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Costa P, Silva AR, Carones A, Teixeira S, Coimbra P. Stroke and Multiorgan Failure as the Initial Manifestations of Lupus. Cureus 2024; 16:e57980. [PMID: 38738098 PMCID: PMC11087013 DOI: 10.7759/cureus.57980] [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] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a persistent autoimmune disorder that manifests across a spectrum ranging from mild to severe disease, often requiring hospitalization and critical care management. We present a severe case of systemic involvement at its onset. A young woman, with a background of arterial hypertension, presented to the emergency department exhibiting a total anterior circulation stroke and exuberant symmetric lower limb edema. Her condition rapidly deteriorated with neurological impairment, respiratory failure requiring mechanical ventilation, and acute kidney injury prompting her admission to the ICU. Following clinical investigation, a diagnosis of SLE was established, according to the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) 2019 and Systemic Lupus International Collaborating Clinics (SLICC) 2012 classification criteria. The patient underwent treatment involving high-dose corticosteroids, followed by the Euro-Lupus protocol, resulting in significant improvement, despite her severe neurological deficit at admission. Lupus is a complex disease that is often difficult to diagnose because of its potential to mimic various other conditions. Our report delves into a case of previously undiagnosed lupus leading the patient to the ICU. The clinical scenario described adds valuable insights to the understanding of lupus-related complications and their management through a multidisciplinary approach.
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Affiliation(s)
- Patrícia Costa
- Intensive Care Unit, Coimbra University Hospital (CHUC), Coimbra, PRT
| | - Ana Rita Silva
- Nephrology, Coimbra University Hospital (CHUC), Coimbra, PRT
| | - Adriana Carones
- Rheumatology, Coimbra University Hospital (CHUC), Coimbra, PRT
| | - Sónia Teixeira
- Intensive Care Unit, Coimbra University Hospital (CHUC), Coimbra, PRT
| | - Paulo Coimbra
- Intensive Care Unit, Coimbra University Hospital (CHUC), Coimbra, PRT
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Fernández-Ávila DG, Vargas-Vanegas ÓR, Galindo-Rozo L, García-Peña Á, Muñoz-Velandia Ó. Clinical characteristics and outcomes of patients with inflammatory and autoimmune rheumatological diseases admitted for intensive care in Colombia. Reumatismo 2023; 75. [PMID: 37721350 DOI: 10.4081/reumatismo.2023.1563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/15/2023] [Indexed: 09/19/2023] Open
Abstract
OBJECTIVE Contemporary studies reporting outcomes of critical care in patients with inflammatory and autoimmune rheumatological diseases are scarce. This study describes 15 years of experience from 2005-2019 in a Colombian referral hospital. METHODS This observational, descriptive, consecutive case series study was performed on adult patients with inflammatory and autoimmune rheumatic diseases who were admitted to the intensive care unit (ICU) of the San Ignacio University Hospital in Bogotá (Colombia), from January 1, 2005, to December 21, 2019. We describe the sociodemographic characteristics, admission causes and criteria, lengths of stay, immunosuppressive treatment, systemic support, and mortality. RESULTS The study included 300 patients with a median age of 48 years [interquartile range (IQR) 31-62 years], predominantly female (76%). Disease exacerbations (30%), infections (17.6%), and cardiovascular diseases (15%) were the main causes of admission. Respiratory failure (23%) most commonly caused by septic shock (24%) was the principal indication for intensive care admission. The most frequent infections were community-acquired pneumonia (11.6%) and soft-tissue infections (9%). In 40.3% of patients, inotropic and vasopressor support was required. The median length of stay was 4 days (IQR 2-8), and global mortality was 21.6%. CONCLUSIONS Rheumatic diseases in the ICU are still associated with high morbidity and mortality. Patients with inflammatory and autoimmune rheumatic diseases require a meticulous clinical approach, strict clinical monitoring, frequent assessment of complications, evaluation of systemic support needs, and specific management.
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Affiliation(s)
- D G Fernández-Ávila
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá.
| | - Ó R Vargas-Vanegas
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá.
| | - L Galindo-Rozo
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá.
| | - Á García-Peña
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá.
| | - Ó Muñoz-Velandia
- Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá.
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3
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AYDIN K, TÜRK İ. The Diagnostic profile and clinical course of patients with rheumatic diseases in the medical intensive care unit. Turk J Med Sci 2023; 53:1084-1093. [PMID: 38813000 PMCID: PMC10763782 DOI: 10.55730/1300-0144.5673] [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: 04/30/2023] [Revised: 10/26/2023] [Accepted: 09/06/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim Immunosuppressive and immunomodulatory treatments developed in recent years as a result of a better understanding of the pathophysiology of systemic rheumatic diseases (SRDs) improve the prognosis. Despite medical advances, individuals with SRDs at any stage may require intensive care and have a high mortality rate. The aim of this study was to investigate the demographic and clinical characteristics of patients with rheumatic diseases admitted to the intensive care unit (ICU), and the factors associated with the risk of mortality. Materials and methods This was a retrospective, cross-sectional study that included patients with rheumatic diseases in the medical ICU. Factors of ICU 28-day mortality were identified by multiple-variable logistic analysis. Results A total of 127 patients with SRDs admitted to the medical ICU were enrolled. Systemic lupus erythematosus (SLE) (32.3%) was the most common diagnosis of SRDs in patients admitted to the ICU. The reasons for admission to the ICU were combined infection and primary SRD flare-up (35.4%), primary SRD flare-up (22%), SRD-unrelated reasons (22%), infection (17.3%), drug side effects (3.9%), and SRD-related complications (0.8%). The most common organ dysfunctions before (49.6%) and during (77.2%) admission to ICU were in the respiratory system. The 28-day mortality was 78 (61.4%). While the maximum procalcitonin, serum lactate, and blood urea nitrogen (BUN) levels were higher in the nonsurvivor group, the platelet and serum albumin levels were statistically significantly lower than those in the survivor group (p < 0.05). Acute respiratory failure (ARF), the presence of septic shock, the need for invasive mechanical ventilation (IMV), BUN level, and low platelet-lymphocyte ratio (PLR) were significant in the final multiple-variable model. Conclusion Significant predictors of mortality in patients with rheumatic diseases may include ARF, septic shock, the need for IMV, and high BUN and low PLR levels.
