hospital-acquired infection in China with substantial morbidity and mortality. But no specific risk assessment model has been well validated in patients with HAP. The aim of this study was to investigate the published risk assessment models that could potentially be used to predict 30-day mortality in HAP patients in non-surgical departments. METHODS This study was a single-center, retrospective study. In total, 223 patients diagnosed with HAP from 2012 to 2017 were included in this study. Clinical and laboratory data during the initial 24 hours after HAP diagnosis were collected to calculate the pneumonia severity index (PSI); consciousness, urea nitrogen, respiratory rate, blood pressure, and age ≥65 years (CURB-65); Acute Physiology and Chronic Health Evaluation II (APACHE II); Sequential Organ Failure Assessment (SOFA); and Quick Sequential Organ Failure Assessment (qSOFA) scores. The discriminatory power was tested by constructing receiver operating characteristic (ROC) curves, and the areas under the curve (AUCs) were calculated. RESULTS The all-cause 30-day mortality rate was 18.4% (41/223). The PSI, CURB-65, SOFA, APACHE II, and qSOFA scores were significantly higher in non-survivors than in survivors (all P < 0.001). The discriminatory abilities of the APACHE II and SOFA scores were better than those of the CURB-65 and qSOFA scores (ROC AUC: APACHE II vs. CURB-65, 0.863 vs. 0.744, Z = 3.055, P = 0.002; APACHE II vs. qSOFA, 0.863 vs. 0.767, Z = 3.017, P = 0.003; SOFA vs. CURB-65, 0.856 vs. 0.744, Z = 2.589, P = 0.010; SOFA vs. qSOFA, 0.856 vs. 0.767, Z = 2.170, P = 0.030). The cut-off values we defined for the SOFA, APACHE II, and qSOFA scores were 4, 14, and 1. CONCLUSIONS These results suggest that the APACHE II and SOFA scores determined during the initial 24 h after HAP diagnosis may be useful for the prediction of 30-day mortality in HAP patients in non-surgical departments. The qSOFA score may be a simple tool that can be used to quickly identify severe infections.
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McEnery T, Martin-Loeches I. Predicting ventilator-associated pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:670. [PMID: 32617290 PMCID: PMC7327331 DOI: 10.21037/atm.2020.03.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Tom McEnery
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland.,Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland.,Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland.,Hospital de Barcelona, IDIBAPS, CIBERes, Barcelona, Spain
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Zhao J, He Y, Xu P, Liu J, Ye S, Cao Y. Serum ammonia levels on admission for predicting sepsis patient mortality at D28 in the emergency department: A 2-center retrospective study. Medicine (Baltimore) 2020; 99:e19477. [PMID: 32176079 PMCID: PMC7220506 DOI: 10.1097/md.0000000000019477] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We assessed the predictive value of serum ammonia level on admission for the 28-day mortality of patients with sepsis.We retrospectively included septic patients admitted to the emergency department of West China Hospital, Sichuan University and The Fourth People's Hospital of Zigong city from June 2017 to May 2018. Patients were divided into 2 groups according to 28-day survival. Comparisons of serum ammonia level and sequential organ failure assessment (SOFA) score were made between 2 groups. Multivariate logistic regression models were employed to determine independent risk factors affecting 28-day mortality rate, and receiver operating characteristic (ROC) curve was also used to evaluate the efficacy of risk factors.Total of 316 patients were included into the study, 221 survived to 28 days and 95 were died before 28 days. The 28-day mortality rate was 30.06%. Multivariate logistic regression analyses revealed that the ammonia level, C reactive protein, SOFA score, and the leukocyte were independent risk factors for the 28-day mortality rate. In predicting the 28-day mortality rate, the SOFA score presented an area under the ROC curve (AUC) of 0.815, and the ammonia levels presented the AUC of 0.813.The ammonia level, C reactive protein, SOFA score, and the leukocyte are independent risk factors for 28-day mortality rate in septic patients. Moreover, the serum ammonia and SOFA score have similar predictive values. The serum ammonia level is also a suitable early indicator for prognostic evaluation of patients with sepsis as well.
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Affiliation(s)
- Jie Zhao
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Yarong He
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Ping Xu
- Emergency Department, The Fourth People's Hospital of Zigong City, Zigong
| | - Junzhao Liu
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Sheng Ye
- Emergency Department, West China Hospital, Sichuan University, Chengdu
| | - Yu Cao
- Emergency Department, West China Hospital, Sichuan University, Chengdu
- Disaster Medicine Center, Sichuan University, Chengdu, China
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17
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Yang WJ, Park E, Min YS, Huh JW, Kim AR, Oh HM, Nam TW, Jung TD. Association between clinical risk factors and severity of dysphagia after extubation based on a videofluoroscopic swallowing study. Korean J Intern Med 2020; 35:79-87. [PMID: 31935322 PMCID: PMC6960055 DOI: 10.3904/kjim.2018.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS This study aimed to evaluate the correlation between clinical risk factors of post-extubation dysphagia (PED) and the severity of impaired pharyngeal swallowing function assessed via videofluoroscopic swallowing studies (VFSSs). METHODS This study was a retrospective review of medical records. Of 116 patients who were admitted to the intensive care unit and underwent VFSS, 32 who had non-neurologic disorders and experienced prolonged intubation (for more than 48 hours) were diagnosed with PED. The severity of PED was evaluated by using a functional dysphagia scale (FDS) and a penetration aspiration scale (PAS), on the basis of VFSS. RESULTS The Simplified Acute Physiology Score 3 and total FDS score were positively correlated (r = 0.40, p = 0.02). Intubation duration was positively correlated with total PAS and FDS scores (r = 0.62, p < 0.001; r = 0.65, p < 0.001, respectively). The amounts of residue in the valleculae (RV) and pyriform sinuses (RP) were associated with intubation duration (r = 0.58, p < 0.001; r = 0.57, p < 0.001, respectively). Multivariate regression analysis revealed that intubation duration was significantly associated with the total FDS score, RV and RP subscales of the FDS, and total PAS score. CONCLUSION The severity of impaired swallowing function, particularly the amount of residue in the pharyngeal recesses assessed via VFSS, was strongly associated with both severity of medical illness and intubation duration. Intubation duration could be a prognostic factor for assessing impaired swallowing function on the basis of VFSS.
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Affiliation(s)
- Won-Jong Yang
- Department of Rehabilitation Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eunhee Park
- Department of Rehabilitation Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Yu-Sun Min
- Department of Rehabilitation Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jae-Won Huh
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Ae Ryoung Kim
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Hyun-Min Oh
- Department of Rehabilitation Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Tae-Woo Nam
- Department of Rehabilitation Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Tae-Du Jung
- Department of Rehabilitation Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
- Department of Rehabilitation Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
- Correspondence to Tae-Du Jung, M.D. Department of Rehabilitation Medicine, Kyungpook National University Chilgok Hospital, 807 Hoguk-ro, Buk-gu, Daegu 41404, Korea Tel: +82-53-200-2167 Fax: +82-53-200-2033 E-mail:
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Khorvash F, Yaghoubi S, Farsaei S, Ataei B, Hakamifard A, Mohajeri F, Gudarzi M. Comparison of two therapeutic approaches for the management of ventilator-associated pneumonia due to multidrug-resistant Acinetobacter: a randomized clinical trial study. J Immunoassay Immunochem 2019; 41:97-105. [PMID: 31777299 DOI: 10.1080/15321819.2019.1696818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Management of ventilator-associated pneumonia (VAP) is a puzzling issue for infectious disease specialist. The present clinical trial study was aimed to comparing the effects of injectable colistin plus nebulized colistin and injectable colistin plus nebulized tobramycin on management of patients with VAP due to multidrug-resistant Acinetobacter. VAP patients were randomly divided into two groups (n = 30/each): Group 1 - patients that received intravenous (IV) meropenem, injectable colistin plus nebulized colistin, as a routine treatment, and Group 2 - patients that received IV meropenem, injectable colistin plus nebulized tobramycin. A total of 14 days of therapeutic intervention are required for every case. Follow-up for subjects was performed at five time-points: days 1, 3, 5, 7, and 14 after intervention. Also, a mean of creatinine levels of patients was determined in five times. In the present study, the clinical pulmonary infection score (CPIS) was determined on the basis of points assigned for various clinically manifestations of VAP. Based on our statistical analysis, there was no significant difference between CPIS and creatinine level in both Groups 1 and 2 (p > .05). CPIS and other clinical investigation appeared effectiveness of the treatment with injected colistin plus nebulized tobramycin; on the other hand, the results of present clinical trial showed that aforementioned therapeutic approach can be used as an alternative treatment for the management of infection in VAP patients.