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Affiliation(s)
- Kaniye AYDIN
- Division of Medical Intensive Care Unit, Department of Internal Medicine, Faculty of Medicine, Çukurova University, Adana,
Turkiye
| | - İpek TÜRK
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Çukurova University, Adana,
Turkiye
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Determination of the main causes, outcome, and prognostic factors of patients with rheumatologic diseases admitted to the medical intensive care unit in Southern Iran. Clin Rheumatol 2022; 41:3859-3868. [PMID: 35969279 PMCID: PMC9376566 DOI: 10.1007/s10067-022-06334-5] [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: 12/24/2021] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Systemic rheumatic diseases (SRD) are a heterogeneous group of diseases that can involve several organ systems and occasionally requires intensive care unit (ICU) admission because of severe systemic disease, life-threatening organ involvement, or complication of treatment. The objective of this study is to determine the causes, outcome, and prognostic factors of patients with rheumatologic diseases admitted in teaching medical ICUs in southern Iran. METHODS A retrospective case review of all patients with rheumatologic diseases admitted in the academic medical ICUs in two referral hospitals in southern Iran, from March 2015 to January 2020. Patients' data were documented from their hospital records and the cause of admission, in-hospital outcome, and prognostic factors was evaluated. RESULTS Ninety-one patients were included, of which 71.4% were female. Systemic lupus erythematosus (54.9%) was the most common disease. Nineteen (20.9%) patients were new cases of rheumatological disease. The most frequent symptom for admittance was dyspnea (54.9%) and hemoptysis (20.9%). The in-hospital mortality rate was 48%, and the leading cause of death was infection (29 patients; 65.5%) followed by disease activity (18 patients; 40.9%). Also, the death of 29.5% of patients was presumed due to both disease activity and infection. Factors associated with mortality included renal insufficiency (p < 0.028), infection (p < 0.001), pneumonia (p < 0.042), dyspnea (p < 0.042), loss of consciousness (p < 0.046), azathioprine consumption (p < 0.004) during 1 month before ICU admission, mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), CNS involvement (p < 0.009), and ICU medications such as cyclosporine and azathioprine (0.03 and 0.03, respectively) or treatments such as plasmapheresis (p < 0.018). CONCLUSION The ICU mortality rate of patients with SRD was high. Infection and disease exacerbation are the leading reasons for ICU admission in systemic rheumatic diseases. Intensivists must keep in mind that SRD exacerbation may require immunosuppressive agents along with lifesaving interventions, more particularly in newly diagnosed SRDs. Key Points • The ICU mortality rate of patients with SRD was high. • Infection and disease exacerbation are the leading reasons for ICU admission in systemic rheumatic diseases. • 63.8% of our patients fall into this category of new cases of rheumatologic disease and disease flare-up.
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Assan F, Bay P, Mathian A, Hekimian G, Bréchot N, Quentric P, Moyon Q, Schmidt M, Cohen-Aubart F, Haroche J, Amoura Z, Luyt CE, Combes A, Pineton de Chambrun M. In-ICU-acquired infections in flare-up systemic rheumatic disease patients receiving immunosuppressant. Clin Rheumatol 2022; 41:2845-2854. [PMID: 35534696 DOI: 10.1007/s10067-022-06197-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/25/2022] [Accepted: 04/30/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Systemic rheumatic diseases (SRDs) are a group of inflammatory disorders that can need intensive care unit (ICU) admission during a flare-up, requiring administration of immunosuppressants. We undertook this study to determine the frequency, outcome, and occurrence associated factors of infections in flare-up SRD patients receiving immunosuppressant. METHODS Monocenter, a retrospective study including SRD patients admitted to ICU for a flare-up requiring immunosuppressant from 2004 to 2019. The primary endpoint was in-ICU-acquired infections. RESULTS Ninety-eight patients (female/male ratio: 1.6; mean age at admission: 39.5 ± 17.4 years) were admitted to the ICU for a SRD flare-up, inaugural in 61.2% cases. A specific treatment was given to every patient: corticosteroids 100%, cyclophosphamide 45.9%, plasma exchange 46.9%. Ninety-five infections occurred in 35 (36%) patients mainly pneumonias. The overall in-hospital mortality was 17.3%, and 46% of patients with a nosocomial infection died during their ICU stay. The logistic regression multivariable model retained renal replacement therapy and mechanical ventilation as independent predictors of infection. CONCLUSION In-ICU-acquired infection in SRD flare-up is a frequent event associated with organ failures but not with in-ICU use of immunosuppressants. These data suggest that the fear of infection should not withhold a careful in-ICU use of immunosuppressive drugs. Key Points • In-ICU infections are frequent in flare-up systemic rheumatic disease patients. • Infections are associated with increased mortality. • Cyclophosphamide given in ICU was not independently associated with infection. • Severe neutropenia occurred in 27% of patients receiving cyclophosphamide in ICU.
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Affiliation(s)
- Florence Assan
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Pierre Bay
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Guillaume Hekimian
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Paul Quentric
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France
| | - Quentin Moyon
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France.,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Fleur Cohen-Aubart
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Julien Haroche
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France.,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, 47-83, boulevard de l'Hôpital, 75651, Paris Cedex, France. .,Service de Médecine Intensive-Réanimation, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Paris, France. .,Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Inserm, Paris, France. .,INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Sorbonne Université, F-75013, Paris, France.
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6
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Günther F, Fleck M. [Severe organ manifestations in rheumatic diseases]. Dtsch Med Wochenschr 2021; 146:1152-1158. [PMID: 34448191 DOI: 10.1055/a-0949-4889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Several inflammatory rheumatic diseases can severely affect any organ system and require immediate intervention and intensive care admission. The early detection of impending organ failure and the underlying rheumatic disease is of paramount importance for the prognosis and outcome of affected patients. Therefore, a thorough knowledge of the potential life threatening organ manifestations of systemic rheumatic diseases is of particular interest for clinicians working in intensive care. This paper provides an overview of diagnostic steps and therapy of organ manifestations in critically ill patients with underlying systemic rheumatic diseases. The presentation of the relevant systemic rheumatic diseases is structured according to the most important organ systems, i. e. the respiratory system, the kidney and the cardiovascular system. Furthermore, there is a focus in this paper on macrophage activation syndrome (MAS) as a potentially lethal complication of several rheumatic diseases and the catastrophic antiphospholipid syndrome (CAPS) as a rare cause of multi organ failure.
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7
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Raibagkar P, Ramineni A. Autoimmune Neurologic Emergencies. Neurol Clin 2021; 39:589-614. [PMID: 33896534 DOI: 10.1016/j.ncl.2021.01.006] [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] [Indexed: 11/17/2022]
Abstract
Over the past decade, understanding of autoimmune neurologic disorders has exponentially increased. Many patients present as a neurologic emergency and require timely evaluation with rapid management and intensive care. However, the diagnosis is often either missed or delayed, which may lead to a significant burden of disabling morbidity and even mortality. A high level of suspicion in the at-risk population should be maintained to facilitate more rapid diagnosis and prompt treatment. At present, there is no all-encompassing algorithm specifically applicable to the management of fulminant autoimmune neurologic disorders. This article discusses manifestations and management of various autoimmune neurologic emergencies.
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Affiliation(s)
- Pooja Raibagkar
- Concord Hospital Neurology Associates, 246 Pleasant Street, Concord, NH 03301, USA.
| | - Anil Ramineni
- Lahey Hospital & Medical Center, Beth Israel Lahey Health, 41 Mall Road, Burlington, MA 01803, USA
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8
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Krasselt M, Baerwald C, Petros S, Seifert O. Sepsis Mortality Is high in Patients With Connective Tissue Diseases Admitted to the Intensive Care Unit (ICU). J Intensive Care Med 2021; 37:401-407. [PMID: 33631998 PMCID: PMC8772250 DOI: 10.1177/0885066621996257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives: Patients with connective tissue diseases (CTD) such as systemic lupus erythematosus (SLE) have an increased risk for infections. This study investigated the outcome and characteristics of CTD patients under intensive care unit (ICU) treatment for sepsis. Methods: A single-center retrospective analysis was conducted and reviewed all patients with a CTD diagnosis admitted to the ICU of a university hospital for sepsis between 2006 and 2019. Mortality was computed and multivariate logistic regression was used to detect independent risk factors for sepsis mortality. Furthermore, the positive predictive value of ICU scores such as Sequential Organ Failure Assessment (SOFA) score was evaluated. Results: This study included 44 patients with CTD (mean age 59.8 ± 16.1 years, 68.2% females), most of them with a diagnosed SLE (61.4%) followed by systemic sclerosis (15.9%). 56.8% (n = 25) were treated with immunosuppressives and 81.8% (n = 36) received glucocorticoids. Rituximab was used in 3 patients (6.8%). The hospital mortality of septic CTD patients was high with 40.9%. It was highest among systemic sclerosis (SSc) patients (85.7%). SOFA score and diagnosis of SSc were independently associated with mortality in multivariate logistic regression (P = 0.004 and 0.03, respectively). The Simplified Acute Physiology Score II (SAPS II), SOFA and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were good predictors of sepsis mortality in the investigated cohort (SAPS II AUC 0.772, P = 0.002; SOFA AUC 0.756, P = 0.004; APACHE II AUC 0.741, P = 0.007). Conclusions: In-hospital sepsis mortality is high in CTD patients. SSc diagnoses and SOFA were independently associated with mortality. Additionally, common ICU scores were good predictors for mortality.
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Affiliation(s)
- Marco Krasselt
- Rheumatology, Medical Department III–Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
- Marco Krasselt, Rheumatology, Medical Department III–Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig Liebigstr. 20/22, 04103 Leipzig, Germany.
| | - Christoph Baerwald
- Rheumatology, Medical Department III–Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - Olga Seifert
- Rheumatology, Medical Department III–Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
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9
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Bay P, Lebreton G, Mathian A, Demondion P, Desnos C, Chommeloux J, Hékimian G, Bréchot N, Nieszkowska A, Schmidt M, Cohen-Aubart F, Leprince P, Luyt CE, Amoura Z, Combes A, Pineton de Chambrun M. Outcomes of severe systemic rheumatic disease patients requiring extracorporeal membrane oxygenation. Ann Intensive Care 2021; 11:29. [PMID: 33559763 PMCID: PMC7871308 DOI: 10.1186/s13613-021-00819-3] [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: 09/18/2020] [Accepted: 01/29/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Systemic rheumatic diseases (SRDs) are a group of inflammatory disorders that can require intensive care unit (ICU) admission because of multiorgan involvement with end-organ failure(s). Critically ill SRD patients requiring extracorporeal membrane oxygenation (ECMO) were studied to gain insight into their characteristics and outcomes. METHODS This French monocenter, retrospective study included all SRD patients requiring venovenous (VV)- or venoarterial (VA)-ECMO admitted to a 26-bed ECMO-dedicated ICU from January 2006 to February 2020. The primary endpoint was in-hospital mortality. RESULTS Ninety patients (male/female ratio: 0.5; mean age at admission: 41.6 ± 15.2 years) admitted to the ICU received VA/VV-ECMO, respectively, for an SRD-related flare (n = 69, n = 38/31) or infection (n = 21, n = 10/11). SRD was diagnosed in-ICU for 31 (34.4%) patients. In-ICU and in-hospital mortality rates were 48.9 and 51.1%, respectively. Nine patients were bridged to cardiac (n = 5) or lung transplantation (n = 4), or left ventricular assist device (n = 2). The Cox multivariable model retained the following independent predictors of in-hospital mortality: in-ICU SRD diagnosis, day-0 Simplified Acute Physiology Score (SAPS) II score ≥ 70 and arterial lactate ≥ 7.5 mmol/L for VA-ECMO-treated patients; diagnosis other than vasculitis, day-0 SAPS II score ≥ 70, ventilator-associated pneumonia and arterial lactate ≥ 7.5 mmol/L for VV-ECMO-treated patients. CONCLUSIONS ECMO support is a relevant rescue technique for critically ill SRD patients, with 49% survival at hospital discharge. Vasculitis was independently associated with favorable outcomes of VV-ECMO-treated patients. Further studies are needed to specify the role of ECMO for SRD patients.