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Affiliation(s)
- Farzin Khorvash
- Acquired Immunodeficiency Research Center, Isfahan University of medical sciences, Isfahan, Iran
| | - Shoeleh Yaghoubi
- Department of infectious disease, School of medicine, Isfahan University of medical sciences, Isfahan, Iran
| | - Shadi Farsaei
- Department of clinical pharmacy and pharmacy practice, Isfahan University of medical sciences, Isfahan, Iran
| | - Behrooz Ataei
- Infectious disease and tropical medicine research center, Isfahan University of medical sciences, Isfahan, Iran
| | - Atousa Hakamifard
- Department of infectious disease, School of medicine, Isfahan University of medical sciences, Isfahan, Iran
| | - Fatemeh Mohajeri
- Department of infectious disease, School of medicine, Isfahan University of medical sciences, Isfahan, Iran
| | - Mohsen Gudarzi
- Department of infectious disease, School of medicine, Isfahan University of medical sciences, Isfahan, Iran
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Economos G, Cavalli P, Guérin T, Filbet M, Perceau-Chambard E. Quality of end-of-life care in the emergency department. Turk J Emerg Med 2019; 19:141-145. [PMID: 31687613 PMCID: PMC6819706 DOI: 10.1016/j.tjem.2019.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 12/21/2022] Open
Abstract
Objective To assess appropriateness of end-of-life treatments provided to actively dying patients attending the emergency department of a primary care hospital. Methods Retrospective cohort study of patients who died in the emergency department of a French primary care hospital between January 2014 and January 2017. The deceased were identified through the admissions register. Then, electronic medical records were screened for bio-demographic data, data relative to decisions to withhold or withdraw treatments, to diagnosis and to the care provided. Patients were clustered into two categories, actively dying or non-actively dying, using clinical opinion based on their medical records. Appropriateness of care was appraised following French guidelines. Results One hundred and forty-six deaths were recorded. Actively dying patients mostly suffered from vascular conditions (29.4%). When compared to the overall sample, they were more likely to have decisions to withhold or withdraw treatments (OR = 5.3 [1.56; 20.7], p-value = 0.003), to have strong opioids (OR = 5.32 [2.1; 13.9], p-value <0.0001), hypnotics (OR = 2.6 [0.95; 8.39], p-value = 0.05), and scopolamine (OR = 2.5 [1.1; 6.13], p-value = 0.03). Moreover, they were less likely to have unbeneficial treatments in terminal conditions, such as resuscitation care (OR = 0.06 [0.001; 0.52], p = 0.002) and antibiotics (OR = 0.42 [0.19; 0.92], p-value = 0.022). There were no differences in rate of hydration, venous access and use of tracheal aspirations. Conclusions Overall, actively dying patients were appropriately supported. However, several issues regarding hydration management, drug administration routes, and broncho-pulmonary secretions management remain to be addressed.
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Affiliation(s)
| | | | - Thomas Guérin
- Emergency Departement, Centre hospitalier de Roanne, France
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Liu W, Jiao Y, Xing H, Hai Y, Li H, Zhang K, Zhao Y, Yang Y, Xu B, Bai H, Bao H, Zhang S, Guo T. Active surveillance of ventilator-associated pneumonia in the intensive care unit and establishment of the risk grading system and effect evaluation. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:617. [PMID: 31930018 PMCID: PMC6944584 DOI: 10.21037/atm.2019.11.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/22/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND To discuss ventilator-associated pneumonia (VAP) patient's clinical characteristic and related factors in the intensive care unit (ICU), and to establish a risk grading system for VAP patients in the ICU in order to provide a reference for VAP prevention. METHODS A total of 1,513 patients in eight ICUs who received mechanical ventilation between June 2015 and June 2018 were randomized and into two groups, with 908 patients in the model group and 605 patients in the verification group. The model group was used to analyze the influencing factors of VAP and establish a risk grading system, while the verification group was used to verify the risk grading system. A receiver operating characteristic (ROC) curve was used to evaluate the predictive effect of the grading system. RESULTS During the 3-year study period, of the 1,513 total patients, 188 patients were infected with VAP, leading to an incidence rate of 12.43% (188/1,513) and an infection rate of 15.23‰ (188/12,347). ICU length of stay, mechanical ventilation days, frequency of oral care, unused subglottic secretion drainage, tracheotomy, APACHE II score, and combined antibiotics use were risk factors of VAP infection for patients who received mechanical ventilation in the modeling group (P<0.05). In a VAP risk-grading system established based on risk factors, the high, medium and low-grade patients had a statistically significantly different VAP infection rate in the model group, and patients with a high grade had a higher risk of VAP infection. Patients' data in the model and verification groups were used to draw a ROC curve which showed a good predictive effect. CONCLUSIONS This study establishes and verifies the VAP risk grading system for patients who receive mechanical ventilation. It is helpful in high-risk patient surveillance and in reducing and preventing VAP infection.
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Affiliation(s)
- Weiping Liu
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Yueying Jiao
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Huimin Xing
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Yunting Hai
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Haoxue Li
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Kai Zhang
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Yuping Zhao
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Yongfang Yang
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Binbin Xu
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Haibo Bai
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Huan Bao
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Shuai Zhang
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Tianhui Guo
- Department of Nosocomial Infection Control, Inner Mongolia People's Hospital, Hohhot 010017, China
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Shi Y, Huang Y, Zhang TT, Cao B, Wang H, Zhuo C, Ye F, Su X, Fan H, Xu JF, Zhang J, Lai GX, She DY, Zhang XY, He B, He LX, Liu YN, Qu JM. Chinese guidelines for the diagnosis and treatment of hospital-acquired pneumonia and ventilator-associated pneumonia in adults (2018 Edition). J Thorac Dis 2019; 11:2581-2616. [PMID: 31372297 PMCID: PMC6626807 DOI: 10.21037/jtd.2019.06.09] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Yi Shi
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Yi Huang
- Department of Pulmonary and Critical Care Medicine, Shanghai Changhai hospital, Navy Medical University, Shanghai 200433, China
| | - Tian-Tuo Zhang
- Department of Pulmonary and Critical Care Medicine, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Capital Medical University, Beijing 100029, China
| | - Hui Wang
- Department of Clinical Laboratory Medicine, Peking University People’s Hospital, Beijing 100044, China
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Feng Ye
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Su
- Department of Pulmonary and Critical Care Medicine, Nanjing Jinling Hospital, Nanjing University, School of Medicine, Nanjing 210002, China
| | - Hong Fan
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin-Fu Xu
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China
| | - Jing Zhang
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Guo-Xiang Lai
- Department of Pulmonary and Critical Care Medicine, Dongfang Hospital, Xiamen University, Fuzhou 350025, China
| | - Dan-Yang She
- Department of Pulmonary and Critical Care Medicine, the First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiang-Yan Zhang
- Department of Pulmonary and Critical Care Medicine, Guizhou Provincial People’s Hospital, Guizhou 550002, China
| | - Bei He
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing 100191, China
| | - Li-Xian He
- Department of Pulmonary Medicine, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - You-Ning Liu
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing 100853, China
| | - Jie-Ming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Li YT, Wang YC, Lee HL, Tsao SC, Lu MC, Yang SF. Monocyte Chemoattractant Protein-1, a Possible Biomarker of Multiorgan Failure and Mortality in Ventilator-Associated Pneumonia. Int J Mol Sci 2019; 20:ijms20092218. [PMID: 31064097 PMCID: PMC6539645 DOI: 10.3390/ijms20092218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 01/22/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) leads to increased patients’ mortality and medical expenditure. Monocyte chemoattractant protein-1 (MCP-1) plays a role in the pathogenesis of lung inflammation and infection. Therefore, the plasma concentration of MCP-1 was assessed and correlated with the clinical course in VAP patients. This retrospective observational study recruited 45 healthy volunteers, 12 non-VAP subjects, and 30 VAP patients. The diagnostic criteria for VAP were based on the American Thoracic Society guidelines, and the level of plasma MCP-1 was determined by ELISA. Plasma MCP-1 concentration was significantly elevated in the acute stage in VAP patients when compared with the control (p < 0.0001) and non-VAP patient groups (p = 0.0006). Subsequently, it was remarkably decreased following antibiotic treatment. Moreover, plasma MCP-1 concentration was positively correlated with indices of pulmonary dysfunction, including the lung injury score (p = 0.02) and the oxygenation index (p = 0.02). When patients with VAP developed adult respiratory distress syndrome (ARDS), their plasma MCP-1 concentrations were significantly higher than those of patients who did not develop ARDS (p = 0.04). Moreover, plasma MCP-1 concentration was highly correlated with organ failure scores, including simplified acute physiology score II (SAPS II, p < 0.0001), sequential organ failure assessment score (SOFA, p < 0.0001), organ dysfunctions and/or infection (ODIN, p < 0.0001), predisposition, insult response and organ dysfunction (PIRO, p = 0.005), and immunodeficiency, blood pressure, multilobular infiltrates on chest radiograph, platelets and hospitalization 10 days before onset of VAP (IBMP-10, p = 0.004). Our results demonstrate that plasma MCP-1 is an excellent marker for recognizing VAP when the cut-off level is set to 347.18 ng/mL (area under the curve (AUC) = 0.936, 95% CI = 0.863–0.977). In conclusion, MCP-1 not only could be a biological marker related to pulmonary dysfunction, organ failure, and mortality in patients with VAP, but also could be used for early recognition of VAP.