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Affiliation(s)
- Pierre Bay
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Guillaume Lebreton
- Service de Chirurgie Cardiothoracique, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Sorbonne Université, APHP, Paris, France
| | - Alexis Mathian
- Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Paris, France
| | - Pierre Demondion
- Service de Chirurgie Cardiothoracique, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Sorbonne Université, APHP, Paris, France
| | - Cyrielle Desnos
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Juliette Chommeloux
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Guillaume Hékimian
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Ania Nieszkowska
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Matthieu Schmidt
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Institut de Cardiométabolisme Et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
| | - Fleur Cohen-Aubart
- Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Paris, France
| | - Pascal Leprince
- Service de Chirurgie Cardiothoracique, Hôpital La Pitié-Salpêtrière, Institut de Cardiologie, Sorbonne Université, APHP, Paris, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Institut de Cardiométabolisme Et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.,Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Paris, France
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Institut de Cardiométabolisme Et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive-Réanimation, Hôpital La Pitié-Salpêtrière, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France. .,Service de Médecine Interne 2, Institut E3M, Sorbonne Université, Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de L'Hôpital, 75651, Paris Cedex 13, France. .,Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Paris, France. .,Institut de Cardiométabolisme Et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France.
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10
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Fujiwara T, Tokuda K, Momii K, Shiomoto K, Tsushima H, Akasaki Y, Ikemura S, Fukushi JI, Maki J, Kaku N, Akahoshi T, Taguchi T, Nakashima Y. Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units. BMC Rheumatol 2020; 4:64. [PMID: 33292831 PMCID: PMC7716508 DOI: 10.1186/s41927-020-00164-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 08/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background Patients with rheumatoid arthritis (RA) have high mortality risk and are frequently treated in intensive care units (ICUs). Methods This was a retrospective observational study. This study included 67 patients (20 males, 47 females) with RA who were admitted at the ICU of our institution for ≥48 h between January 2008 and December 2017. We analyzed the 30-day mortality of these patients and the investigated prognostic factors in RA patients admitted to our ICU. Results Upon admission, the median age was 70 (range, 33–96) years, and RA duration was 10 (range, 0–61) years. The 5-year survival after ICU admission was 47%, and 30-day, 90-day, and 1-year mortality rates were 22, 27, and 37%, respectively. The major reasons for ICU admission were cardiovascular complications (24%) and infection (40%) and the most common ICU treatments were mechanical ventilation (69%), renal replacement (25%), and vasopressor (78%). In the 30-day mortality group, infection led to a fatal outcome in most cases (67%), and nonsurvival was associated with a significantly higher glucocorticoid dose, updated Charlson’s comorbidity index (CCI), and acute physiology and chronic health evaluation (APACHE) II score. Laboratory data obtained at ICU admission showed that lower platelet number and total protein and higher creatinine and prothrombin time international normalized ratio (PT-INR) indicated significantly poorer prognosis. The multivariate Cox proportional hazard model revealed that nonuse of csDMARDs, high updated CCI, increased APACHE II score, and prolonged PT-INR were associated with a higher risk of mortality after ICU admission. Conclusion Our study demonstrated that the nonuse of csDMARDs, high updated CCI, elevated APACHE II score, and coagulation abnormalities predicted poorer prognosis in RA patients admitted to the ICU.
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Affiliation(s)
- Toshifumi Fujiwara
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan. .,Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan.
| | - Kentaro Tokuda
- Intensive Care Unit, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Kenta Momii
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan.,Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Kyohei Shiomoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Hidetoshi Tsushima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Yukio Akasaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Satoshi Ikemura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Jun-Ichi Fukushi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
| | - Jun Maki
- Intensive Care Unit, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Noriyuki Kaku
- Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Tomohiko Akahoshi
- Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Tomoaki Taguchi
- Emergency & Critical Care Center, Kyushu University Hospital, Fukuoka-shi, Japan.,Intensive Care Unit, Kyushu University Hospital, Fukuoka-shi, Japan
| | - Yasuharu Nakashima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka prefecture, 812-8582, Japan
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11
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Krasselt M, Baerwald C, Petros S, Seifert O. Outcome of Patients With Necrotizing Vasculitis Admitted to the Intensive Care Unit (ICU) for Sepsis: Results of a Single-Centre Retrospective Analysis. J Intensive Care Med 2020; 36:1410-1416. [PMID: 32873111 PMCID: PMC8600591 DOI: 10.1177/0885066620953768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION/BACKGROUND Vasculitis patients have a high risk for infections that may require intensive care unit (ICU) treatment in case of resulting sepsis. Since data on sepsis mortality in this patient group is limited, the present study investigated the clinical characteristics and outcomes of vasculitis patients admitted to the ICU for sepsis. METHODS The medical records of all necrotizing vasculitis patients admitted to the ICU of a tertiary hospital for sepsis in a 13-year period have been reviewed. Mortality was calculated and multivariate logistic regression was used to determine independent risk factors for sepsis mortality. Moreover, the predictive power of common ICU scores was further evaluated. RESULTS The study included 34 patients with necrotizing vasculitis (mean age 69 ± 9.9 years, 35.3% females). 47.1% (n = 16) were treated with immunosuppressives (mostly cyclophosphamide, n = 35.3%) and 76.5% (n = 26) received glucocorticoids. Rituximab was used in 4 patients (11.8%).The in-hospital mortality of septic vasculitis patients was 41.2%. The Sequential Organ Failure Assessment (SOFA) score (p = 0.003) was independently associated with mortality in multivariate logistic regression. Acute Physiology And Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II) and SOFA scores were good predictors of sepsis mortality in the investigated vasculitis patients (APACHE II AUC 0.73, p = 0.02; SAPS II AUC 0.81, p < 0.01; SOFA AUC 0.898, p < 0.0001). CONCLUSIONS Sepsis mortality was high in vasculitis patients. SOFA was independently associated with mortality in a logistic regression model. SOFA and other well-established ICU scores were good mortality predictors.