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Affiliation(s)
- Yia-Ting Li
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.
- Division of Respiratory Therapy, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan.
| | - Yao-Chen Wang
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan.
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.
| | - Hsiang-Lin Lee
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.
- Division of Gastroenterology, Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan.
| | - Su-Chin Tsao
- Department of Nursing, Chung Shan Medical University Hospital, Taichung 402, Taiwan.
| | - Min-Chi Lu
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung 404, Taiwan.
- Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung 402, Taiwan.
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan.
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan.
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Karakuzu Z, Iscimen R, Akalin H, Kelebek Girgin N, Kahveci F, Sinirtas M. Prognostic Risk Factors in Ventilator-Associated Pneumonia. Med Sci Monit 2018; 24:1321-1328. [PMID: 29503436 PMCID: PMC5848715 DOI: 10.12659/msm.905919] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a nosocomial infection commonly seen in patients in intensive care units (ICU). This study aimed to analyze factors affecting prognosis of patients diagnosed with VAP. MATERIAL AND METHODS Critically ill patients with VAP were retrospectively evaluated between June 2002 and June 2011 in the ICU. VAP diagnosis was made according to 2005 ATS/IDSA (Infectious Diseases Society of America/American Thoracic Society) criteria. First pneumonia attacks of patients were analyzed. RESULTS When early- and late-onset pneumonia causes were compared according to ICU and hospital admittance, resistant bacteria were found to be more common in pneumonias classified as early-onset according to ICU admittance. APACHE II score of >21 (p=0.016), SOFA score of >6 (p<0.001) on admission to ICU and SOFA score of >6 (p<0.001) on day of diagnosis are risk factors affecting mortality. Additionally, low PaO2/FIO2 ratio at onset of VAP had a negative effect on prognosis (p<0.001). SOFA score of >6 on the day of VAP diagnosis was an independent risk factor for mortality [(p<0.001; OR (95%CI): 1.4 (1.2-1.6)]. CONCLUSIONS Resistant bacteria might be present in early-onset VAP. Especially, taking LOS into consideration may better estimate the presence of resistant bacteria. Acinetobacter baumannii, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent causative microorganisms for VAP. SOFA score might be more valuable than APACHE II score. Frequently surveilling SOFA scores may improve predictive performance over time.
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Affiliation(s)
- Ziyaattin Karakuzu
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Remzi Iscimen
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Halis Akalin
- Department of Microbiology and Infectious Disease, Uludag University, School of Medicine, Bursa, Turkey
| | - Nermin Kelebek Girgin
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Ferda Kahveci
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Melda Sinirtas
- Department of Microbiology and Infectious Disease, Uludag University, School of Medicine, Bursa, Turkey
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Zheng S, Weng Q, Wu W, Ding G. Blood purification treatment initiated at the time of sepsis diagnosis effectively attenuates serum HMGB1 upregulation and improves patient prognosis. Exp Ther Med 2017; 14:3029-3035. [PMID: 28912856 PMCID: PMC5585716 DOI: 10.3892/etm.2017.4854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 05/05/2017] [Indexed: 01/21/2023] Open
Abstract
The aim of the present study was to investigate the increase in serum and urine levels of high mobility group box protein 1 (HMGB1) during sepsis and the effect of blood purification treatments on HMGB1 levels and patient prognosis. A total of 40 intensive care patients with sepsis were randomly assigned to different groups (n=10 per group): A control group (sepsis group), a continuous renal replacement treatment (CRRT) group, a hemoperfusion (HP) group and an HP+CRRT group. The blood purification treatments using HP and/or CRRT were performed immediately after the diagnosis of sepsis. HMGB1 levels were measured using ELISA, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and 30-day survival rates were evaluated. Relative to a healthy control group (n=10), HMGB1 levels were observed to be significantly upregulated during sepsis (P<0.05). Following the initiation of sepsis, serum HMGB1 continued to increase in the sepsis group and was significantly elevated at 24 h (P<0.05), whereas urine HMGB1 levels decreased significantly at 12 and 24 h (P<0.05). Serum HMGB1 levels were significantly positively correlated with APACHE II scores (r=0.7284, P<0.01) and significantly negatively correlated with urine HMGB1 levels (r=−0.5103, P=0.026). Serum HMGB1 levels were significantly reduced in the HP and HP+CRRT groups by 12 and 24 h following the initiation of treatment (both P<0.05). Changes in the urine HMGB1 level differed in each group. Relative to the sepsis group, the APACHE II scores of all blood purification groups were significantly reduced (P<0.05) and the 30-day survival rate of the HP+CRRT group was significantly increased (P=0.0107). The results of the present study indicate that blood purification initiated at the point of diagnosis in patients with sepsis may attenuate serum HMGB1 upregulation, promote urinary excretion of HMGB1 and improve the prognosis of sepsis.
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Affiliation(s)
- Shixiang Zheng
- Division of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Qinyong Weng
- Division of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Wenwei Wu
- Division of Critical Care Medicine, Union Hospital of Fujian Medical University, Fuzhou, Fujian 350001, P.R. China
| | - Guohua Ding
- Division of Nephrology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430000, P.R. China
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Abstract
BACKGROUND Patient- and family-centered care permeates critical care where there are often multiple teams involved in management. A method of facilitating information sharing to support shared decision making is essential in appropriately rendering care.This study sought to determine whether incorporating family members on rounds in the intensive care unit (ICU) improves patient and family knowledge and whether doing so improves team time management and satisfaction with the process. METHODS A nonrandomized comparative before-and-after trial of incorporating family members on rounds (July to December 2009 vs January to July 2010) in a single quarternary center's surgical ICU assessed (1) family members' knowledge, (2) nurse's and physician's satisfaction with the intervention, (3) frequency and timing of family meetings, and (4) physician's workflow. RESULTS Intensive care unit demographics and use were similar between time frames. Presurvey (n = 412 family members; 49 nurses) and postsurvey (n = 427 family members; 47 nurses) were coupled with presurvey (n = 5) and postsurvey (n = 6) physicians' informal feedback. Family knowledge of the clinical course and plans increased from 146 (35.4%) of 412 to 374 (87.6%) of 427 (p < 0.0001). Nurses were nearly uniformly satisfied with planned family interaction on rounds (presurvey: 9/49 [18.4%] vs postsurvey: 46/47 [97.9%]; p < 0.0001). Family meetings per week outside of rounds substantially decreased from a mean of 5.3 ± 2.7 to 0.3 ± 0.9; p < 0.001). Goals of therapy including end-of-life care became an element frequently discussed on rounds with families (presurvey: 9.4% ± 4.7% vs postsurvey: 82.5% ± 14.8%; p < 0.0001). One intensivist was dissatisfied with the process. CONCLUSION Incorporating family members on rounds in the ICU improves communication and satisfaction and shifts the team's time away from family communication events outside of rounds, condensing most of those activities within the rounding structure. Critical care nurses and intensivists were principally satisfied with the process. LEVEL OF EVIDENCE Therapeutic, level III.
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Khan RA, Aziz Z. A retrospective study of antibiotic de-escalation in patients with ventilator-associated pneumonia in Malaysia. Int J Clin Pharm 2017. [DOI: 10.1007/s11096-017-0499-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Srinivasan M, Shetty N, Gadekari S, Thunga G, Rao K, Kunhikatta V. Comparison of the Nosocomial Pneumonia Mortality Prediction (NPMP) model with standard mortality prediction tools. J Hosp Infect 2017; 96:250-255. [PMID: 28506672 DOI: 10.1016/j.jhin.2017.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Severity or mortality prediction of nosocomial pneumonia could aid in the effective triage of patients and assisting physicians. AIM To compare various severity assessment scoring systems for predicting intensive care unit (ICU) mortality in nosocomial pneumonia patients. METHODS A prospective cohort study was conducted in a tertiary care university-affiliated hospital in Manipal, India. One hundred patients with nosocomial pneumonia, admitted in the ICUs who developed pneumonia after >48h of admission, were included. The Nosocomial Pneumonia Mortality Prediction (NPMP) model, developed in our hospital, was compared with Acute Physiology and Chronic Health Evaluation II (APACHE II), Mortality Probability Model II (MPM72 II), Simplified Acute Physiology Score II (SAPS II), Multiple Organ Dysfunction Score (MODS), Sequential Organ Failure Assessment (SOFA), Clinical Pulmonary Infection Score (CPIS), Ventilator-Associated Pneumonia Predisposition, Insult, Response, Organ dysfunction (VAP-PIRO). Data and clinical variables were collected on the day of pneumonia diagnosis. The outcome for the study was ICU mortality. The sensitivity and specificity of the various scoring systems was analysed by plotting receiver operating characteristic (ROC) curves and computing the area under the curve for each of the mortality predicting tools. FINDINGS NPMP, APACHE II, SAPS II, MPM72 II, SOFA, and VAP-PIRO were found to have similar and acceptable discrimination power as assessed by the area under the ROC curve. The AUC values for the above scores ranged from 0.735 to 0.762. CPIS and MODS showed least discrimination. CONCLUSION NPMP is a specific tool to predict mortality in nosocomial pneumonia and is comparable to other standard scores.
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Affiliation(s)
- M Srinivasan
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - N Shetty
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - S Gadekari
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - G Thunga
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India
| | - K Rao
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - V Kunhikatta
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, Karnataka, India.
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Risk prediction models for mortality in patients with ventilator-associated pneumonia: A systematic review and meta-analysis. J Crit Care 2016; 37:112-118. [PMID: 27676171 DOI: 10.1016/j.jcrc.2016.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/01/2016] [Accepted: 09/03/2016] [Indexed: 01/15/2023]
Abstract
PURPOSE Ventilator-associated pneumonia (VAP) is a common and serious complication in patients requiring mechanical ventilation in the intensive care unit. The aims of this study were to identify models used to predict mortality in VAP patients and to assess their prognostic accuracy. METHODS The PubMed and EMBASE were searched in February 2016. We included studies in English that evaluated models' ability to predict the risk of mortality in patients with VAP. The reported mortality with the longest follow-up was used in the meta-analysis. Prognostic accuracy was measured with the area under the receiver operator characteristic curve (AUC). RESULTS We identified 19 articles studying 7 different models' ability to predict mortality in VAP patients. The models were Acute Physiology and Chronic Health Evaluation (APACHE) II (9 studies, n = 1398); Clinical Pulmonary Infection Score (4 studies, n = 303); "Immunodeficiency, Blood pressure, Multilobular infiltrates on chest radiograph, Platelets and hospitalization 10 days before onset of VAP" (3 studies, n = 406); "VAP Predisposition, Insult Response and Organ dysfunction" (2 studies, n = 589); Sequential Organ Failure Assessment (7 studies, n = 1019); Simplified Acute Physiology Score II (6 studies, n = 1043); and APACHE III (1 study, n = 198). APACHE II had the highest pooled AUC (95% confidence intervals), 0.72 (0.64-0.80), and CPIS had the lowest pooled AUC, 0.64 (0.55-0.72). CONCLUSION We identified 7 models that have been evaluated for their ability to predict mortality in patients with VAP. The models had nearly equal predictive accuracies, although some models are more complex and time consuming.
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Hosseini M, Ramazani J. Evaluation of Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scoring systems for prognostication of outcomes among Intensive Care Unit's patients. Saudi J Anaesth 2016; 10:168-73. [PMID: 27051367 PMCID: PMC4799608 DOI: 10.4103/1658-354x.168817] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Context: Acute Physiology and Chronic Health Evaluation II (APACHE II) and sequential organ failure assessment (SOFA) are of the most validated and prevalent general scoring systems over the world. Aims: The aim of the current study was to evaluate APACHE II and SOFA ability in predicting the outcomes (survivors, nonsurvivors) in surgical and medical Intensive Care Unit (ICU). Setting and Design: This was an observational and prospective study of 300 consecutive patients admitted in surgical and medical ICU during a 6-month period. Materials and Methods: APACHE II and SOFA scores and demographic characteristics were recorded for each patient separately in the first admission 24 h. Statistical Analysis Used: Receiver operator characteristic (ROC) curves, Hosmer–Lemeshow test, and logistic regression were used in the statistical analysis (95% confidence interval). Results: Data analysis showed a significant statistical difference in APACHE II and SOFA scores between survivor and nonsurvivor patients (P < 0.0001, P = 0.001; respectively). The discrimination power was acceptable for APACHE II and poor for SOFA (area under ROC [AUC] curve: 73.7% (standard error [SE]: 3.2%), 63.4% [SE: 3.6%]; respectively). The acceptable calibration was seen just for SOFA (χ2 = 11.018, P = 0.051). Conclusions: Both APACHE II and SOFA showed good predictive accuracy for results in surgical and medical ICUs; however, the SOFA is the choice to select, because of being simpler and easier to record data.
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Affiliation(s)
- M Hosseini
- Faculty Member, Department of Nursing, North Khorasan University of Medical Sciences, North Khorasan Province, Iran
| | - J Ramazani
- Faculty Member, Department of Nursing, Islamic Azad University, Bojnord, North Khorasan Province, Iran
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Bor C, Demirag K, Okcu O, Cankayali I, Uyar M. Ventilator-associated pneumonia in critically ill patients with intensive antibiotic usage. Pak J Med Sci 2016; 31:1441-6. [PMID: 26870112 PMCID: PMC4744297 DOI: 10.12669/pjms.316.8038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: Ventilator-associated pneumonia (VAP) is an infection with high mortality and morbidity that prolongs the length of stay in the intensive care unit (ICU) and hospitalisation. VAP is one of the most common infections in critically ill patients. This study aimed to prospectively determine the VAP rate and associated factors in critically ill patients with intensive antibiotic usage during a one-year period. Methods: In total, 125 out of 360 patients admitted to the intensive care unit during the one-year study period (September 2010-2011) were included for follow-up for VAP diagnosis. Demographic data, APACHE II scores, diagnoses on admission, clinical pulmonary infection scores (CPIS), CRP, procalcitonin, risk factors for infection, time to VAP diagnosis, and bacteriological culture results were recorded. All data were assessed in terms of ICU, hospital and 28-day mortality. Results: In total, 56 (45%) out of 125 patients were diagnosed with VAP. In addition, 91% of patients diagnosed with VAP were administered antibiotics before diagnosis. In the VAP patients, the mortality rates were 48, 68 and 71% for 28-day, ICU and hospital mortality, respectively. Conclusion: The coexistence of clinical and microbiological parameters should not be sought when diagnosing VAP in patients who use antibiotics intensively. VAP can be diagnosed when CPIS≤6 in cases with sufficient microbiological evidence. This strategy may decrease mortality by preventing a delay in therapy.
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Affiliation(s)
- Canan Bor
- Canan Bor, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey
| | - Kubilay Demirag
- Kubilay Demirag, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey
| | - Ozlem Okcu
- Ozlem Okcu, Department of Radiology, Ege University School of Medicine Hospital, Izmir, Turkey
| | - Ilkin Cankayali
- Ilkin Cankayali, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey
| | - Mehmet Uyar
- Mehmet Uyar, Department of Anaesthesiology and Intensive Care Unit, Ege University School of Medicine Hospital, Izmir, Turkey
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Li YT, Wang YC, Lee HL, Lu MC, Yang SF. Elevated Plasma Matrix Metalloproteinase-9 and Its Correlations with Severity of Disease in Patients with Ventilator-Associated Pneumonia. Int J Med Sci 2016; 13:638-45. [PMID: 27499696 PMCID: PMC4974912 DOI: 10.7150/ijms.16187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/13/2016] [Indexed: 02/07/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) increases patient mortality and medical expenditure, and a real-time and reliable method for the rapid diagnosis of VAP may help reduce fatal complications. Matrix metalloproteinases-9 (MMP-9) is considered significant in the pathogenesis of lung inflammation and infection. Therefore, we examined its relationship with the clinical course of VAP. This retrospective observational study recruited 30 healthy volunteers, 12 patients who used mechanical ventilation without the development of VAP (hereafter, patients without VAP), and 30 patients with a clinical diagnosis of VAP (hereafter, patients with VAP). The activity and level of plasma MMP-9 were determined through a gelatin zymography assay and ELISA. Our results report that both plasma MMP-9 activity and concentration were significantly elevated in the acute stage of patients with VAP when compared with control group and patients without VAP (p < 0.001). Subsequently, the plasma MMP-9 of patients with VAP decreased significantly after antibiotic treatment. Furthermore, plasma MMP-9 concentration was positively correlated with the clinical pulmonary infection score (r = 0.409, p = 0.007), WBCs (r = 0.620, p < 0.001), and neutrophils counts (r = 0.335, p = 0.035). In addition, plasma MMP-9 is an excellent tool for recognizing VAP when the cutoff level is set to 92.62 ng/mL (AUC = 0.863, 95% CI = 0.761 to 0.932). In conclusions, we concluded that MMP-9 levels play a role in the development of VAP and might have the potential to be applied in the development of VAP therapies.