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Affiliation(s)
- Marco Krasselt
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Liebigstr, Leipzig, Germany
| | - Christoph Baerwald
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Liebigstr, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Liebigstr, Leipzig, Germany
| | - Olga Seifert
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Liebigstr, Leipzig, Germany
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12
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Suárez-Avellaneda A, Quintana JH, Aragón CC, Gallego LM, Gallego CN, Bolaños JD, A Guerra M, Ochoa ME, Granados M, Ruiz-Ordoñez I, Tobón GJ. Systemic lupus erythematosus in the intensive care unit: a systematic review. Lupus 2020; 29:1364-1376. [PMID: 32723062 DOI: 10.1177/0961203320941941] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with heterogeneous pathophysiologic mechanisms and diverse clinical manifestations. SLE is a frequent cause of intensive care unit (ICU) admissions. Multiple studies with controversial findings on the causes, evolution and outcomes of ICU-admitted patients with SLE have been published. The aim of this paper is to review the literature reporting the clinical characteristics and outcomes, such as mortality and associated factors, in such patients. Among the main causes of ICU admissions are SLE disease activity, respiratory failure, multi-organ failure and infections. The main factors associated with mortality are a high Acute Physiology and Chronic Health Evaluation (APACHE) score, the need for mechanical ventilation, and vasoactive and inotropic agent use. Reported mortality rates are 18.4%-78.5%. Therefore, it is important to evaluate SLE disease severity for optimizing clinical management and patient outcomes.
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Affiliation(s)
- Ana Suárez-Avellaneda
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| | | | - Cristian C Aragón
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| | | | | | | | | | - Maria Elena Ochoa
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia
| | - Marcela Granados
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia
| | - Ingrid Ruiz-Ordoñez
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
| | - Gabriel J Tobón
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina Traslacional; Fundación Valle Del Lili and Universidad Icesi, Cali, Colombia
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13
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Larcher R, Pineton de Chambrun M, Garnier F, Rubenstein E, Carr J, Charbit J, Chalard K, Mourad M, Amalric M, Platon L, Brunot V, Amoura Z, Jaber S, Jung B, Luyt CE, Klouche K. One-Year Outcome of Critically Ill Patients With Systemic Rheumatic Disease: A Multicenter Cohort Study. Chest 2020; 158:1017-1026. [PMID: 32289313 DOI: 10.1016/j.chest.2020.03.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/15/2020] [Accepted: 03/09/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Critically ill patients with systemic rheumatic disease (SRD) have benefited from better provision of rheumatic and critical care in recent years. Recent comprehensive data regarding in-hospital mortality rates and, most importantly, long-term outcomes are scarce. RESEARCH QUESTION The aim of this study was to assess short and long-term outcome of patients with SRD who were admitted to the ICU. STUDY DESIGN AND METHODS All records of patients with SRD who were admitted to ICU between 2006 and 2016 were reviewed. In-hospital and one-year mortality rates were assessed, and predictive factors of death were identified. RESULTS A total of 525 patients with SRD were included. Causes of admission were most frequently shock (40.8%) and acute respiratory failure (31.8%). Main diagnoses were infection (39%) and SRD flare-up (35%). In-hospital and one-year mortality rates were 30.5% and 37.7%, respectively. Predictive factors that were associated with in-hospital and one-year mortalities were, respectively, age, prior corticosteroid therapy, simplified acute physiology score II ≥50, need for invasive mechanical ventilation, or need for renal replacement therapy. Knaus scale C or D and prior conventional disease modifying antirheumatic drug therapy was associated independently with death one-year after ICU admission. INTERPRETATION Critically ill patients with SRD had a fair outcome after an ICU stay. Increased age, prior corticosteroid therapy, and severity of critical illness were associated significantly with short- and long-term mortality rates. The one-year mortality rate was also associated with prior health status and conventional disease modifying antirheumatic drug therapy.
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Affiliation(s)
- Romaric Larcher
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France.
| | - Marc Pineton de Chambrun
- Department of Internal Medicine 2, E3M Institute, Paris, France; Medical Intensive Care Unit, Institute of Cardiology, La Pitie-Salpetriere Hospital, University of Paris 6, Paris, France
| | - Fanny Garnier
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; UPRES EA2415, Laboratory of biostatistics, Epidemiology, Clinical Research and Health Economics, University of Montpellier, Montpellier, France
| | - Emma Rubenstein
- Internal Medicine Department, Saint Louis Hospital, University of Paris 7, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Julie Carr
- Anesthesiology and Intensive Care Departments, Saint Eloi Hospital, Montpellier, France
| | | | | | - Marc Mourad
- Arnaud de Villeneuve Hospital, University Hospital of Montpellier, Montpellier, France
| | - Matthieu Amalric
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - Laura Platon
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - Vincent Brunot
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France
| | - Zahir Amoura
- Department of Internal Medicine 2, E3M Institute, Paris, France
| | - Samir Jaber
- Anesthesiology and Intensive Care Departments, Saint Eloi Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Boris Jung
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Charles-Edouard Luyt
- Medical Intensive Care Unit, Institute of Cardiology, La Pitie-Salpetriere Hospital, University of Paris 6, Paris, France
| | - Kada Klouche
- Intensive Care Medicine Department, Lapeyronie Hospital, Montpellier, France; PhyMedExp, INSERM, CNRS, Montpellier, France
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14
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Krasselt M, Baerwald C, Petros S, Seifert O. Mortality of Sepsis in Patients With Rheumatoid Arthritis: A Single-Center Retrospective Analysis and Comparison With a Control Group. J Intensive Care Med 2020; 36:766-774. [PMID: 32249644 PMCID: PMC8165740 DOI: 10.1177/0885066620917588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION/BACKGROUND Patients with rheumatoid arthritis (RA) have a high risk of infections that may require intensive care unit (ICU) admission in case of resulting sepsis. Data regarding the mortality of these patients are very limited. This study investigated clinical characteristics and outcomes of patients with RA admitted to the ICU for sepsis and compared the results to a control cohort without RA. METHODS All patients with RA as well as sex-, age-, and admission year-matched controls admitted to the ICU of a university hospital for sepsis between 2006 and 2019 were retrospectively analyzed. Mortality was calculated for both the groups, and multivariate logistic regression was used to determine independent risk factors for sepsis mortality. The positive predictive value of common ICU scores was also investigated. RESULTS The study included 49 patients with RA (mean age 67.2 ± 9.0 years, 63.3% females) and 51 matched controls (mean age 67.4 ± 9.5 years, 64.7% females). Among the patients with RA, 42.9% (n = 21) were treated with conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) and 30.6% (n = 15) received glucocorticoids only. Seven (14.3%) patients received biologic (b) DMARDs. The hospital mortality was higher among patients with RA (42.9% vs 15.7%, P = .0016). Rheumatoid arthritis was independently associated with mortality in multivariate logistic regression (P = .001). In patients with RA, renal replacement therapy (P = .024), renal failure (P = .027), and diabetes mellitus (P = .028) were independently associated with mortality. Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Sequential Organ Failure Assessment (SOFA) scores were good predictors of sepsis mortality in patients with RA (APACHE II area under the curve [AUC]: 0.78, P = .001; SAPS II AUC: 0.78, P < .001; SOFA AUC 0.78, P < .001), but their predictive power was higher among controls. CONCLUSIONS Hospital sepsis mortality was higher in patients with RA than in controls. Rheumatoid arthritis itself is independently associated with an increased sepsis mortality. Renal replacement therapy, renal failure, and diabetes were associated with an increased mortality. Common ICU scores were less well predictors of sepsis mortality in patients with RA compared to non-RA controls.
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Affiliation(s)
- Marco Krasselt
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
| | - Christoph Baerwald
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical Intensive Care Unit, University Hospital of Leipzig, Leipzig, Germany
| | - Olga Seifert
- Rheumatology, Medical Department III-Endocrinology, Nephrology and Rheumatology, University Hospital of Leipzig, Leipzig, Germany
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15
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Al-Mayouf SM, Fallatah R, Al-Twajery M, Alayed T, Alsonbul A. Outcome of children with systemic rheumatic diseases admitted to pediatric intensive care unit: An experience of a tertiary hospital. Int J Pediatr Adolesc Med 2019; 6:142-145. [PMID: 31890839 PMCID: PMC6926232 DOI: 10.1016/j.ijpam.2019.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/15/2019] [Accepted: 07/02/2019] [Indexed: 11/22/2022]
Abstract
Objective To report the outcome of children with rheumatic diseases admitted to pediatric intensive care unit (PICU) in a tertiary hospital. Methods Database from PICU and pediatric rheumatology section used to retrieve all candidate patients admitted to PICU from June 2000 to December 2017. Medical records of all enrolled patients reviewed for diagnosis, organ involvement, reason of PICU admission, the length of stay, and outcome. Results Twenty-five patients (17 female, 8 male) with total of 41 admissions identified. The median PICU stay was 13.5 days (range, 3–24). The most frequent diagnoses were systemic lupus erythematosus (SLE) (48%), followed by systemic vasculitis (16%). Most admissions were from the medical ward (68.3%), while 24.4% from the emergency room. The main reason of PICU admission was a disease flare or related complications (48.8%), followed by infection (34.2%). Fifty one percent of the admissions were due to respiratory dysfunction, 46% required non-invasive respiratory support while 38% was in need for mechanical ventilation. During PICU stay, anti-microbial agents used 90.3%, immunosuppressive treatment adjustment 75.6%, anti-hypertensive 24.4% and vasopressors 12.2%. Twelve patients (48%) fully recovered and 40% partially recovered while three patients died during their PICU stay. The causes of death were macrophage activation syndrome complicated by sepsis in two patients and advanced pulmonary hypertension in one patient. Conclusion Our data showed that children with rheumatic diseases, particularly SLE, are mostly admitted to PICU with serious disease exacerbation or severe infection. To improve the outcome, early diagnosis of critical condition and proper intervention are fundamental in reducing mortality.
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Affiliation(s)
- Sulaiman M Al-Mayouf
- Pediatric Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rehab Fallatah
- Pediatric Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mohammed Al-Twajery
- Pediatric Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tareq Alayed
- Pediatric Intensive Care Unit, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah Alsonbul
- Pediatric Rheumatology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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16
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Restrepo-Escobar M, A Ríos N, Hernández-Zapata LJ, Velásquez M, Eraso R. Factors associated with infection amongst paediatric patients with systemic lupus erythematosus treated in the intensive care unit. Lupus 2019; 28:1141-1147. [DOI: 10.1177/0961203319860194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Objective To identify determinants and outcomes associated with infection in paediatric systemic lupus erythematosus (SLE) patients at admission and during hospitalization in intensive care units (ICUs). Patients and methods A retrospective cohort study of paediatric SLE patients admitted to two ICUs was conducted. Frequency and risk factors of infection as well as mortality were studied. Results Seventy-three infection episodes amongst 55 patients were analysed. The median age was 14.4 years (IQR 12.5–16). The median SLEDAI was 16 (IQR 12–20). Twenty-nine episodes were documented at admission; the CRP was higher in these patients (6.58 versus 1.04 mg/dl, p<0.001) than in non-infected patients, even after multivariate adjustment (OR 8.6, 95% CI = 2.1–34.8, p = 0.003). Twenty-five (34.7%) episodes occurred during hospitalization. Lupus activity (OR 1.14, 95% CI = 1.01–1.27, p = 0.029), cyclophosphamide (OR 17.9, 95% CI = 2–156, p = 0.009) and mechanical ventilation (OR 16, 95% CI = 2.1–122, p = 0.008) were associated with infection. Ten episodes (14%) led to death. Admission to the ICU due to infection was strongly associated with mortality (90% versus 31.8%, OR 19.4, 95% CI = 2.3–163, p = 0.006). Conclusion In paediatric lupus patients admitted to the ICU, elevated CRP should alert clinicians to possible infection. During hospitalization, SLE activity and cyclophosphamide were associated with infection. Infection at admission to the ICU was strongly associated with mortality.