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Affiliation(s)
- Yia-Ting Li
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan;; Division of Respiratory Therapy, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yao-Chen Wang
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan;; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hsiang-Lin Lee
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan;; Division of Gastroenterology, Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Min-Chi Lu
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan;; Department of Microbiology and Immunology, School of Medicine, China Medical University, Taichung, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan;; Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
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AlOtair HA, Hussein MA, Elhoseny MA, Alzeer AH, Khan MF. Severe pneumonia requiring ICU admission: Revisited. J Taibah Univ Med Sci 2015. [DOI: 10.1016/j.jtumed.2015.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Lee HW, Min J, Park J, Lee YJ, Kim SJ, Park JS, Yoon HI, Lee JH, Lee CT, Cho YJ. Clinical impact of early bronchoscopy in mechanically ventilated patients with aspiration pneumonia. Respirology 2015; 20:1115-22. [PMID: 26147124 DOI: 10.1111/resp.12590] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/22/2015] [Accepted: 04/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE A handful of studies have reported that bronchoscopies influence the clinical outcome of mechanically ventilated patients with aspiration pneumonia. The purpose of the present study is to elucidate the therapeutic role of early bronchoscopy in patients with aspiration who are mechanically ventilated. METHODS A retrospective cohort study was conducted via medical record review from 2003 through 2013 in a tertiary hospital. All the diagnoses of pneumonia were supported by the probability of aspiration and consolidation of dependent areas confirmed by computed tomography. Patients who underwent bronchoscopy within 24 h after intubation were categorized as the early bronchoscopy group and the others as the late bronchoscopy group. We compared the demographics, clinical parameters and outcomes between the two groups. RESULTS Of the 154 patients who were included, the early bronchoscopy group (n = 93) showed significantly lower in-intensive care unit (ICU) mortality and 90-day mortality (in-ICU: 4.9% vs 24.6%; 90-day: 11.8 vs 32.8%) regardless of the initial empirical antibiotics. In addition, their sequential organ failure assessment score on day 7 tended to decrease more rapidly. Among the survivors, patients in the early bronchoscopy group were extubated earlier with a higher success rate, had a shorter length of mechanical ventilation and had a shorter ICU stay. The early bronchoscopy was associated with lower 90-day mortality in multivariate analysis (odds ratio: 0.412; 95% confidence interval: 0.192-0.883). CONCLUSIONS Early bronchoscopy could benefit the clinical outcomes of mechanically ventilated patients with aspiration pneumonia.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jinsoo Min
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jisoo Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Se Joong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jae-Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
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Rendón-Ramirez EJ, Ortiz-Stern A, Martinez-Mejia C, Salinas-Carmona MC, Rendon A, Mata-Tijerina VL, Rosas-Taraco AG. TGF-β Blood Levels Distinguish Between Influenza A (H1N1)pdm09 Virus Sepsis and Sepsis due to Other Forms of Community-Acquired Pneumonia. Viral Immunol 2015; 28:248-54. [PMID: 25923384 DOI: 10.1089/vim.2014.0123] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
There is a strong interest in finding adequate biomarkers to aid in the diagnosis and prognosis of influenza A (H1N1)pdm09 virus infection. In this study, serum levels of inflammatory cytokines and laboratory markers were evaluated to assess their usefulness as biomarkers of influenza A (H1N1)pdm09 and their association with fatal cases. Serum samples of consecutive patients with a clinical presentation suggestive of influenza A (H1N1)pdm09 and progression to sepsis were evaluated. Serum inflammatory cytokines and routine laboratory tests were performed and correlated with positivity for influenza A (H1N1)pdm09 influenza by real time reverse transcription polymerase chain reaction and the results of three clinical severity scores (Sequential Organ Failure Assessment [SOFA], CURB-65, and Acute Physiology and Chronic Health Evaluation II [APACHE II]). High SOFA scores and some of its individual components, but not CURB-65 or APACHE II scores, correlate with fatal cases regardless of etiology. Total and unconjugated bilirubin, Ca(++), Cl(-), prothrombin times, and partial thromboplastin times discriminate influenza A (H1N1)pdm09 from other causes of community-acquired pneumonia. High levels of IL-8, IL-10, and IL-17 were increased in influenza A (H1N1)pdm09 patients when compared with controls (p<0.05). IL-6 levels were significantly elevated in influenza A (H1N1)pdm09 patients and non-(H1N1)pdm09 patients when compared with controls (p<0.05). TGF-β serum levels discern between healthy controls, influenza A (H1N1)pdm09 patients, and patients with other causes of community-acquired pneumonia. TGF-β levels were negatively correlated with SOFA on admission in influenza A (H1N1)pdm09 patients. TGF-β levels are a useful tool for differentiating influenza A (H1N1)pdm09 from other causes of pneumonia progressing to sepsis.
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Affiliation(s)
- Erick J Rendón-Ramirez
- 1Department of Immunology, Faculty of Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,2Department of Internal Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Alejandro Ortiz-Stern
- 1Department of Immunology, Faculty of Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,2Department of Internal Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Corazon Martinez-Mejia
- 1Department of Immunology, Faculty of Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,2Department of Internal Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Mario C Salinas-Carmona
- 1Department of Immunology, Faculty of Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,2Department of Internal Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Adrian Rendon
- 3CIPTIR (Centro de Investigación, Prevención y Tratamiento de Infecciones Respiratorias), Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Viviana L Mata-Tijerina
- 4Centro de Investigaciones Biomédicas del Noreste del Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Adrian G Rosas-Taraco
- 1Department of Immunology, Faculty of Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,2Department of Internal Medicine, Universidad Autónoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
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Naeini AE, Abbasi S, Haghighipour S, Shirani K. Comparing the APACHE II score and IBM-10 score for predicting mortality in patients with ventilator-associated pneumonia. Adv Biomed Res 2015; 4:47. [PMID: 25789273 PMCID: PMC4358029 DOI: 10.4103/2277-9175.151419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/31/2014] [Indexed: 01/25/2023] Open
Abstract
Background: VAP is defined as pneumonia in patients who use ventilators. The acute physiology and chronic health evaluation (APACHE II) scoring system was originally developed for predicting mortality in patients who were admitted to the intensive care unit. Due to the complexity, a simpler score called IBMP-10 was developed. We designed the study to confirm and further investigate these two methods. Materials and Methods: This cross-sectional and analysis-descriptive study was done at the moment of VAP diagnosis on 60 patients in intensive care units. APACHE II and the IBMP-10 scores were calculated. ROC curves were generated to compare the new prediction rule with the APACHE II score. Results were reported as adjusted odds ratios with 95% confidence intervals (CIs). Analyses were performed using SPSS, version 20 and P values of 0.05 were considered to be statistically significant. Results: APACHE II Score means (P < 0.001) and IBMP-10 score (P < 0.001) means had significant increase in Non-survivor patient than in patients who survived. APACHE II can be used as a good prediction measure for mortality rate. In IBMP-10 method, specificity and PPV were greater than APACHE II, but in mc-nemar test, there was no significant difference between the two methods (P = 0.55). Both prediction rules had high NPV. In our study, survivors’ prediction value in APACHE II was 46.7%, and in IBMP-10, it was 46.7%. Conclusion: IBMP-10, compared to APACHE II, has greater sensitivity, specificity, and AUC to predict mortality. So the consequence of the use of IBMP-10 was better than APACHE II.