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Affiliation(s)
- M Restrepo-Escobar
- University of Antioquia, Medellín, Colombia
- Pablo Tobón Uribe Hospital, Medellín, Colombia
| | - N A Ríos
- University of Antioquia, Medellín, Colombia
| | | | - M Velásquez
- San Vicente Fundación University Hospital, Medellín, Colombia
| | - R Eraso
- University of Antioquia, Medellín, Colombia
- Pablo Tobón Uribe Hospital, Medellín, Colombia
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Patients with small-vessel vasculitides have the highest mortality among systemic autoimmune diseases patients treated in intensive care unit: A retrospective study with 5-year follow-up. J Crit Care 2018; 48:166-171. [DOI: 10.1016/j.jcrc.2018.08.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 01/06/2023]
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18
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Patients with systemic rheumatic diseases admitted to the intensive care unit: what the rheumatologist needs to know. Rheumatol Int 2018; 38:1163-1168. [PMID: 29549383 DOI: 10.1007/s00296-018-4008-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
Abstract
Patients with systemic rheumatic diseases (SRDs) may require admission to the intensive care unit (ICU) throughout the course of their disease. Therefore, the rheumatologist needs an understanding of the factors which may influence the course of patients with SRDs who are admitted to ICU. These include the causes for admission, patient characteristics including comorbidities and drug therapies, outcome (in-ICU mortality and causes of death), and prognostic factors. Infections and exacerbation/complications of SRDs are the most common (and potentially reversible) reasons for both admission and death on ICU. Mortality in patients with SRDs admitted to ICU has been reported to be either no different or higher than 'general' ICU patients. Reported prognostic factors included patient and disease characteristics, as well as ICU factors, including scoring systems. Rheumatologists need to be aware of the factors surrounding admission of patients with SRDs to ICU, including the need for strong links with critical care medicine.
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19
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Wang M, Su S, Lv J, Zhou G, Wang Q, Guo C. Analysis of clinical features and prognostic factors in Chinese patients with rheumatic diseases in an intensive care unit. EGYPTIAN RHEUMATOLOGIST 2018. [DOI: 10.1016/j.ejr.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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20
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Pieringer H, Hintenberger R, Pohanka E, Steinwender C, Meier J, Gruber F, Auer-Hackenberg L. RABBIT risk score and ICU admission due to infection in patients with rheumatoid arthritis. Clin Rheumatol 2017; 36:2439-2445. [PMID: 28905133 DOI: 10.1007/s10067-017-3825-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/30/2017] [Accepted: 09/04/2017] [Indexed: 01/26/2023]
Abstract
Rheumatoid arthritis (RA) patients are at increased risk of infection. Aim of the present study was to investigate whether RA patients admitted to an intensive care unit (ICU) due to infection have higher Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk scores compared to control RA patients. Seventy-four RA patients (32.4% male) admitted to an ICU due to infection (from January 2002 to December 2013) and 74 frequency-matched control RA patients (16.2% male) were included in this cross-sectional study. There was strong evidence for a higher RABBIT risk score in ICU patients (median 2.0; IQR 1.3-3.2) as compared to controls (1.3; IQR 0.8-2.0; p < 0.0001). Traditional disease-modifying anti-rheumatic drugs (DMARDs) (82.4 vs 64.9%; p = 0.015) and biological DMARDs (28.4 vs 14.9%; p = 0.012) were more frequently given to RA patients without ICU admission. Glucocorticoid users were more frequently found in the ICU group (51.4 vs 31.1%; p = 0.012). In a multivariable analysis tDMARD use was associated with lower (OR 0.38; 95% CI 0.15-0.93; p = 0.034) and glucocorticoid use with borderline higher odds of ICU admission (OR 2.05; 95% CI 0.92-4.58; p = 0.078). Chronic obstructive pulmonary disease (OR 2.89; 95% CI 1.10-7.54; p = 0.03), chronic kidney disease (OR 16.08; 95% CI 2.00-129.48; p = 0.009), and age category (OR 2.67; 95% CI 1.46-4.87; p = 0.001) were strongly associated with ICU admission. There was a strong trend towards higher odds of ICU admission with increasing RABBIT risk score. Use of tDMARDs was associated with lower odds of ICU admission. In an adjusted analysis, bDMARDs were not associated with ICU admission. COPD, CKD, and age were strong risk factors for ICU admission.
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Affiliation(s)
- Herwig Pieringer
- Academic Research Unit, 2nd Department of Internal Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria. .,Paracelsus Private Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
| | - Rainer Hintenberger
- Academic Research Unit, 2nd Department of Internal Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria
| | - Erich Pohanka
- Academic Research Unit, 2nd Department of Internal Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria
| | - Clemens Steinwender
- Paracelsus Private Medical University Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.,1st Department of Internal Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria
| | - Jens Meier
- Department of Anesthesiology and Operative Intensive Care Medicine, Kepler University Hospital Linz, Krankenhausstr. 9, Linz, Austria
| | - Franz Gruber
- Department of Neurology 2, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, Linz, Austria
| | - Lorenz Auer-Hackenberg
- Academic Research Unit, 2nd Department of Internal Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria
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21
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Beil M, Sviri S, de la Guardia V, Stav I, Ben-Chetrit E, van Heerden PV. Prognosis of patients with rheumatic diseases admitted to intensive care. Anaesth Intensive Care 2017; 45:67-72. [PMID: 28072937 DOI: 10.1177/0310057x1704500110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Variable mortality rates have been reported for patients with rheumatic diseases admitted to an intensive care unit (ICU). Due to the absence of appropriate control groups in previous studies, it is not known whether the presence of a rheumatic disease constitutes a risk factor. Moreover, the accuracy of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score for predicting outcome in this group of patients has been questioned. The primary goal of this study was to compare outcome of patients with rheumatic diseases admitted to a medical ICU to those of controls. The records of all patients admitted between 1 April 2003 and 30 June 2014 (n=4020) were screened for the presence of a rheumatic disease during admission (n=138). The diagnosis of a rheumatic disease was by standard criteria for these conditions. An age- and gender-matched control group of patients without a rheumatic disease was extracted from the patient population in the database during the same period (n=831). Mortality in ICU, in hospital and after 180 days did not differ significantly between patients with and without rheumatic diseases. There was no difference in the performance of the APACHE II score for predicting outcome in patients with rheumatic diseases and controls. This score, as well as a requirement for the use of inotropes or vasopressors, accurately predicted hospital mortality in the group of patients with rheumatic diseases. In conclusion, patients with a rheumatic condition admitted to intensive care do not do significantly worse than patients without such a disease.