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Affiliation(s)
- Alireza Emami Naeini
- Department of Infectious and Tropical Medicine, Infectious Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeid Abbasi
- Department of Anesthesiology, Intensive Care Unit, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Haghighipour
- Department of Infectious and Tropical Medicine, Infectious Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Kiana Shirani
- Department of Infectious and Tropical Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Inchai J, Pothirat C, Liwsrisakun C, Deesomchok A, Kositsakulchai W, Chalermpanchai N. Ventilator-associated pneumonia: epidemiology and prognostic indicators of 30-day mortality. Jpn J Infect Dis 2014; 68:181-6. [PMID: 25672347 DOI: 10.7883/yoken.jjid.2014.282] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We conducted a retrospective cohort study in the medical intensive care unit of Chaing Mai University Hospital to describe the epidemiology of ventilator-associated pneumonia (VAP) and identify prognostic indicators of 30-day VAP mortality. A total of 621 patients diagnosed with VAP between January 2005 and December 2011 were included. The overall 30-day mortality rate was 44.4%. The major causative pathogens were Acinetobacter baumannii (54.3%), Pseudomonas aeruginosa (35.2%), and methicillin-resistant Staphylococcus aureus (15.1%). Most A. baumannii (90.2%) comprised drug-resistant strains. Identified prognostic indicators were co-morbid malignancy (hazard ratio [HR] = 1.60; 95% confidence interval [CI] 1.02-2.42; P = 0.040), septic shock (HR = 2.51; 95% CI, 1.60-4.00; P < 0.001), Simplified Acute Physiology Score II >45 (HR = 1.62; 95% CI, 1.03-2.56; P = 0.041), Sequential Organ Failure Assessment score >5 (HR = 3.40; 95% CI 2.00-5.81; P < 0.001), and delayed inappropriate empirical antibiotic treatment (HR = 2.23; 95% CI, 1.12-4.45; P = 0.022). VAP was associated with high mortality. The major causative pathogen was drug-resistant A. baumannii. Therefore, early detection of VAP by surveillance in mechanically ventilated patients leading to earlier treatment may improve patient outcomes. Guidelines for prescribing appropriate empirical antibiotics to cover drug-resistant bacteria could be established using local epidemiological data.
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Affiliation(s)
- Juthamas Inchai
- Division of Pulmonary, Critical Care and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
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A comparison of APACHE II and CPIS scores for the prediction of 30-day mortality in patients with ventilator-associated pneumonia. Int J Infect Dis 2014; 30:144-7. [PMID: 25461659 DOI: 10.1016/j.ijid.2014.11.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 10/26/2014] [Accepted: 11/05/2014] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The aim of this study was to compare the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Clinical Pulmonary Infection Score (CPIS) for the prediction of 30-day mortality in patients with ventilator-associated pneumonia (VAP). METHODS A single-center, prospective cohort study design was employed between January 1, 2010 and January 1, 2014. APACHE II and CPIS scores were determined on the day of VAP diagnosis. Discrimination was tested using receiver-operating characteristic (ROC) curves and the areas under the curve (AUC). Calibration was tested using the Hosmer-Lemeshow statistic. RESULTS Of 135 patients with VAP, 39 died; the 30-day mortality was 28.9%. APACHE II and CPIS scores were significantly higher in non-survivors compared to survivors (23.1±4.8 vs. 16.7±4.6, p<0.001; 6.8±1.3 vs. 6.2±1.3, p=0.016). APACHE II had excellent discrimination for predicting 30-day mortality in patients with VAP, with AUC 0.808 (95% confidence interval (CI) 0.704-0.912, p<0.001). However, the CPIS score did not have discrimination power for predicting mortality, with AUC 0.612 (95% CI 0.485-0.739, p=0.083). The Hosmer-Lemeshow statistic showed good goodness-of-fit for observed 30-day mortality and APACHE II expected mortality (Chi-square=1.099, p=0.785). However, CPIS expected 30-day mortality did not fit the observed mortality (Chi-square=6.72, p=0.004). CONCLUSIONS These data suggest that APACHE II is useful for predicting 30-day mortality in patients with VAP, but that the CPIS does not have good discrimination and calibration for predicting mortality.
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Wang X, Wang J, Li J, Wang J. Analysis of ventilator-associated pneumonia infection route by genome macrorestriction-pulsed-field gel electrophoresis and its prevention with combined nursing strategies. Exp Ther Med 2014; 8:1922-1926. [PMID: 25371757 PMCID: PMC4217765 DOI: 10.3892/etm.2014.1994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 09/10/2014] [Indexed: 11/06/2022] Open
Abstract
The aim of the present study was to explore the infection route of ventilator-associated pneumonia (VAP) and assess the effectiveness of a combined nursing strategy to prevent VAP in intensive care units. Bacteria from the gastric juice and drainage from the hypolarynx and lower respiratory tracts of patients with VAP were analyzed using genome macrorestriction-pulsed-field gel electrophoresis (GM-PFGE). A total of 124 patients with tracheal intubation were placed in the intervention group and were treated with a combined nursing strategy, comprising mosapride (gastric motility stimulant) administration and semi-reclining positioning. A total of 112 intubated patients were placed in the control group and received routine nursing care. The incidence rate of VAP, days of ventilation and mortality rate of patients were compared between the two groups. The GM-PFGE fingerprinting results of three strains of Pseudomonas aeruginosa from the gastric juice, subglottic secretion drainage and drainage of the lower respiratory tract in patients with VAP were similar across groups. The number of days spent on a ventilator by patients in the intervention group (7.37±5.32 days) was lower compared with that by patients in the control group (12.34±4.98 days) (P<0.05). The incidence rate of VAP was reduced from 40.81 to 21.25% following intervention with the combined nursing strategy (P<0.05); furthermore, the mortality rate of intubated patients in the intervention group was 29.46%, a significant reduction compared with the 41.94% mortality rate observed in the control group (P<0.05). Gastroesophageal reflux (GER) was confirmed as one of the infection routes for VAP. The combined nursing strategy of gastric motility stimulant administration and the adoption of a semi-reclining position was effective in preventing VAP by reducing the occurrence of GER.
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Affiliation(s)
- Xiaodong Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Junping Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jing Li
- Department of Nursing, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Jing Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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Chronic obstructive pulmonary disease (COPD): evaluation from clinical, immunological and bacterial pathogenesis perspectives. J Microbiol 2014; 52:211-26. [PMID: 24585052 DOI: 10.1007/s12275-014-4068-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/08/2014] [Indexed: 01/09/2023]
Abstract
Chronic obstructive pulmonary disease (COPD), a disease manifested by significantly impaired airflow, afflicts ∼14.2 million cases in the United States alone with an estimated 63 million people world-wide. Although there are a number of causes, the predominant cause is excessive tobacco smoke. In fact, in China, there have been estimates of 315,000,000 people that smoke. Other less frequent causes are associated with indirect cigarette smoke, air pollutants, biomass fuels, and genetic mutations. COPD is often associated with heart disease, lung cancer, osteoporosis and conditions can worsen in patients with sudden falls. COPD also affects both innate and adaptive immune processes. Cigarette smoke increases the expression of matrix metalloproteases and proinflammatory chemokines and increases lung titers of natural killer cells and neutrophils. Yet, neutrophil reactive oxygen species (ROS) mediated by the phagocytic respiratory burst and phagocytosis is impaired by nicotine. In contrast to innate immunity in COPD, dendritic cells represent leukocytes recruited to the lung that link the innate immune responses to adaptive immune responses by activating naïve T cells through antigen presentation. The autoimmune process that is also a significant part of inflammation associated with COPD. Moreover, coupled with restricted FEV1 values, are the prevalence of patients with single or multiple infections by bacteria, viruses and fungi. Finally, we focus on one of the more problematic infectious agents, the Gram-negative opportunistic pathogenic bacterium, Pseudomonas aeruginosa. Specifically, we delve into the development of highly problematic biofilm infections that are highly refractory to conventional antibiotic therapies in COPD. We offer a non-conventional, biocidal treatment that may be effective for COPD airway infections as well as with combinations of current antibiotic regimens for more effective treatment outcomes and relief for patients with COPD.
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Yousef AAAM, Suliman GA. The predictive prognostic values of serum TNF-α in comparison to SOFA score monitoring in critically ill patients. BIOMED RESEARCH INTERNATIONAL 2013; 2013:258029. [PMID: 24175285 PMCID: PMC3791570 DOI: 10.1155/2013/258029] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/05/2013] [Accepted: 07/08/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of inflammatory markers to follow up critically ill patients is controversial. The short time frame, the need for frequent and serial measurement of biomarkers, the presence of soluble receptor and their relatively high cost are the major drawbacks. Our study's objective is to compare the prognostic values of serum TNF-α and SOFA score monitoring in critically ill patients. PATIENTS AND METHODS A total of ninety patients were included in the study. Forty-five patients developed septic complication (sepsis group). Forty-five patients were critically ill without evidence of infectious organism (SIRS group). Patients' data include clinical status, central venous pressure, and laboratory analysis were measured. A serum level of TNF-α and SOFA score were monitored. RESULTS Monitoring of TNF-α revealed significant elevation of TNF-α at 3rd and 5th days of ICU admission in both groups. Monitoring of SOFA score revealed significant elevation of SOFA scores in both groups throughout their ICU stay, particularly in nonsurvivors. Positive predictive ability of SOFA score was demonstrated in critically ill patients. CONCLUSION Transient significant increase in serum levels of TNF-α were detected in septic patients. Persistent elevation of SOFA score was detected in nonsurvivor septic patients. SOFA score is an independent prognostic value in critically ill patients.
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Peña C, Gómez-Zorrilla S, Oriol I, Tubau F, Dominguez MA, Pujol M, Ariza J. Impact of multidrug resistance on Pseudomonas aeruginosa ventilator-associated pneumonia outcome: predictors of early and crude mortality. Eur J Clin Microbiol Infect Dis 2013; 32:413-20. [PMID: 23344827 DOI: 10.1007/s10096-012-1758-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 10/02/2012] [Indexed: 01/23/2023]
Abstract
The prevalence of multidrug-resistant (MDR) Pseudomonas aeruginosa has increased over the past decade and a significant rise in these isolates in ventilator-associated pneumonia (VAP) has been observed. However, the impact of MDR on VAP outcome has not been analysed in depth. We investigated the risk factors for early and crude mortality in a retrospective study of microbiologically and clinically documented VAP. Ninety-one VAP episodes in 83 patients were included, 31 caused by susceptible P. aeruginosa and 60 by MDR strains, of which 42 (70 %) were extensively drug-resistant (XDR) P. aeruginosa. Thirteen episodes concomitantly presented P. aeruginosa bacteraemia, in seven of which the origin was the respiratory tract. Whereas susceptible P. aeruginosa episodes were more likely than MDR episodes to receive adequate empirical (68 % vs. 30 %; p < 0.001) and definitive antimicrobial therapy (96 % vs. 50 %; p < 0.001), susceptible P. aeruginosa VAP presented a trend towards early mortality (29 % vs. 15 %; p = 0.06). A logistic regression model with early mortality as the dependent variable identified multiorgan dysfunction syndrome (MODS) [odds ratio (OR) 10.4; 95 % confidence interval (CI) 1.7-63.5; p = 0.01] and inadequate antibiotic therapy (OR 4.27; 95 % CI 0.98-18.4; p = 0.052) as independent risk factors for early mortality. A similar analysis identified MODS (OR 4.31; 95 % CI 1.14-16.2; p = 0.03) as the only independent predictor of crude mortality. The severity of acute illness clinical presentation was the main predictor of mortality. Despite adequate antibiotic therapy, susceptible P. aeruginosa seems to cause major early mortality. Although adequate therapy is essential to treat VAP, the severity of acute illness is a more important factor than drug resistance.
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Affiliation(s)
- C Peña
- Infectious Diseases Service, IDIBELL, Hospital Universitari de Bellvitge, C/ Feixa Llarga S/n., L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
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Qiao Q, Lu G, Li M, Shen Y, Xu D. Prediction of outcome in critically ill elderly patients using APACHE II and SOFA scores. J Int Med Res 2013; 40:1114-21. [PMID: 22906285 DOI: 10.1177/147323001204000331] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Performances of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment (SOFA) score were assessed in predicting mortality outcome in critically ill elderly patients. METHODS Mean APACHE II and SOFA scores were compared in 106 intensive care unit patients aged > 65 years classified as survivors or deaths. The discriminatory ability of the scores was evaluated using the area under the receiver operating characteristic (ROC) curve. Calibration was assessed using the Hosmer-Lemeshow test. RESULTS Mean APACHE II and SOFA scores in survivors were lower than in those who died. There was a positive correlation between the APACHE II and SOFA scores. The area under the ROC curve was 0.76 for the APACHE II score and ranged from 0.74 for the initial SOFA score to 0.98 for the maximum SOFA score. Hosmer-Lemeshow values for the APACHE II score and various SOFA scores indicated that predictions based on these scores closely fit the observed outcomes. CONCLUSIONS APACHE II and SOFA scores can accurately predict mortality outcome in critically ill elderly patients, especially the maximum SOFA score and the difference between the maximum and initial SOFA scores.
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Affiliation(s)
- Q Qiao
- Department of Nephrology, First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu Province 215006, China.
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Lin Q, Fu F, Shen L, Zhu B. Pentraxin 3 in the assessment of ventilator-associated pneumonia: an early marker of severity. Heart Lung 2012; 42:139-45. [PMID: 23273657 DOI: 10.1016/j.hrtlng.2012.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 11/19/2012] [Accepted: 11/21/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The aim was to assess the diagnostic and prognostic value of measuring pentraxin 3 (PTX3) together with C-reactive protein (CRP) in patients with ventilator-associated pneumonia (VAP). BACKGROUND The PTX3 values increase rapidly during multiple inflammatory conditions, but little is known about its characteristics in VAP. METHODS Measurement of PTX3 and CRP levels in plasma from 136 consecutive patients receiving mechanical ventilation > 48 h in a prospective single center study. RESULTS A PTX3 threshold of >16.43 ng/ml provided a specificity of 74.0% and a sensitivity of 68.6% for the diagnosis of VAP. PTX3 correlated with severity of sepsis and peaked earlier than CRP in patients with confirmed VAP. Multivariate Cox regression analysis showed PTX3 was the independent predictor for mortality of VAP. CONCLUSIONS PTX3 was not superior to CRP as a biomarker to diagnose VAP, but it was an early indicator of inflammation and had better prognostic value to predict mortality than CRP.
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Affiliation(s)
- Qionghua Lin
- Department of Anaesthesia, Critical Care and Pain Medicine, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China
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Tseng CC, Liu SF, Wang CC, Tu ML, Chung YH, Lin MC, Fang WF. Impact of clinical severity index, infective pathogens, and initial empiric antibiotic use on hospital mortality in patients with ventilator-associated pneumonia. Am J Infect Control 2012; 40:648-52. [PMID: 22243991 DOI: 10.1016/j.ajic.2011.08.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 08/23/2011] [Accepted: 08/23/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The prompt initial use of appropriate antibiotics should improve mortality rates in adults with ventilator-associated pneumonia (VAP). However, the incidence of multidrug-resistant (MDR) pathogen infections is on the rise, and the choice of the initial empiric antibiotic may be challenging. We investigated whether appropriate initial antibiotic therapy, infective pathogens, and the clinical severity index influence hospital mortality in patients with VAP and determined independent risk factors for the same. METHODS This study evaluated 163 adult patients (aged ≥ 18 years) at Chang Gung Memorial Hospital, Kaohsiung, Taiwan, from January 1, 2007, to January 31, 2008. Eligibility was evaluated based on criteria for VAP. Sequential Organ Failure Assessment (SOFA) scores, Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) scores, oxygenation index, underlying comorbidities, septic shock status, previous tracheostomy status, and factors related to pneumonia were collected for analysis. RESULTS Ninety-two patients survived from a total 163 patients with VAP during the course of their confinement in the intensive care unit. Multivariable logistic regression analysis identified that a pre-existing Charlson Comorbidity Index score (P = .011), initial oxygenation index (P = .025), SOFA score (P = .043), VAP caused by Acinetobacter baumanii (P = .030), and infection with MDR pathogens (P = .003) were independent risk factors for hospital mortality in patients with VAP. CONCLUSION High Charlson Comorbidity Index score, high initial oxygenation index, high SOFA score, and infection with Acinetobacter baumannii or MDR pathogens significantly affect hospital mortality in patients with VAP.
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Affiliation(s)
- Chia-Cheng Tseng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Tseng CC, Huang KT, Chen YC, Wang CC, Liu SF, Tu ML, Chung YH, Fang WF, Lin MC. Factors predicting ventilator dependence in patients with ventilator-associated pneumonia. ScientificWorldJournal 2012; 2012:547241. [PMID: 22919335 PMCID: PMC3417186 DOI: 10.1100/2012/547241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 05/27/2012] [Indexed: 01/08/2023] Open
Abstract
Objectives. To determine risk factors associated with ventilator dependence in patients with ventilator-associated pneumonia (VAP). Study Design. A retrospective study was conducted at Chang Gung Memorial Hospital, Kaohsiung, from January 1, 2007 to January 31, 2008. Methods. This study evaluated 163 adult patients (aged ≥18 years). Eligibility was evaluated according to the criterion for VAP, Sequential Organ Failure Assessment (SOFA) score, Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) score. Oxygenation index, underlying comorbidities, septic shock status, previous tracheostomy status, and factors related to pneumonia were collected for analysis. Results. Of the 163 VAP patients in the study, 90 patients survived, yielding a mortality rate of 44.8%. Among the 90 surviving patients, only 36 (40%) had been weaned off ventilators at the time of discharge. Multivariate logistic regression analysis was used to identify underlying factors such as congestive cardiac failure (P = 0.009), initial high oxygenation index value (P = 0.04), increased SOFA scores (P = 0.01), and increased APACHE II scores (P = 0.02) as independent predictors of ventilator dependence. Results from the Kaplan-Meier method indicate that initial therapy with antibiotics could increase the ventilator weaning rate (log Rank test, P < 0.001). Conclusions. Preexisting cardiopulmonary function, high APACHE II and SOFA scores, and high oxygenation index were the strongest predictors of ventilator dependence. Initial empiric antibiotic treatment can improve ventilator weaning rates at the time of discharge.