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Affiliation(s)
- M Beil
- Visiting Professor, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel, University of Ulm, Germany
| | - S Sviri
- Director, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - V de la Guardia
- Fellow, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - I Stav
- Data Analyst, Medical Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - E Ben-Chetrit
- Professor, Rheumatology Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
| | - P V van Heerden
- Professor of Anesthesiology, General Intensive Care Unit, Hadassah University Hospital, En Kerem, Jerusalem, Israel
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22
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Haviv Y, Shovman O, Bragazzi NL, Sharif K, Yavne Y, Shoenfeld Y, Amital H, Watad A. Patients With Vasculitides Admitted to the Intensive Care Unit: Implications From a Single-Center Retrospective Study. J Intensive Care Med 2017; 34:828-834. [DOI: 10.1177/0885066617717223] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: Vasculitides are a group of disorders characterized by inflammation of vessels. Vasculitides may have life-threatening complications with significant morbidity and mortality; however, information regarding the outcome and prognosis of patients with vasculitides requiring intensive care unit (ICU) is scarce. Methods: Data of patients with vasculitides admitted to the ICU of the Sheba Medical Center between the years 2000 and 2014 were retrieved retrospectively. Continuous variables were computed as mean (standard deviation), whereas categorical variables were recorded as percentages. In order to investigate the impact of clinical variables on mortality, Student t test and χ2 analyses were performed. Results: Twenty-five patients with vasculitides were admitted to the ICU during the study period with mean age of 52 ± 14 years and sex ratio of male/female: 12/13. The mortality rate among these patients was 48%. Leading causes for ICU admission were infection (64%), disease exacerbation (34%), and hemorrhage (16%), while respiratory or cardiovascular involvement accounted for the majority of mortality during admission. An elevated Sequential Organ Failure Assessment (SOFA) score was significantly associated with mortality ( P = .041). Conclusion: Our study confirms the high mortality rate among patients with vasculitides who require ICU care as well as the roles of infection and disease flare-up as causes for admission. An elevated SOFA score was found to be predictive of mortality.
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Affiliation(s)
- Yael Haviv
- Department of General Intensive Care, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
| | - Ora Shovman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
- Department of Medicine ‘B’, Tel Aviv University, Tel Aviv, Israel, Israel
- Zabludowicz center for Autoimmune Diseases, Tel Aviv University, Tel Aviv, Israel, Israel
| | - Nicola Luigi Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Kassem Sharif
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
- Department of Medicine ‘B’, Tel Aviv University, Tel Aviv, Israel, Israel
| | - Yarden Yavne
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
- Zabludowicz center for Autoimmune Diseases, Tel Aviv University, Tel Aviv, Israel, Israel
| | - Howard Amital
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
- Department of Medicine ‘B’, Tel Aviv University, Tel Aviv, Israel, Israel
- Zabludowicz center for Autoimmune Diseases, Tel Aviv University, Tel Aviv, Israel, Israel
| | - Abdulla Watad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Israel
- Department of Medicine ‘B’, Tel Aviv University, Tel Aviv, Israel, Israel
- Zabludowicz center for Autoimmune Diseases, Tel Aviv University, Tel Aviv, Israel, Israel
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23
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Rush B, Biagioni BJ, Berger L, McDermid R. Mechanical Ventilation Outcomes in Patients With Pulmonary Hypertension in the United States: A National Retrospective Cohort Analysis. J Intensive Care Med 2016; 32:588-592. [PMID: 27279084 DOI: 10.1177/0885066616653926] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The outcome of patients with pulmonary arterial hypertension (PAH) who undergo mechanical ventilation is not well known. METHODS The Nationwide Inpatient Sample for 2006 to 2012 was used to isolate patients with a diagnosis of PAH who also underwent invasive (MV) and noninvasive (NIMV) mechanical ventilation. The primary outcome was in-hospital mortality. RESULTS The hospital records of 55 208 382 patients were studied, and there were 21 070 patients with PAH, of whom 1646 (7.8%) received MV and 834 (4.0%) received NIMV. Those receiving MV had higher mortality (39.1% vs 12.6%, P < .001) and longer hospital stays (11.9 days, interquartile range [IQR] 6.1-22.2 vs 6.7 days, IQR 3.4-11.9, P < .001) than those undergoing NIMV. Of the patients treated with MV, 4.4% also used home oxygen therapy and had similar overall mortality to those who did not use home oxygen (35.3% vs 39.1%, P = .46). Similarly, there was no relationship between home oxygen use and mortality in patients treated with NIMV (10.6% vs 12.6%, P = .48). Notably, more patients treated with NIMV used home oxygen than those treated with MV (14.4% vs 4.4%, P < .001). CONCLUSION Patients with PAH who undergo invasive mechanical ventilation have an in-hospital mortality of 39.1%. Future work may help identify the types of patients who benefit most from advanced respiratory support in a critical care setting.
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Affiliation(s)
- Barret Rush
- 1 Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,2 Harvard T.H. Chan School of Public Health, Harvard University, MA, USA
| | - Bradly J Biagioni
- 3 Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Landon Berger
- 1 Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,4 Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert McDermid
- 1 Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,5 Department of Critical Care Medicine, Surrey Memorial Hospital, Surrey, British Columbia, Canada
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