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Affiliation(s)
- Chia-Cheng Tseng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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Huang HH, Chang SJ, Hsu CW, Chang TM, Kang SP, Liu MY. Severity of illness influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. J Acad Nutr Diet 2012; 112:1138-46. [PMID: 22682883 DOI: 10.1016/j.jand.2012.04.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 04/14/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few trials have studied the influence of illness severity on clinical outcomes of different tube-feeding routes. Whether gastric or postpyloric feeding route is more beneficial to patients receiving enteral nutrition remains controversial. OBJECTIVE To test whether illness severity influences the efficacy of enteral feeding route on clinical outcomes in patients with critical illness. DESIGN A 2-year prospective, randomized, clinical study was conducted to assess the differences between the nasogastric (NG) and nasoduodenal (ND) tube feedings on clinical outcomes. PARTICIPANTS/SETTING One hundred one medical adult intensive care unit (ICU) patients requiring enteral nutrition were enrolled in this study. INTERVENTION Patients were randomly assigned to the NG (n=51) or ND (n=50) feeding route during a 21-day study period. Illness severity was dichotomized as "less severe" and "more severe," with the cutoff set at Acute Physiology and Chronic Health Evaluation II score of 20. MAIN OUTCOME MEASURES Daily energy and protein intake, feeding complications (eg, gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, hospital mortality, nitrogen balance, albumin, and prealbumin. STATISTICAL ANALYSES PERFORMED Two-tailed Student t tests and Mann-Whitney U tests were used to analyze significant differences between variables in the study groups. Multiple regression was used to assess the effects of illness severity and enteral feeding routes on clinical outcomes. RESULTS Among less severely ill patients, no differences existed between the NG and ND groups in daily energy and protein intake, feeding complications, length of ICU stay, and nitrogen balance. Among more severely ill patients, the NG group experienced lower energy and protein intake, more tube feeding complications, longer ICU stay, and poorer nitrogen balance than the ND group. CONCLUSIONS To optimize nutritional support and taking medical resources into account, the gastric feeding route is recommended for less severely ill patients and the postpyloric feeding route for more severely ill patients.
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Affiliation(s)
- Hsiu-Hua Huang
- Department of Life Sciences, College of Bioscience and Biotechnology, National Cheng Kung University, No. 1 University Rd., Tainan City 701, Taiwan
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Huang HH, Hsu CW, Kang SP, Liu MY, Chang SJ. Association between illness severity and timing of initial enteral feeding in critically ill patients: a retrospective observational study. Nutr J 2012; 11:30. [PMID: 22554240 PMCID: PMC3436719 DOI: 10.1186/1475-2891-11-30] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 05/03/2012] [Indexed: 12/26/2022] Open
Abstract
Background Early enteral nutrition is recommended in cases of critical illness. It is unclear whether this recommendation is of most benefit to extremely ill patients. We aim to determine the association between illness severity and commencement of enteral feeding. Methods One hundred and eight critically ill patients were grouped as “less severe” and “more severe” for this cross-sectional, retrospective observational study. The cut off value was based on Acute Physiology and Chronic Health Evaluation II score 20. Patients who received enteral feeding within 48 h of medical intensive care unit (ICU) admission were considered early feeding cases otherwise they were assessed as late feeding cases. Feeding complications (gastric retention/vomiting/diarrhea/gastrointestinal bleeding), length of ICU stay, length of hospital stay, ventilator-associated pneumonia, hospital mortality, nutritional intake, serum albumin, serum prealbumin, nitrogen balance (NB), and 24-h urinary urea nitrogen data were collected over 21 days. Results There were no differences in measured outcomes between early and late feedings for less severely ill patients. Among more severely ill patients, however, the early feeding group showed improved serum albumin (p = 0.036) and prealbumin (p = 0.014) but worsened NB (p = 0.01), more feeding complications (p = 0.005), and prolonged ICU stays (p = 0.005) compared to their late feeding counterparts. Conclusions There is a significant association between severity of illness and timing of enteral feeding initiation. In more severe illness, early feeding was associated with improved nutritional outcomes, while late feeding was associated with reduced feeding complications and length of ICU stay. However, the feeding complications of more severely ill early feeders can be handled without significantly affecting nutritional intake and there is no eventual difference in length of hospital stay or mortality between groups. Consequently, early feeding shows to be a more beneficial nutritional intervention option than late feeding in patients with more severe illness.
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Affiliation(s)
- Hsiu-Hua Huang
- Department of Life Sciences, College of Bioscience and Biotechnology, National Cheng Kung University, No,1, University Rd,, Tainan City 701, Taiwan
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Furtado GH, Wiskirchen DE, Kuti JL, Nicolau DP. Performance of the PIRO score for predicting mortality in patients with ventilator-associated pneumonia. Anaesth Intensive Care 2012; 40:285-91. [PMID: 22417023 DOI: 10.1177/0310057x1204000211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ventilator-associated pneumonia (VAP) PIRO score is a new scoring system based on the PIRO concept. The aim of this study was to validate the PIRO score against the Acute Physiology and Chronic Health Evaluation (APACHE) II and VAP APACHE II in an independent group of VAP patients. Areas under the receiver operating characteristic curves were compared to determine the tests' abilities to predict intensive care unit and 28-day mortality. Variables associated with intensive care unit mortality were evaluated. One hundred and forty-eight intensive care unit patients who met radiographic and clinical criteria for VAP were included. The area under the receiver operating characteristic curves for predicting intensive care unit mortality with the PIRO, APACHE II and VAP APACHE II scores were 0.605 (P=0.03), 0.631 (P=0.01) and 0.724 (P <0.0001), respectively. Areas under the receiver operating characteristic curve for predicting 28-day mortality were 0.614 (P=0.01) for PIRO, 0.633 (P=0.01) for APACHE II and 0.697 (P=0.002) for VAP APACHE II. No differences in area under the receiver operating characteristic curve between scores were found at either endpoint. Variables independently associated with intensive care unit mortality were bacteraemia (adjusted odds ratio 7.16, 95% confidence interval 1.19 to 42.98, P=0.03) and APACHE II (1.06, 1.01 to 1.11, P=0.006). VAP PIRO score was not a good predictor of intensive care unit and 28-day mortality. The low sensitivity and specificity of VAP PIRO score preclude its use clinically.
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Affiliation(s)
- G H Furtado
- Center for Anti-Infective Research and Development, Division of Infectious Diseases, Hartford Hospital, Connecticut, USA.
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Early tracheostomy decreases ventilation time but has no impact on mortality of intensive care patients: a randomized study. Langenbecks Arch Surg 2012; 397:1001-8. [PMID: 22322214 DOI: 10.1007/s00423-011-0873-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 11/03/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Long-term ventilation in intensive care units (ICUs) is associated with several problems such as increased mortality, increased rates of ventilator-associated pneumonia (VAP), and prolonged time of hospitalization, and thus leads to enormous healthcare expenditure. While the influence of tracheostomy on VAP incidence, duration of ventilation, and time of hospitalization has already been analyzed in several studies, the timing of the tracheostomy procedure on patient's mortality is still controversial. The aim of our study was to investigate whether early tracheostomy improved outcome in critically ill patients. MATERIALS AND METHODS Within 2 years, 100 critically ill, predominantly surgical patients entered this prospective randomized study. A percutaneous dilatational tracheostomy was performed either early (≤4 days, 2.8 days median) or late (≥6 days, 8.1 days median) after intubation. RESULTS We could demonstrate that mortality was not significantly reduced in the early tracheostomy (ET) group in contrast to the late tracheostomy (LT) group. ET was associated with decreased VAP incidence (ET 38% vs. LT 64%), decreased duration of ventilation (ET 367.5 h vs LT 507.5 h), and shorter time of hospitalization both in hospital (ET 31.5 days vs LT 68 days) and in ICU (ET 21.5 days vs LT 27 days). CONCLUSION Despite many advantages like reduced time of ventilation and hospitalization, early tracheostomy is not associated with decreased mortality in critically ill patients.
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